What Might Be Required for Inspections to Be Considered Fair? Comment on “What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya’s Health Facility Inspection Reforms”

Tama et al offer us an interesting analysis of a piloted regulatory reform that introduced a Joint Health Inspections (JHIs) system in three Kenyan counties. The study highlights key factors facilitating or hindering the implementation of the reform. In this commentary we reflect on the concept of fairness, which is one of the topics that is discussed in the study. We describe four important dimensions of fairness in the context of inspections: expectation clarity, consistency of assessment, consistency of enforcement, and fairness to patients. We argue that all four dimensions are important in the regulatory design, in order for the inspection to be perceived as fair.publishedVersio

Learning team-based quality improvement in a virtual setting: a qualitative study

Objective The objective was to explore students’ perceptions of learning quality improvement (QI) in a virtual setting and identify factors that promote or inhibit virtual learning. Design We used an exploratory case study design with focus group interviews. The data were analysed using a thematic analysis approach, with an analytical framework derived from activity theory and Bloom’s revised taxonomy of six categories of cognitive processes of learning. Setting Postgraduate students participating in a virtual 1-day simulation module to learn QI at two universities in Norway. Participants Four focus groups with a total of 12 participants. Results The students’ descriptions of learning outcomes indicate that the learning activity involved a variety of cognitive activities, including higher-order cognitive processes. We identified three themes pertaining to the students’ experiences of the virtual learning activity: learning through active participation, constructing a virtual learning opportunity and creating a virtual learning environment. The students described that participation and active engagement led to a greater understanding and an integration of theory and practical improvement skills. They reported that to engage in the virtual learning opportunity, it was necessary to create a learning environment where they felt psychologically safe. Conclusion Our findings indicate that it is possible to facilitate collaborative learning integrating theoretical knowledge and practical skills in a virtual setting. Students experienced that engaging in the virtual learning activity contributed to the integration of theoretical knowledge and practical skills. Psychological safety seems to be important for students’ engagement in the virtual learning activity. A virtual learning environment alters prior common norms for interaction based on physical presence, which in turn affect students feeling of psychological safety. Educators need to be aware of this and facilitate a virtual learning environment where students feel comfortable to engage.publishedVersio

Contextual factors of external inspections and mechanisms for improvement in healthcare organizations: a realist evaluation

External inspections constitute a key element of healthcare regulation. Improved quality of care is one of the important goals of inspections but the mechanisms of how inspections might contribute to quality improvement are poorly understood. Drawing on interviews with healthcare professionals and managers and health record data from inspected organizations, we used a realist evaluation approach to explore how twelve inspections of healthcare providers in x= Norway influenced quality improvement. We found that for inspections to contribute to quality improvement, there must be contextual structures present supporting accountability and engaging staff in improvement work. When such structures are present, inspections can contribute to improvement by creating awareness of gaps between desired and current practices, which leads to readiness for change and stimulates intra-organizational reasoning around quality improvement. We discuss our findings using the theory of de- and recoupling, noting how regulators can identify decoupling between intended goals, management systems, practices, and patient outcomes. We further argue that regulators can contribute to a recoupling between these levels by having the capacity to track the providers' clinical performance over time. This will hold the organization accountable for implementing improvement measures and evaluate the effects of the measures on quality of care.publishedVersio

External inspections of healthcare organizations : A study of organizational and clinical effects of inspections on the management of sepsis in Norwegian hospitals

