Barriers to staff adoption of a surgical safety checklist

International audienceObjective: Implementation of a surgical checklist depends on many organisational factors and on socio-cultural patterns. The objective of this study was to identify barriers to effective implementation of a surgical checklist and to develop a best use strategy.Setting: 18 cancer centres in France.Design: The authors first assessed use compliance and completeness rates of the surgical checklist on a random sample of 80 surgical procedures performed under general or loco-regional anaesthesia in each of the 18 centres. They then developed a typology of the organisational and cultural barriers to effective checklist implementation and defined each barrier's contents using data from collective and semi-structured individual interviews of key staff, the results of an email questionnaire sent to the 18 centres, and direct observations over 20 h in two centres.Results: The study consisted of 1440 surgical procedures, 1299 checklists, and 28 578 items. The mean compliance rate was 90.2% (0, 100). The mean completion rate was 61% (0, 84). 11 barriers to effective checklist implementation were identified. Their incidence varied widely across centres. The main barriers were duplication of items within existing checklists (16/18 centres), poor communication between surgeon and anaesthetist (10/18), time spent completing the checklist for no perceived benefit, and lack of understanding and timing of item checks (9/18), ambiguity (8/18), unaccounted risks (7/18) and a time-honoured hierarchy (6/18).Conclusions: Several of the barriers to the successful implementation of the surgical checklist depended on organisational and cultural factors within each centre. The authors propose a strategy for change for checklist design, use and assessment, which could be used to construct a feedback loop for local team organisation and national initiatives

Current developments in delivering customized care: a scoping review

International audienceBackground In recent years, there has been a growing interest in health care personalization and customization (i.e. personalized medicine and patient-centered care). While some positive impacts of these approaches have been reported, there has been a dearth of research on how these approaches are implemented and combined for health care delivery systems. The present study undertakes a scoping review of articles on customized care to describe which patient characteristics are used for segmenting care, and to identify the challenges face to implement customized intervention in routine care.Methods Article searches were initially conducted in November 2018, and updated in January 2019 and March 2019, according to Prisma guidelines. Two investigators independently searched MEDLINE, PubMed, PsycINFO, Web of Science, Science Direct and JSTOR, The search was focused on articles that included “care customization”, “personalized service and health care”, individualized care” and “targeting population” in the title or abstract. Inclusion and exclusion criteria were defined. Disagreements on study selection and data extraction were resolved by consensus and discussion between two reviewers.Results We identified 70 articles published between 2008 and 2019. Most of the articles ( n = 43) were published from 2016 to 2019. Four categories of patient characteristics used for segmentation analysis emerged: clinical, psychosocial, service and costs. We observed these characteristics often coexisted with the most commonly described combinations, namely clinical, psychosocial and service. A small number of articles ( n = 18) reported assessments on quality of care, experiences and costs. Finally, few articles ( n = 6) formally defined a conceptual basis related to mass customization, whereas only half of articles used existing theories to guide their analysis or interpretation.Conclusions There is no common theory based strategy for providing customized care. In response, we have highlighted three areas for researchers and managers to advance the customization in health care delivery systems: better define the content of the segmentation analysis and the intervention steps, demonstrate its added value, in particular its economic viability, and align the logics of action that underpin current efforts of customization. These steps would allow them to use customization to reduce costs and improve quality of care

Should payment for performance depend on mortality?

