Analysing 'big picture' policy reform mechanisms: The Australian health service safety and quality accreditation scheme

© 2015 John Wiley & Sons Ltd. Background: Agencies promoting national health-care accreditation reform to improve the quality of care and safety of patients are largely working without specific blueprints that can increase the likelihood of success. Objective: This study investigated the development and implementation of the Australian Health Service Safety and Quality Accreditation Scheme and National Safety and Quality Health Service Standards (the Scheme), their expected benefits, and challenges and facilitators to implementation. Methods: A multimethod study was conducted using document analysis, observation and interviews. Data sources were eight government reports, 25 h of observation and 34 interviews with 197 diverse stakeholders. Results: Development of the Scheme was achieved through extensive consultation conducted over a prolonged period, that is, from 2000 onwards. Participants, prior to implementation, believed the Scheme would produce benefits at multiple levels of the health system. The Scheme offered a national framework to promote patient-centred care, allowing organizations to engage and coordinate professionals' quality improvement activities. Significant challenges are apparent, including developing and maintaining stakeholder understanding of the Scheme's requirements. Risks must also be addressed. The standardized application of, and reliable assessment against, the standards must be achieved to maintain credibility with the Scheme. Government employment of effective stakeholder engagement strategies, such as structured consultation processes, was viewed as necessary for successful, sustainable implementation. Conclusion: The Australian experience demonstrates that national accreditation reform can engender widespread stakeholder support, but implementation challenges must be overcome. In particular, the fundamental role of continued stakeholder engagement increases the likelihood that such reforms are taken up and spread across health systems

Development and content validation of the Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey

Aim: To develop a validated tool to measure nursing and midwifery documentation burden. Background: While an important record of care, documentation can be burdensome for nurses and midwives and may remove them from direct patient care, resulting in decreased job satisfaction, associated with decreased patient satisfaction. The amount of documentation is increasing at a time where staff rationalisation results in decreasing numbers of clinicians at the bedside. No instrument is available to measure staff perceptions of the burden of clinical documentation. Design: Survey development, followed by rwo rounds of content validation (April and May 2019). Methods: Based on the literature a 28 item survey, with items in 6 subscales, representing key areas of documentation burden was developed. Item (I-CVI), subscale (S-CVI/Ave by subscale) and overall content validity indexes (S-CVI/Ave) were calculated following two review rounds by an expert panel of clinical and academic nurses and midwives. Results: Level of agreement for the first iteration of the survey was low, with many items failing to reach the critical I-CVI threshold of 0.78. No subscale reached a S-CVI/Ave above 0.8 and the overall scale only achieved a S-CVI/Ave score of 0.67. Thirteen items were removed, seven were edited and five new items added, based on the expert panel feedback, substantially improving the content validity. All individual items achieved an I-CVI ≥0.78, the S-CVI/Ave was above 0.85 for all subscales and the total S-CVI/Ave was 0.94. Conclusion: The Burden of Documentation for Nurses and Midwives (BurDoNsaM) survey can be considered as content valid, according to the content validity analysis by an expert panel. Impact: The BurDoNsaM survey may be used by nurse leaders and researchers to measure the burden of documentation, providing the opportunity to review practice and implement strategies to decrease documentation burden, potentially improving patient satisfaction with the care received

Piloting staff education in Australia to reduce falls in older hospital patients experiencing delirium

This study piloted a hospital-based delirium and falls education program to investigate the impacts on staff knowledge and practice plus patient falls. On a medical ward, staff knowledge was compared before and after education sessions. Other data – collected a day before and after program implementation – addressed documentation of patients' delirium and evidence of compliance with falls risk minimization protocols. These data, and numbers of patient falls, were compared before and after program implementation. Almost all ward staff members participated in education sessions (7 doctors, 7 allied health practitioners, and 45 nurses) and knowledge was significantly improved in the 22 who completed surveys both before and after session attendance. Patients assessed as having delirium (5 before implementation, 4 afterwards) were all documented as either confused or delirious. Small changes eventuated in adherence with falls risk management protocols for confused patients and the number of falls decreased. The program merits a stronger emphasis on staff activities relating to the detection, documentation, and management of delirium to inter-professional roles and communication. Evidence of practice enhancement from program implementation should precede rigorous testing of impacts upon falls

Documentation of in-hospital falls on incident reports: Qualitative investigation of an imperfect process

<p>Abstract</p> <p>Background</p> <p>Incident reporting is the prevailing approach to gathering data on accidental falls in hospitals for both research and quality assurance purposes, though is of questionable quality as staff time pressures, perception of blame and other factors are thought to contribute to under-reporting.</p> <p>Methods</p> <p>This research aimed to identify contextual factors influencing recording of in-hospital falls on incident reports. A qualitative multi-centre investigation using an open written response questionnaire was undertaken. Participants were asked to describe any factors that made them feel more or less likely to record a fall on an incident report. 212 hospital staff from 30 wards in 7 hospitals in Queensland, Australia provided a response. A framework approach was employed to identify and understand inter-relationships between emergent categories.</p> <p>Results</p> <p>Three main categories were developed. The first, determinants of reporting, describes a hierarchical structure of primary (principle of reporting), secondary (patient injury), and tertiary determinants that influenced the likelihood that an in-hospital fall would be recorded on an incident report. The tertiary determinants frequently had an inconsistent effect. The second and third main categories described environmental/cultural facilitators and barriers respectively which form a background upon which the determinants of reporting exists.</p> <p>Conclusion</p> <p>A distinctive framework with clear differences to recording of other types of adverse events on incident reports was apparent. Providing information to hospital staff regarding the purpose of incident reporting and the usefulness of incident reporting for preventing future falls may improve incident reporting practices.</p

