Systems Approach to daily clinical care

AbstractSafety and quality of healthcare provision are affected by a number of factors. These factors include the clinical skills of the treating surgeon or other physician, but also the way practitioners think and behave as members of a healthcare team, and the clinical environment in which care is provided. We first discuss Bahal et al.’s paper as a demonstration of the Systems Approach to clinical performance and patient safety. We then highlight recent advances driven by the Systems Approach in understanding and measuring clinical decision-making, teamworking, and the clinical environment. We conclude that human factors research can provide an understanding of how to balance conflicting opinions and priorities in clinical care with the best interests of the patient, in a manner which allows each doctor to fulfil their duty of care

Implementation outcome assessment instruments used in physical healthcare settings and their measurement properties:a systematic review protocol

INTRODUCTION: Over the past 10 years, research into methods that promote the uptake, implementation and sustainability of evidence-based interventions has gathered pace. However, implementation outcomes are defined in different ways and assessed by different measures; the extent to which these measures are valid and reliable is unknown. The aim of this systematic review is to identify and appraise studies that assess the measurement properties of quantitative implementation outcome instruments used in physical healthcare settings, to advance the use of precise and accurate measures.  METHODS AND ANALYSIS: The following databases will be searched from inception to March 2017: MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Library. Grey literature will be sought via HMIC, OpenGrey, ProQuest for theses and Web of Science Conference Proceedings Citation Index-Science. Reference lists of included studies and relevant reviews will be hand searched. Three search strings will be combined to identify eligible studies: (1) implementation literature, (2) implementation outcomes and (3) measurement properties. Screening of titles, abstracts and full papers will be assessed for eligibility by two reviewers independently and any discrepancies resolved via consensus with the wider team. The methodological quality of the studies will be assessed using the COnsensus-based Standards for the selection of health Measurement INstruments checklist. A set of bespoke criteria to determine the quality of the instruments will be used, and the relationship between instrument usability and quality will be explored.  ETHICS AND DISSEMINATION: Ethical approval is not necessary for systematic review protocols. Researchers and healthcare professionals can use the findings of this systematic review to guide the selection of implementation outcomes instruments, based on their psychometric quality, to assess the impact of their implementation efforts. The findings will also provide a useful guide for reviewers of papers and grants to determine the psychometric quality of the measures used in implementation research.  TRIAL REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (PROSPERO): CRD42017065348

Individual differences in athletes' perception of expressive body movements

© 2016 Elsevier Ltd.Objectives: Understanding others' actions depends on the observer's individual characteristics and sensorimotor experience. Motor performance domains, such as sports and the performing arts, provide optimal situations to investigate the determinants of action perception. We investigated athletes' perceptual identification of expression intensity in body movements. Design: A within-subjects design was used. Method: Participants watched point-light displays (1000 ms long) depicting expressive and inexpressive dance movements. The task was to identify the dancer's intended expression intensity. Results: The results indicate that expressive body movements can be reliably identified, with judgement accuracy correlating with self-report empathy indices, intuitive/deliberate decision-making preferences, and indices of sports training. Only years of sports training could predict perceptual identification accuracy. Conclusions: We discuss the findings in relation to motor and cognitive-emotional contributions to action simulation. The potential of cross-domain transfer of motor expertise for boosting perceptual judgements and a hierarchical role of factors eliciting action simulation are also outlined

Opportunities for system level improvement in antibiotic use across the surgical pathway

Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement

Analysis of communication styles underpinning clinical decision-making in cancer multidisciplinary team meetings