International audienceThe introduction of the Hospital Value Based Purchasing (HVBP) programme, as shown recently by Jose F Figueroa and colleagues, did not improve 30 day mortality of Medicare beneficiaries admitted to US hospitals for three incentivised conditions. We agree with the authors’ conclusion that an “appropriate mix of quality metrics and incentives to improve patient outcomes” has yet to be identified.The programme was designed to promote better clinical outcomes for hospital patients and to improve their experience of care during hospital stays. However, if reducing mortality was the primary objective, a specific set of indicators should have been selected from relevant practice and organisational guidelines, which was not the case when the programme was designed. The absence of HVBP’s impact on mortality is therefore not surprising.In their conclusion Figueroa and colleagues say, “Nations considering similar pay for performance programs may want to consider alternative models.” This raises a question: should payment depend on achieving a decrease in mortality rates? The primary objective of pay for performance programmes could still be the development and maintenance of continuous quality improvement (CQI) programmes based on relevant process indicators to assess critical steps in patient management, such as the effective use of checklists in surgical procedures. These process indicators are apt to detect dangerous misconduct, less susceptible to bias, and more actionable.However, a problem remains: such CQI programmes in hospitals rely on a limited number of people repeatedly trying to motivate a large number of health professionals who are insensitive to the benefits of CQI. Instead of diverting the small percentage of budget devoted to pay for performance programmes it could be more profitable, for patients, to think of a better use for this money

Incitation Financière à l'Amélioration de la Qualité (IFAQ) pour les établissements de santé français: Résultats de l'expérimentation (2012-2014)

International audienceThe French Ministry of Health and the National Authority for Health launched an experiment of a Financial Incentive to Improve Quality (IFAQ) within 222 acute care hospitals, in June 2012. A working group made of representatives from hospital federations and governmental agencies was created on purpose. The research team COMPAQH (EA7348 Healthcare management Research-EHESP), was in charge of the program design and development. IFAQ was modeled after the Value-Based Purchasing (VBP) program, which was implemented previously, in the US.The objective was to design a model that would rank the participating hospitals according to the results obtained to a set of indicators, and award bonuses to the highest performers.The model was intended to account for both improvement and achievement. It selected quality and safety indicators that were already mandatory to collect, and disclosed publicly, as well as a measure of the level of use of information technologies.Of the 222 hospitals enrolled 93 of them were rewarded. The incentive size was calculated as a portion of their annual budget.Finally, IFAQ diverged from VBP in terms of metric choice, calculation of the score, and incentive structure.Une expérimentation sur l’Incitation financière à la qualité (IFAQ) a été lancée en France en juin 2012 par le Ministère de la Santé et la Haute Autorité de Santé. Un groupe de travail composé des fédérations hospitalières, des administrations chargées de la santé et de l’assurance maladie a été créé. L’équipe du projet COMPAQH (EA7348-Management des Organisations de Santé, EHESP) a été missionnée pour l’élaboration de la méthode et la conduite de l’expérimentation. La construction du modèle s’est notamment appuyée sur le programme référent en termes de paiement à la performance développé aux Etats-Unis : the Hospital Value Based Pur- chasing (VBP). L’objectif d’IFAQ est de construire un modèle approprié au contexte français permettant de classer les établissements de santé et de rémunérer les meilleurs d’entre eux en fonction de leurs résultats, mais également de leur progression. Le modèle est basé sur l’évaluation de la qualité des établissements de santé à partir d’indicateurs de qualité et de sécurité des soins issus des démarches nationales, de la certification HAS et du niveau de développement de l’informatisation. 222 établissements de santé ont été retenus pour participer à l’expérimentation, 93 ont reçu une rémunération. Le montant de la rémunération dépend du classement et de la valorisation financière de son activité d’hospitalisation en MCO (Médecine Chirurgie Obstétrique) versée par l’assurance maladie. L’expérimentation IFAQ s’est inspirée du modèle VBP mais des différences existent notamment en termes de choix des composantes, du choix de l’expression des résultats des indicateurs, de la prise en compte de l’évolution des résultats et du système d’incitation

International experiences on pay-for-performance programs and implications for China

International audienceIn the past decade, pay-for-performance (P4P) programs in the health care sector have been implemented throughout the world. These programs differ in their design, as they have different targets (hospitals or physicians) and different performance sectors incentivised. P4P has also been introduced to Chinese hospitals recently. This article reviews major P4P initiatives (programs of the U.K., U.S., France, etc.) and collects common design factors for analysis (targets, quality measures, incentive schemes, performance benchmarks, etc.). The pros and cons of each design factor are discussed, and some inevitable empirical pitfalls are also reviewed. It is anticipated that such international experiences can provide possible future reference for the Chinese hospital remuneration reform