Reducing Medical Admissions into Hospital through Optimising Medicines (REMAIN HOME) Study: Protocol for a stepped wedge, cluster randomised trial

Introduction: A model of general practitioner (GP) and pharmacist collaboration in primary care may be an effective strategy to reduce medication-related problems and provide better support to patients after discharge. The aim of this study is to investigate whether a model of structured pharmacist and GP care reduces hospital readmissions in patients at risk of readmission. Methods and analysis: This protocol details a stepped wedge cluster randomised trial that will recruit participants over nine months with a 12 month follow up. There will be 14 clusters each representing a different general practice medical centre. A total of 2240 participants will be recruited from hospital who attend an enrolled medical centre, take five or more long-term medicines or whose reason for admission was related to heart failure or chronic obstructive pulmonary disease. The intervention is a multi-faceted service, involving a pharmacist integrated into a medical centre to assist patients after hospitalisation. Participants will meet with the practice pharmacist and their GP after discharge to review and reconcile their medicines and discuss changes made in hospital. The pharmacist will follow up with the participant and liaise with other health professionals involved in the participant’s care. The control will be usual care, which usually involves a patient self-organising a visit to their GP after hospital discharge. The primary outcome is the rate of unplanned, all-cause hospital readmissions over 12 months which will be analysed using a mixed effects Poisson regression model with a random effect for cluster and a fixed effect to account for any temporal trend. A cost analysis will be undertaken to compare the healthcare costs associated with the intervention to those of usual care

Structures, processes and outcomes of specialist critical care nurse education: An integrative review

Objectives: The objective of this study was to review and synthesise international literature to reveal the contemporary structures, processes, and outcomes of critical care nurse (CCN) education. Method: An integrative review on specialist critical care education was guided by Whittemore and Knafl's integrative review steps: problem identification; literature search; and data evaluation, analysis, and presentation. Donabedian's Quality Framework (Structure-Process-Outcome) provided a useful analytical lens and structure for the reporting of findings. Results: (1) Structures for CCN education incorporated transition-to-practice and ongoing education programs typically offered by hospitals and health services and university-level graduate certificate, diploma, and masters programs. Structural expectations included a standard core curriculum, clinically credible academic staff, and courses compliant with a higher education framework. Published workforce standards and policies were important structures for the practice learning environment. (2) Processes included incremental exposure to increasing patient acuity; consistent and appropriately supported and competent hospital-based preceptors/assessors; courses delivered with a flexible, modular approach; curricula that support nontechnical skills and patient- and family-centred care; stakeholder engagement between the education provider and the clinical setting to guide course planning, evaluation and revalidation; and evidence-based measurement of clinical capabilities/competence. (3) Outcomes included articulation of the scope and levels of graduate attributes and professional activities associated with each level. The role of higher degree research programs for knowledge creation and critical care academic leadership was noted. Conclusions: Provision of high-quality critical care education is multifaceted and complex. These findings provide information for healthcare organisations and education providers. This may enable best practice structures and processes for critical care specialist training that meets the needs of industry and safely supports developing CCN expertise. There is an acknowledged tension between the expectations of governing bodies for policies, standards, and position statements to enhance quality and reduce care variance and the availability of high-quality evidence to underpin these across international contexts

Strategies to reduce medication errors with reference to older adults

Background  In Australia, around 59% of the general population uses prescription medication with this number increasing to about 86% in those aged 65 and over and 83% of the population over 85 using two or more medications simultaneously. A recent report suggests that between 2% and 3% of all hospital admissions in Australia may be medication related with older Australians at higher risk because of higher levels of medicine intake and increased likelihood of being admitted to hospital. The most common medication errors encountered in hospitals in Australia are prescription/medication ordering errors, dispensing, administration and medication recording errors. Contributing factors to these errors have largely not been reported in the hospital environment. In the community, inappropriate drugs, prescribing errors, administration errors, and inappropriate dose errors are most common. Objectives  To present the best available evidence for strategies to prevent or reduce the incidence of medication errors associated with the prescribing, dispensing and administration of medicines in the older persons in the acute, subacute and residential care settings, with specific attention to persons aged 65 years and over. Search strategy  Bibliographic databases PubMed, Embase, Current contents, The Cochrane Library and others were searched from 1986 to present along with existing health technology websites. The reference lists of included studies and reviews were searched for any additional literature. Selection criteria  Systematic reviews, randomised controlled trials and other research methods such as non-randomised controlled trials, longitudinal studies, cohort or case-control studies, or descriptive studies that evaluate strategies to identify and manage medication incidents. Those people who are involved in the prescribing, dispensing or administering of medication to the older persons (aged 65 years and older) in the acute, subacute or residential care settings were included. Where these studies were limited, evidence available on the general patient population was used. Data collection and analysis  Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary. Results  Strategies that have some evidence for reducing medication incidents are: •  computerised physician ordering entry systems combined with clinical decision support systems; •  individual medication supply systems when compared with other dispensing systems such as ward stock approaches; •  use of clinical pharmacists in the inpatient setting; •  checking of medication orders by two nurses before dispensing medication; •  a Medication Administration Review and Safety committee; and •  providing bedside glucose monitors and educating nurses on importance of timely insulin administration. In general, the evidence for the effectiveness of intervention strategies to reduce the incidence of medication errors is weak and high-quality controlled trials are needed in all areas of medication prescription and delivery