Improving patient understanding on discharge from the short stay unit:an integrated human factors and quality improvement approach

This intervention used a systems approach to improve patient understanding on discharge from the adult acute medicine short stay unit (SSU). Patient understanding was assessed across five domains: diagnosis, medication changes, follow-up care, return instructions and knowing who their consultant was. The aim of this approach was that at least 90% of patients achieved near-complete understanding (score >4) on questionnaire across all five discharge domains by the end of April 2021. Pre-intervention most patients received verbal instructions and only a minority received written information. Through staff interviews, we identified the electronic discharge document (EDD) as a practical source of written information. However, testing with patients showed that the format required substantial redesign to be written in patient-friendly language, using signposting, spacing information out and avoiding jargon. The effect of this intervention was assessed with a structured telephone questionnaire, which included both a patient self-rated score and a comparative understanding score to assess true patient understanding of the revised EDD. Pre-intervention 29 discharged patients were interviewed across 10 days and post-intervention 10 patients were interviewed in 7 days. Patients consistently over-rated their understanding of discharge information. Only one patient achieved the aim of comparative understanding >4 across all domains post-intervention. Understanding improved across all but one of the domains, the exception being medication changes. An important unanticipated consequence was that interviews identified inconsistencies in EDD information and gaps in patient understanding, which required escalation to the SSU team. In summary, this intervention improved patient understanding across four of the five domains. However, further work is required on process reliability for the redesigned EDD and on improving understanding of medication changes. Furthermore, the interviews revealed clinically important inconsistencies in EDD information and gaps in patient understanding

Systematic reviews of and integrated report on the quantitative, qualitative and economic evidence base for the management of obesity in men

<b>Background</b><p></p> Obesity increases the risk of many serious illnesses such as coronary heart disease, type 2 diabetes and osteoarthritis. More men than women are overweight or obese in the UK but men are less likely to perceive their weight as a problem and less likely to engage with weight-loss services.<p></p> <b>Objective</b><p></p> The aim of this study was to systematically review evidence-based management strategies for treating obesity in men and investigate how to engage men in obesity services by integrating the quantitative, qualitative and health economic evidence base.<p></p> <b>Data sources</b><p></p> Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database were searched from inception to January 2012, with a limited update search in July 2012. Subject-specific websites, reference lists and professional health-care and commercial organisations were also consulted.<p></p> <b>Review methods</b><p></p> Six systematic reviews were conducted to consider the clinical effectiveness, cost-effectiveness and qualitative evidence on interventions for treating obesity in men, and men in contrast to women, and the effectiveness of interventions to engage men in their weight reduction. Randomised controlled trials (RCTs) with follow-up data of at least 1 year, or any study design and length of follow-up for UK studies, were included. Qualitative and mixed-method studies linked to RCTs and non-randomised intervention studies, and UK-based, men-only qualitative studies not linked to interventions were included. One reviewer extracted data from the included studies and a second reviewer checked data for omissions or inaccuracies. Two reviewers carried out quality assessment. We undertook meta-analysis of quantitative data and a realist approach to integrating the qualitative and quantitative evidence synthesis.<p></p> <b>Results</b><p></p> From a total of 12,764 titles reviewed, 33 RCTs with 12 linked reports, 24 non-randomised reports, five economic evaluations with two linked reports, and 22 qualitative studies were included. Men were more likely than women to benefit if physical activity was part of a weight-loss programme. Reducing diets tended to produce more favourable weight loss than physical activity alone (mean weight change after 1 year from a reducing diet compared with an exercise programme -3.2 kg, 95% CI -4.8 kg to -1.6 kg). The type of reducing diet did not affect long-term weight loss. A reducing diet plus physical activity and behaviour change gave the most effective results. Low-fat reducing diets, some with meal replacements, combined with physical activity and behaviour change training gave the most effective long-term weight change in men [-5.2 kg (standard error 0.2 kg) after 4 years]. Such trials may prevent type 2 diabetes in men and improve erectile dysfunction. Although fewer men joined weight-loss programmes, once recruited they were less likely to drop out than women (difference 11%, 95% CI 8% to 14%). The perception of having a health problem (e.g. being defined as obese by a health professional), the impact of weight loss on health problems and desire to improve personal appearance without looking too thin were motivators for weight loss amongst men. The key components differ from those found for women, with men preferring more factual information on how to lose weight and more emphasis on physical activity programmes. Interventions delivered in social settings were preferred to those delivered in health-care settings. Group-based programmes showed benefits by facilitating support for men with similar health problems, and some individual tailoring of advice assisted weight loss in some studies. Generally, men preferred interventions that were individualised, fact-based and flexible, which used business-like language and which included simple to understand information. Preferences for men-only versus mixed-sex weight-loss group programmes were divided. In terms of context, programmes which were cited in a sporting context where participants have a strong sense of affiliation showed low drop out rates and high satisfaction. Although some men preferred weight-loss programmes delivered in an NHS context, the evidence comparing NHS and commercial programmes for men was unclear. The effect of family and friends on participants in weight-loss programmes was inconsistent in the evidence reviewed - benefits were shown in some cases, but the social role of food in maintaining relationships may also act as a barrier to weight loss. Evidence on the economics of managing obesity in men was limited and heterogeneous.<p></p> <b>Limitations</b><p></p> The main limitations were the limited quantity and quality of the evidence base and narrow outcome reporting, particularly for men from disadvantaged and minority groups. Few of the studies were undertaken in the UK.<p></p> <b>Conclusions</b><p></p> Weight reduction for men is best achieved and maintained with the combination of a reducing diet, physical activity advice or a physical activity programme, and behaviour change techniques. Tailoring interventions and settings for men may enhance effectiveness, though further research is needed to better understand the influence of context and content. Future studies should include cost-effectiveness analyses in the UK setting

A qualitative study of organisational resilience in care homes in Scotland.

Providing care for the dependent older person is complex and there have been persistent concerns about care quality as well as a growing recognition of the need for systems approaches to improvement. The I-SCOPE (Improving Systems of Care for the Older person) project employed Resilient Healthcare (RHC) theory and the CARE (Concepts for Applying Resilience) Model to study how care organisations adapt to complexity in everyday work, with the aim of exploring how to support resilient performance. The project was an in-depth qualitative study across multiple sites over 24 months. There were: 68 hours of non-participant observation, shadowing care staff at work and starting broad before narrowing to observe care domains of interest; n = 33 recorded one-to-one interviews (32 care staff and one senior inspector); three focus groups (n = 19; two with inspectors and one multi-disciplinary group); and five round table discussions on emergent results at a final project workshop (n = 31). All interviews and discussion groups were recorded and transcribed verbatim. Resident and family interviews (n = 8) were facilitated through use of emotional touchpoints. Analysis using QSR NVivo 12.0 focused on a) capturing everyday work in terms of the interplay between demand and capacity, adaptations and intended and unintended outcomes and b) a higher-level thematic description (care planning and use of information; coordination of everyday care activity; providing person-centred care) which gives an overview of resilient performance and how it might be enhanced. This gives important new insight for improvement. Conclusions are that resilience can be supported through more efficient use of information, supporting flexible adaptation, coordination across care domains, design of the physical environment, and family involvement based on realistic conversations about quality of life

Consolidated criteria for reporting qualitative studies (COREQ) checklist.

(DOC)</p

Examples of ‘work-as-done’ in care homes, viewed through the CARE resilience model.

Examples of ‘work-as-done’ in care homes, viewed through the CARE resilience model.</p

Themes in everyday work, with description of key resilience activities.

Themes in everyday work, with description of key resilience activities.</p