Incitation Financière à l'Amélioration de la Qualité (IFAQ) pour les établissements de santé français: Résultats de l'expérimentation (2012-2014)

International audienceUne expérimentation sur l’Incitation financière à la qualité (IFAQ) a été lancée en France en juin 2012 par le Ministère de la Santé et la Haute Autorité de Santé. Un groupe de travail composé des fédérations hospitalières, des administrations chargées de la santé et de l’assurance maladie a été créé. L’équipe du projet COMPAQH (EA7348-Management des Organisations de Santé, EHESP) a été missionnée pour l’élaboration de la méthode et la conduite de l’expérimentation. La construction du modèle s’est notamment appuyée sur le programme référent en termes de paiement à la performance développé aux Etats-Unis : the Hospital Value Based Pur- chasing (VBP). L’objectif d’IFAQ est de construire un modèle approprié au contexte français permettant de classer les établissements de santé et de rémunérer les meilleurs d’entre eux en fonction de leurs résultats, mais également de leur progression. Le modèle est basé sur l’évaluation de la qualité des établissements de santé à partir d’indicateurs de qualité et de sécurité des soins issus des démarches nationales, de la certification HAS et du niveau de développement de l’informatisation. 222 établissements de santé ont été retenus pour participer à l’expérimentation, 93 ont reçu une rémunération. Le montant de la rémunération dépend du classement et de la valorisation financière de son activité d’hospitalisation en MCO (Médecine Chirurgie Obstétrique) versée par l’assurance maladie. L’expérimentation IFAQ s’est inspirée du modèle VBP mais des différences existent notamment en termes de choix des composantes, du choix de l’expression des résultats des indicateurs, de la prise en compte de l’évolution des résultats et du système d’incitation

How to Design a Remote Patient Monitoring System? A French Case Study

International audienceBackground: Remote Patient Monitoring Systems (RPMS) based on e-health, Nurse Navigators (NNs) and patient engagement can improve patient follow-up and have a positive impact on quality of care (by limiting adverse events) and costs (by reducing readmissions). However, the extent of this impact depends on effective implementation which is often restricted. This is partly due to the lack of attention paid to the RPMS design phaseprior to implementation. The content of the RPMS can be carefully designed at this stage and various obstacles anticipated. Our aim was to report on an RPMS design case to provide insights into the methodology required in order to manage this phase.Methods: This study was carried out at Gustave Roussy, a comprehensive cancer centre, in France. A multidisciplinary team coordinated the CAPRI RPMS design process (2013–2015) that later produced positive outcomes. Data were collected during eight studies conducted according to the Medical Research Council (MRC) framework. This project was approved by the French National Data Protection Authorities.Results: Based on the study results, the multidisciplinary team defined strategies for resolving obstacles prior to the implementation of CAPRI. Consequently, the final CAPRI design includes a web app with two interfaces (patient and health care professionals) and two NNs. The NNs provide regular follow-up via telephone or email to manage patients’ symptoms and toxicity, treatment compliance and care packages. Patients contact the NNs via a secure messaging system. Eighty clinical decision support tools enable NNs to prioritise and decide on the course ofaction to be taken.Conclusion: In our experience, the RPMS design process and, more generally, that of any complex intervention programme, is an important phase that requires a sound methodological basis. This study is also consistent with the notion that an RPMS is more than a technological innovation. This is indeed an organizational innovation, and principles identified during the design phase can help in the effective use of a RPMS (e.g. locating NNs if possible within the care organization; recruiting NNs with clinical and managerial skills; defining algorithms for clinical decision support tools for assessment, but also for patient decision and orientation)

: Résultats d'une enquête par questionnaire

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