Highlights • The interrelationship between the concepts patient empowerment, patient participation and patient-centeredness is clarified. • Patient empowerment is a meta-paradigm. • Patient ...participation is a strategy to achieve patient-centered care. • A patient-centered approach leads to patient empowerment. • The application of the concepts might lead to a better quality of care and a better quality of life.
Background:Excessive interhospital variation threatens healthcare quality. Data on variation in patient outcomes across the whole cardiovascular spectrum are lacking. We aimed to examine ...interhospital variability for 28 cardiovascular All Patient Refined-Diagnosis-related Groups (APR-DRGs).Methods:We studied 103,299 cardiovascular admissions in 99 (98%) Belgian acute-care hospitals between 2012 and 2018. Using generalized linear mixed models, we estimated hospital-specific and APR-DRG-specific risk-standardized rates for in-hospital mortality, 30-day readmissions, and length-of-stay above the APR-DRG-specific 90th percentile. Interhospital variation was assessed based on estimated variance components and time trends between the 2012–2014 and 2016–2018 periods were examined.Results:There was strong evidence of interhospital variation, with statistically significant variation across the 3 outcomes for 5 APR-DRGs after accounting for patient and hospital factors: percutaneous cardiovascular procedures with acute myocardial infarction, heart failure, hypertension, angina pectoris, and arrhythmia. Medical diagnoses, with in particular hypertension, heart failure, angina pectoris, and cardiac arrest, showed strongest variability, with hypertension displaying the largest median odds ratio for mortality (2.51). Overall, hospitals performing at the upper-quartile level should achieve improvements to the median level, and an annual 633 deaths, 322 readmissions, and 1578 extended hospital stays could potentially be avoided.Conclusions:Analysis of interhospital variation highlights important outcome differences that are not explained by known patient or hospital characteristics. Targeting variation is therefore a promising strategy to improve cardiovascular care. Considering their treatment in multidisciplinary teams, policy makers, and managers should prioritize heart failure, hypertension, cardiac arrest, and angina pectoris improvements by targeting guideline implementation outside the cardiology department.
We performed a secondary exploratory cluster analysis on the data collected from the validation phase of the study leading to the development of the model care pathway (CP) for Myasthenia Gravis ...(MG), in which a panel of 85 international experts were asked some characteristics about themselves and their opinion about the model CP. Our aim was to identify which characteristics of the experts play a role in the genesis of their opinion.
We extracted the questions probing an opinion and those describing a characteristic of the expert from the original questionnaire. We performed a multiple correspondence analysis (MCA) and a subsequent hierarchical clustering on principal component (HCPC) on the opinion variables, integrating the characteristic variables as supplementary (predicted).
After reducing the dimensionality of the questionnaire to three dimensions we noticed that the not-appropriateness judgement of the clinical activities may overlap with the completeness one. From the HCPC it seems that the working setting of the expert may play a crucial role in determining the opinion about the setting of the sub-processes of MG: shifting from a cluster where the experts do not work in sub-specialist settings to one where the experts are working in them, the opinion changes accordingly from a mono-disciplinary setting to a multi-disciplinary one. Another interesting result is that the experience in neuromuscular diseases (NMD) measured in years and the expert typology (whether general neurologist or NMD expert) seem not to contribute significantly to the opinions.
These findings might indicate a poor ability of the expert to discriminate what is not appropriate from what is not complete. Also, the opinion of the expert might be influenced by the working setting, but not by the experience in NMD (as measured in years).
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective Hospitals demonstrated increased efforts into quality improvement over the past years. Their growing commitment to quality combined with a heterogeneity in perceptions among healthcare ...stakeholders cause concerns on the sustainable incorporation of quality into the daily workflow. Questions are raised on the drivers for a sustainable hospital quality policy. We aimed to identify drivers and incorporate them into a new, unique roadmap towards sustainable quality of care in hospitals. Design A multi-method design guided by an eight-phase approach to develop a conceptual framework consists of multiple, iterative phases of data collection, synthesis and validation. Starting with a narrative review followed by a qualitative in-depth analysis and including feedback of national and international healthcare stakeholders. Setting Hospitals. Results The narrative review included 59 relevant papers focusing on quality improvement and the sustainability of these improved quality results. By integrating, synthesising and resynthesizing concepts during thematic and content analysis, the narrative review evolved to an integrated, co-creation roadmap. The Flanders Quality Model (FlaQuM) is presented as a driver diagram that features six primary drivers for a sustainable quality policy: (1) Quality Design and Planning, (2) Quality Control, (3) Quality Improvement, (4) Quality Leadership, (5) Quality Culture and (6) Quality Context. Six primary drivers are described in 19 building blocks (secondary drivers) and 104 evidence-based action fields. Conclusions The framework suggests that a manageable number of drivers, building blocks and action fields may support the sustainable incorporation of quality into the daily workflow. Therefore, FlaQuM can serve as a useful roadmap for future sustainable quality policies in hospitals and for future empirical and theoretical work in sustainable quality management.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
ObjectiveTo examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and ...midwives.DesignCross-sectional, retrospective surveys of physicians, midwives and nurses.Setting33 Belgian hospitals.Participants913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident.Main outcome measuresThe Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey.ResultsIndividual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture.ConclusionsHealthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident.