INTRODUCTION: In cancer care, multidisciplinary team (MDT) meetings are the gold standard. While they are trying to maximize productivity on the back of the steadily increasing workload, growing cancer incidence, financial constraints, and staff shortages, concerns have been raised with regards to the quality of team output, as reported by Cancer Research UK in 2017: "Sometimes we discuss up to 70 patients. This is after a whole day of clinics, and we do not finish until after 19.00. Would you want to be number 70?". This study aimed to explore systematically some of the dynamics of group interaction and teamwork in MDT meetings. MATERIALS AND METHODS: This was a prospective observational study conducted across three MDTs/university hospitals in the United Kingdom. We video-recorded 30 weekly meetings where 822 patient cases were reviewed. A cross-section of the recordings was transcribed using the Jefferson notation system and analyzed using frequency counts (quantitative) and some principles of conversation analysis (qualitative). RESULTS: We found that, across teams, surgeons were the most frequent initiators and responders of interactional sequences, speaking on average 47% of the time during case discussions. Cancer nurse specialists and coordinators were the least frequent initiators, with the former speaking 4% of the time and the latter speaking 1% of the time. We also found that the meetings had high levels of interactivity, with an initiator-responder ratio of 1:1.63, meaning that for every sequence of interactions initiated, the initiator received more than a single response. Lastly, we found that verbal dysfluencies (laughter, interruptions, and incomplete sentences) were more common in the second half of meetings, where a 45% increase in their frequency was observed. DISCUSSION: Our findings highlight the importance of teamwork in planning MDT meetings, particularly with regard to Cancer Research UK in 2017 cognitive load/fatigue and decision-making, the hierarchy of clinical expertise, and the increased integration of patients' psychosocial information into MDT discussion and their perspectives. Utilizing a micro-level methodology, we highlight identifiable patterns of interaction among participants in MDT meetings and how these can be used to inform the optimization of teamwork

Aviation and healthcare: a comparative review with implications for patient safety

Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing

Development and implementation of a national quality improvement skills curriculum for urology residents in the United Kingdom: A prospective multi-method, multi-center study

Background: Surgical quality improvement (QI) is a global priority. We report the design and proof-of concept testing of a QI skills curriculum for urology residents. Methods: ‘Umbrella review’ of QI curricula (Phase-1); development of draft QI curriculum (Phase-2); curriculum review by Steering Committee of urologists (Attendings & Residents), QI and medical education experts and patients (Phase-3); proof-of-concept testing (Phase-4). Results: Phase-1: Six systematic reviews were identified of 4,332 search hits. Most curricula are developed/evaluated in the USA; use mixed teaching methods (incl. didactic, QI exercises & self-reflection); and introduce core QI techniques (e.g., Plan-Do-Study-Act). Phase-2: curriculum drafted. Phase-3: the curriculum was judged to represent state-of-the-art, relevant QI training. Stronger patient involvement element was incorporated. Phase-4: the curriculum was delivered to 43 urology residents. The delivery was feasible; the curriculum implementable; and a knowledge-skills-attitudes evaluation approach successful. Conclusion: We have developed a practical QI curriculum, for further evaluation and national implementation

Driving sustainable change in antimicrobial prescribing practice:how can social and behavioural sciences help?

Addressing the growing threat of antimicrobial resistance is, in part, reliant on the complex challenge of changing human behaviour—in terms of reducing inappropriate antibiotic use and preventing infection. Whilst there is no ‘one size fits all’ recommended behavioural solution for improving antimicrobial stewardship, the behavioural and social sciences offer a range of theories, frameworks, methods and evidence-based principles that can help inform the design of behaviour change interventions that are context-specific and thus more likely to be effective. However, the state-of-the-art in antimicrobial stewardship research and practice suggests that behavioural and social influences are often not given due consideration in the design and evaluation of interventions to improve antimicrobial prescribing. In this paper, we discuss four potential areas where the behavioural and social sciences can help drive more effective and sustained behaviour change in antimicrobial stewardship: (i) defining the problem in behavioural terms and understanding current behaviour in context; (ii) adopting a theory-driven, systematic approach to intervention design; (iii) investigating implementation and sustainability of interventions in practice; and (iv) maximizing learning through evidence synthesis and detailed intervention reporting

Implementation science: a reappraisal of our journal mission and scope.

The implementation of research findings into healthcare practice has become increasingly recognised as a major priority for researchers, service providers, research funders and policymakers over the past decade. Nine years after its establishment, Implementation Science, an international online open access journal, currently publishes over 150 articles each year. This is fewer than 30% of those submitted for publication. The majority of manuscript rejections occur at the point of initial editorial screening, frequently because we judge them to fall outside of journal scope. There are a number of common reasons as to why manuscripts are rejected on grounds of scope. Furthermore, as the field of implementation research has evolved and our journal submissions have risen, we have, out of necessity, had to become more selective in what we publish. We have also expanded our scope, particularly around patient-mediated and population health interventions, and will monitor the impact of such changes. We hope this editorial on our evolving priorities and common reasons for rejection without peer review will help authors to better judge the relevance of their papers to Implementation Science