External inspections of healthcare organizations serve different purposes, one of which is to bring about quality improvements in the care offered to patients. Research has offered many different perspectives on how well inspections and other external assessment approaches fare in this endeavor. There is, however, no general agreement about the effects of inspections or the mechanisms by which inspections influence quality improvement work. This thesis is part of a research project, headed by the Norwegian Board of Health Supervision, into the effects of inspections. The thesis examines the effects of inspections of care for patients with sepsis in the emergency departments of 24 hospitals in Norway during the period 2016 to 2018. The research aim has been to find out if inspections of healthcare organizations can lead to improved work processes and health outcomes for patients, and to explore the mechanisms that link external inspections and internal improvement efforts. The results have been reported in three published studies. The two first studies relied on data from electronic health records and the Norwegian Patient Registry. Study 1 is an observational study of the care processes and patient outcomes for patients with sepsis presenting to emergency departments. We included data from 1559 patients presenting to hospital emergency departments with sepsis. Assessing the timeliness of diagnostic procedures for recognizing sepsis, we found that 72.9% (95% confidence interval [CI]: 70.7-75.1) had documented triage within 15 minutes of presentation to the emergency departments, 44.9% (95% CI: 42.4 47.4) were examined by a physician in accordance with the triage priority, 44.4% (95% CI: 41.4-46.9) were adequately observed through continual monitoring of signs while in the emergency department, and 25.4% (95% CI: 23.2-27.7) received antibiotics within 1 hour. Next, we estimated associations between diagnostic procedures and time to antibiotic treatment, and between time to antibiotic treatment and mortality. We found that delay or non-completion of key diagnostic procedures predicted a delay of more than 2.5 hours to antibiotic treatment. Patients who received antibiotics within 1 hour had an observed 30-day all-cause mortality of 13.6% (95% CI: 10.1-17.1), in the timespan 2 to 3 hours after admission 5.9% (95% CI: 2.8 9.1), and 4 hours or later after admission 10.5% (5.7-15.3). Study 2 is a stepped wedge study of the effects of the inspection on care processes and patient outcomes. The study included 7407 patients presenting to hospital emergency departments with sepsis. We first studied the effects of the inspection on process measures for sepsis diagnostics and treatment. We found significant improvements in the proportions of patients examined by a physician within the time frame set in triage (odds ratio [OR] = 1.28, 95% CI: 1.07-1.53), undergoing a complete set of vital measurements within 1 hour (OR = 1.78, 95% CI: 1.10 2.87), having lactate measured within 1 hour (OR = 2.75, 95% CI: 1.83 4.15), having an adequate observation regimen (OR = 2.20, 95% CI: 1.51-3.20), and receiving antibiotics within 1 hour (OR = 2.16, 95% CI: 1.83-2.55). We then studied the effects of the inspection on length of hospital stay and 30-day all-cause mortality. We found a significant reduction in mortality and length of stay, but these findings were no longer significant when adjusting the analyses for year of admission. Study 3 used focus group interviews with inspection teams, hospital management, and hospital staff to explore how the inspections affected quality improvement work in inspected hospitals. The data of this study were twelve focus groups interviews, with a total of 47 participants. We identified three themes that were central for understanding how the inspection could contribute to clinical improvement in the emergency departments: 1) increasing awareness about the need to improve the quality of care by providing data on clinical performance, 2) building acceptance for improvement through professional credibility and focus on clinical practice, and 3) fostering leader¬ship commitment. In conclusion, the three studies suggest that the inspections brought to light deficiencies in the emergency departments’ work with recognizing sepsis and treating patients presenting with sepsis. After the inspections, the process measures of diagnosis and treatment had improved, and our analyses showed that these changes were associated with the inspections. This indicates that the inspection had a positive effect on the emergency departments’ efforts to improve the management of patients with sepsis. The focus group interviews offer some insight into how the inspection may have contributed to improving care: The inspection could help hospitals to identify and understand weaknesses in the clinical care processes and bolster the organizational commitment to systemic quality improvement. This shows the potential for the inspection to become an instrument of improvement. It is, however, also important to recognize that such change processes are context-dependent, and that regulatory agencies should reflect on how to design inspections in a way that contributes to the goal of improved care for patients

What Might Be Required for Inspections to Be Considered Fair? Comment on “What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya’s Health Facility Inspection Reforms”

Tama et al offer us an interesting analysis of a piloted regulatory reform that introduced a Joint Health Inspections (JHIs) system in three Kenyan counties. The study highlights key factors facilitating or hindering the implementation of the reform. In this commentary we reflect on the concept of fairness, which is one of the topics that is discussed in the study. We describe four important dimensions of fairness in the context of inspections: expectation clarity, consistency of assessment, consistency of enforcement, and fairness to patients. We argue that all four dimensions are important in the regulatory design, in order for the inspection to be perceived as fair

What Might Be Required for Inspections to Be Considered Fair?

Tama et al offer us an interesting analysis of a piloted regulatory reform that introduced a Joint Health Inspections (JHIs) system in three Kenyan counties. The study highlights key factors facilitating or hindering the implementation of the reform. In this commentary we reflect on the concept of fairness, which is one of the topics that is discussed in the study. We describe four important dimensions of fairness in the context of inspections: expectation clarity, consistency of assessment, consistency of enforcement, and fairness to patients. We argue that all four dimensions are important in the regulatory design, in order for the inspection to be perceived as fair

Learning team-based quality improvement in a virtual setting: a qualitative study