The modified Rankin Scale (mRS) after 90 days documents outcome in stroke patients, but focusses only on activities of daily living. Here we studied stroke outcome beyond these activities by the ...Dutch-Flemish version of the Patient Reported Outcomes Measurement Information System (PROMIS) questionnaire.
We documented the mRS at day 90 in stroke patients who filled out a questionnaire on pain intensity and seven PROMIS domains: physical function, ability to participate in social roles, anxiety, fatigue, depression, sleep disturbance, pain interference. In a subgroup of patients this questionnaire was reduced to one overall question per PROMIS domain. We correlated these findings with the mRS.
We received 102 questionnaires and identified physical function as the most affected PROMIS domain. The strongest correlation with mRS was found for the health domains of physical function (ρs = 0.70,
< 0.001) and ability to participate in social roles (ρs = 0.61,
< 0.001). The other domains with substantial proportions of patients with worse scores compared to the general population (19-44%) correlated weakly with the mRS. We identified a strong correlation between the single question per health domain and the overall score per PROMIS domain.
PROMIS better reflects the overall health status of stroke patients beyond functional outcome as measured by the mRS. Simplification of the questionnaire with a single question per PROMIS domain could potentially replace the full questionnaire, but needs further validation.
Care pathways are often said to promote interprofessional teamwork. As no systematic review on pathway effectiveness has ever focused on how care pathways promote teamwork, the objective of this ...review was to study this relationship. We performed an extensive search of electronic databases and identified 26 relevant studies. In our analysis of these studies we identified 20 team indicators and found that care pathways positively affected 17 of these indicators. Most frequently positive effects were found on staff knowledge, interprofessional documentation, team communication and team relations. However, the level of evidence was rather low. We found Level II evidence for improved interprofessional documentation. We also found Level II evidence for increased workload; improved actual versus planned team size; and improved continuity of care. The studies most frequently mentioned the need for a multidisciplinary approach and educational training sessions in order for pathways to be successful. The systematic review revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. Necessary conditions are a context that supports teamwork and including appropriate active pathway components that can mediate an effect on team processes. To achieve this, each care pathway requires a clearly defined team approach customized to the individual teams’ needs.
► This review enhances understanding on how and in what circumstances care pathways work. ► Most frequently found effects were improved team knowledge, interprofessional documentation, communication and relations. ► A supportive context that puts care processes and teams in the frontline of concern, needs to be pursued. ► Teams involved in care pathways need to be trained to improve team processes and manage team conflicts appropriately. ► To be successful, each care pathway requires a clearly defined team approach, customized to the individual teams’ needs.
BACKGROUND:Human errors occur everywhere, including in health care. Not only the patient, but also the involved health professional is affected (ie, the “second victim”).
OBJECTIVES:To investigate ...the prevalence of health care professionals being personally involved in a patient safety incident (PSI), as well as the relationship of involvement and degree of harm with problematic medication use, excessive alcohol consumption, risk of burnout, work-home interference (WHI), and turnover intentions.
RESEARCH DESIGN:Multilevel path analyses were conducted to analyze cross-sectional survey data from 37 Belgian hospitals.
SUBJECTS:A total of 5788 nurses (79.4%) and physicians (20.6%) in 26 acute and 11 psychiatric hospitals were included.
MEASURES:“Involvement in a patient safety incident during the prior 6 months,” “degree of harm,” and 5 outcomes were measured using self-report scales.
RESULTS:Nine percent of the total sample had been involved in a PSI during the prior 6 months. Involvement in a PSI was related to a greater risk of burnout (β=0.40, OR=2.07), to problematic medication use (β=0.33, OR=1.84), to greater WHI (β=0.24), and to more turnover intentions (β=0.22). Harm to the patient was a predictor of problematic medication use (β=0.14, OR=1.56), risk of burnout (β=0.16, OR=1.62), and WHI (β=0.19).
CONCLUSIONS:Second victims experience significant negative outcomes in the aftermath of a PSI. An appropriate organizational response should be provided to mitigate the negative effects.
Abstract
Background
Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, ...a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy.
Objective
First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy.
Methods
In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (
n
= 62) and 2019 (
n
= 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed.
Results
QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents.
Conclusions
Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare stakeholders are heterogeneous. To assure quality of care remains a top-priority for acute-care hospitals, we recommend a revision of the current multicomponent quality policy where the adoption of all initiatives is streamlined and co-created bottom-up.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background: It is twenty years since the US Institute of Medicine (IOM) defined quality in healthcare, as comprising six domains: person-centredness, timeliness, efficiency, effectiveness, safety and ...equity. Since then, a new quality movement has emerged, with the development of numerous interventions aimed at improving quality, with a focus on accessibility, safety and effectiveness of care. Further gains in equity and timeliness have proven even more challenging.
The challenge: With the emergence of "service-oriented" systems, complexity science, the challenges of climate change, the growth of social media and the internet and the new reality of COVID-19, the original domains proposed by the IOM invite reflection on their relevance and possibility for improvement.
The possible solution: In this paper we propose a revised model of quality that is built on never-ending learning and includes new domains, such as Ecology and Transparency, which reflect the changing worldview of healthcare. We also introduce the concept of person- or "kin-centred care" to emphasise the shared humanity of people involved in the interdependent work. This is a more expansive view of what "person-centredness" began. The delivery of health and healthcare requires people working in differing roles, with explicit attention to the lived realities of the people in the roles of professional and patient. The new model will provide a construct that may make the attainment of equity in healthcare more possible with a focus on kindness for all.
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