Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards

Objectives To understand how frontline reports of day-to-day care failings might be better translated into improvement. Design Qualitative evaluation of an interdisciplinary team intervention to capitalise on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS. Results PCTS fostered psychological safety – a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and the relative comfort afforded by the avoidance of accountability. At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described. Conclusions Prospective safety strategies relying on staff-volunteered data do approximate the realities of frontline care, but still produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, they give managers access to these accounts, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations

Quality of care in adult patients with inflammatory bowel disease transferring between healthcare providers: multicentre audit

Background: Inflammatory bowel disease (IBD) predominantly affects young adults at critical socioeconomic periods of their lives. There are no studies examining the process of transfer of care for adult patients with IBD changing healthcare providers. Our aims were to assess the quality of referral information provided when patients with an established IBD diagnosis transfer care between heathcare providers and to assess the impact of referral quality on patient outcome. / Methods: Retrospective data pertaining to IBD transfer of care referrals were collected from 16 hospitals across London over a 2-month period. Data were collected on patient demographics, source and content of referral and cross-referenced with an established transfer of care checklist. Patient outcome within the 6 months following transfer was also documented. / Results: 154 cases were identified, over half of which transferred due to patient relocation. Details included in transfer letters were in many cases incomplete. In over 70% of cases, the letter came from primary care, including when a tertiary opinion was sought. Although referrals from primary care contained fewer patient data points, there was no association with poor patient outcomes at 6 months. / Conclusion: This is the first study examining the quality of transfer of care in adult patients with IBD. We highlighted a significant and underreported issue and found that the majority of referrals were led by primary care. Though the inclusion in the referral of fewer data points was not associated with poor outcomes, we highlighted an area where gastroenterologists might take more responsibility to provide smooth and robust transfer of care

Challenging sex segregation: A philosophical evaluation of the football association’s rules on mixed football

The Football Association (FA) has been under pressure to allow girls to play in mixed teams since 1978, following 12-year old Theresa Bennett’s application to play with boys in a local league. In 1991, over a decade after Bennett’s legal challenge, the FA agreed to remove its ban on mixed football and introduced Rule C4 in order to permit males and females to play together in competitive matches under the age of 11. More recently, following a campaign by parents, coaches, local Members of Parliament and the Women’s Sport Foundation, the FA agreed to trial mixed football for the under-12 to under-15 age categories in order to establish, among other things, the risk of injury to players in sex-integrated competitions. A series of exponential changes ensued: between 2010 and 2014, the age at which mixed football was permitted increased from U11 to U16. In 2015, the FA announced the decision to raise the age limit on mixed football from U16 to U18 for the forthcoming 2015–2016 season. We critically examine the reasons given by the FA for enforcing segregated participation beyond the age of 18, namely that males have an unfair advantage and that females face an unacceptable risk of injury. We also discuss the argument that removing the ban might harm the women’s game. In conclusion, we suggest that the FA ought to abandon the ban on mixed football over the age of 18

Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities

Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers – particularly middle managers – also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of frontline staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions

Rethinking medical ward quality

Medical wards deliver the majority of acute inpatient care in health systems worldwide. This care is expensive, costing the NHS around £5bn (€5.5bn; $6.2bn) a year, a quarter of its inpatient expenditure. Improving the performance of medical wards is an international priority, not only because of the scale of care that they deliver. Their core workload—treating complex, increasingly frail patients in a time pressurised setting—represents the broader challenges facing healthcare. Yet major gaps remain in our understanding of how wards perform

What matters to medical ward patients, and do we measure it? A qualitative comparison of patient priorities and current practice in quality measurement, on UK NHS medical wards

Objectives To compare the quality metrics selected for public display on medical wards to patients’ and carers’ expressed quality priorities. Methods Multimodal qualitative evaluation of general medical wards and semi-structured interviews. Setting UK tertiary National Health Service (public) hospital. Participants Fourteen patients and carers on acute medical wards and geriatric wards. Results Quality metrics on public display evaluated hand hygiene, hospital-acquired infections, nurse staffing, pressure ulcers, falls and patient feedback. The intended audience for these metrics was unclear, and the displays gave no indication as to whether performance was improving or worsening. Interviews identified three perceived key components of high-quality ward care: communication, staff attitudes and hygiene. These aligned poorly with the priorities on display. Suboptimal performance reporting had the potential to reduce patients’ trust in their medical teams. More philosophically, patients’ and carers’ ongoing experiences of care would override any other evaluation, and they felt little need for measures relating to previous performance. The display of performance reports only served to emphasise patients’ and carers’ lack of control in this inpatient setting. Conclusions There is a gap between general medical inpatients’ care priorities and the aspects of care that are publicly reported. Patients and carers do not act as ‘informed choosers’ of healthcare in the inpatient setting, and tokenistic quality measurement may have unintended consequences