Objective The objective was to explore students’ perceptions of learning quality improvement (QI) in a virtual setting and identify factors that promote or inhibit virtual learning. Design We used an exploratory case study design with focus group interviews. The data were analysed using a thematic analysis approach, with an analytical framework derived from activity theory and Bloom’s revised taxonomy of six categories of cognitive processes of learning. Setting Postgraduate students participating in a virtual 1-day simulation module to learn QI at two universities in Norway. Participants Four focus groups with a total of 12 participants. Results The students’ descriptions of learning outcomes indicate that the learning activity involved a variety of cognitive activities, including higher-order cognitive processes. We identified three themes pertaining to the students’ experiences of the virtual learning activity: learning through active participation, constructing a virtual learning opportunity and creating a virtual learning environment. The students described that participation and active engagement led to a greater understanding and an integration of theory and practical improvement skills. They reported that to engage in the virtual learning opportunity, it was necessary to create a learning environment where they felt psychologically safe. Conclusion Our findings indicate that it is possible to facilitate collaborative learning integrating theoretical knowledge and practical skills in a virtual setting. Students experienced that engaging in the virtual learning activity contributed to the integration of theoretical knowledge and practical skills. Psychological safety seems to be important for students’ engagement in the virtual learning activity. A virtual learning environment alters prior common norms for interaction based on physical presence, which in turn affect students feeling of psychological safety. Educators need to be aware of this and facilitate a virtual learning environment where students feel comfortable to engage

Promoting leadership and quality improvement through external inspections of management of sepsis in Norwegian hospitals: a focus group study

Objective Inspections and other forms of external assessment may contribute to positive changes in the health services, but the mechanisms of such change remain unclear. We did a study to explore how external inspections may foster clinical improvement in hospitals. Design Focus group study. Setting Statutory inspections of sepsis treatment in hospital emergency departments in Norway. Participants Clinicians, managers and inspection teams involved with the inspections of sepsis treatment in emergency departments at four different hospitals. Twelve focus group interviews were carried out, with a total of 47 participants. Results Three themes emerged as central for understanding how the inspections could contribute to clinical improvement in the emergency departments: (1) increasing awareness about the need to improve the quality of care by providing data on clinical performance, (2) building acceptance for improvement through professional credibility and focus on clinical practice, and (3) fostering leadership commitment. Conclusion Our findings suggest that the inspections have the potential to enhance hospital management and staff’s understanding of complicated care processes and help strengthen the organisational commitment to bring about systemic quality improvements

Promoting leadership and quality improvement through external inspections of management of sepsis in Norwegian hospitals: a focus group study

Objective Inspections and other forms of external assessment may contribute to positive changes in the health services, but the mechanisms of such change remain unclear. We did a study to explore how external inspections may foster clinical improvement in hospitals. Design Focus group study. Setting Statutory inspections of sepsis treatment in hospital emergency departments in Norway. Participants Clinicians, managers and inspection teams involved with the inspections of sepsis treatment in emergency departments at four different hospitals. Twelve focus group interviews were carried out, with a total of 47 participants. Results Three themes emerged as central for understanding how the inspections could contribute to clinical improvement in the emergency departments: (1) increasing awareness about the need to improve the quality of care by providing data on clinical performance, (2) building acceptance for improvement through professional credibility and focus on clinical practice, and (3) fostering leadership commitment. Conclusion Our findings suggest that the inspections have the potential to enhance hospital management and staff’s understanding of complicated care processes and help strengthen the organisational commitment to bring about systemic quality improvements

Learning team-based quality improvement in a virtual setting: A qualitative study

Objective: The objective was to explore students’ perceptions of learning quality improvement (QI) in a virtual setting and identify factors that promote or inhibit virtual learning. Design: We used an exploratory case study design with focus group interviews. The data were analysed using a thematic analysis approach, with an analytical framework derived from activity theory and Bloom’s revised taxonomy of six categories of cognitive processes of learning. Setting: Postgraduate students participating in a virtual 1-day simulation module to learn QI at two universities in Norway. Participants: Four focus groups with a total of 12 participants. Results: The students’ descriptions of learning outcomes indicate that the learning activity involved a variety of cognitive activities, including higher-order cognitive processes. We identified three themes pertaining to the students’ experiences of the virtual learning activity: learning through active participation, constructing a virtual learning opportunity and creating a virtual learning environment. The students described that participation and active engagement led to a greater understanding and an integration of theory and practical improvement skills. They reported that to engage in the virtual learning opportunity, it was necessary to create a learning environment where they felt psychologically safe. Conclusion: Our findings indicate that it is possible to facilitate collaborative learning integrating theoretical knowledge and practical skills in a virtual setting. Students experienced that engaging in the virtual learning activity contributed to the integration of theoretical knowledge and practical skills. Psychological safety seems to be important for students’ engagement in the virtual learning activity. A virtual learning environment alters prior common norms for interaction based on physical presence, which in turn affect students feeling of psychological safety. Educators need to be aware of this and facilitate a virtual learning environment where students feel comfortable to engage