Initiatives to reduce treatments in bronchiolitis in the emergency department and primary care.

We performed a quality improvement initiative to reduce unnecessary treatments for acute bronchiolitis (AB) in primary care (PC) and the referral paediatric emergency department (ED). The quality improvement initiative involved two seasons: 2016-2017 (preintervention) and 2017-2018 (postintervention). We distributed an evidence-based protocol, informative posters and badges with the slogan 'Bronchiolitis, less is more'. We also held interactive sessions, and paediatricians received weekly reports on bronchodilator prescription. The main outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were epinephrine, antibiotic and corticosteroid prescription rates. Control measures were ED visit and hospitalisation rates, triage level, length of stay, intensive care admission and unscheduled returns with admission. We included 1878 ED and 1192 PC visits of which 855 (44.5%) and 534 (44.7%) occurred in the postintervention period, respectively. In the ED, salbutamol and epinephrine prescription rates fell from 13.8% (95% CI 11.8% to 16%) to 9.1% (95% CI 7.3% to 11.2%) (p<0.01) and 10.4% (95% CI 8.6% to 12.4%) to 9% (95% CI 7.2% to 11.1%) (n.s.), respectively. In PC, salbutamol, corticosteroid and antibiotic prescription rates fell from 38.3% (95% CI 34.6% to 42.0%) to 15.9% (95% CI 12.9% to 19.5%) (p<0.01), 12.9% (95% CI 10.5% to 15.7%) to 3.6% (95% CI 2.2% to 5.7%) (p<0.01) and 29.6% (95% CI 26.2% to 33.2%) to 9.5% (95% CI 7.2% to 12.5%) (p<0.01), respectively. No significant variations were noted in control measures. We safely decreased the use of unnecessary treatments for AB. Collaboration between PC and ED appears to be an important factor for success.

Made to Measure: The Ethics of Routine Measurement for Healthcare Improvement.

This paper analyses the ethics of routine measurement for healthcare improvement. Routine measurement is an increasingly central part of healthcare system design and is taken to be necessary for successful healthcare improvement efforts. It is widely recognised that the effectiveness of routine measurement in bringing about improvement is limited-it often produces only modest effects or fails to generate anticipated improvements at all. We seek to show that these concerns do not exhaust the ethics of routine measurement. Even if routine measurement does lead to healthcare improvements, it has associated ethical costs which are not necessarily justified by its benefits. We argue that the practice of routine measurement changes the function of the healthcare system, resulting in an unintended and ethically significant transformation of the sector. It is difficult to determine whether such changes are justified or offset by the benefits of routine measurement because there may be no shared understanding of what is 'good' in healthcare by which to compare the benefits of routine measurement with the goods that are precluded by it. We counsel that the practice of routine measurement should proceed with caution and should be recognised to be an ethically significant choice, rather than an inevitability.

[Ethical issues in the clinical records of a group of terminal patients admitted into a third level hospital. Lacks and improvements.] / Cuestiones éticas en los registros clínicos de un grupo de pacientes terminales ingresados en un hospital de tercer nivel. Carencias y mejoras.

OBJECTIVE: Terminal patients and their relatives must know their real situation, and be treated according to the principle of autonomy, to establish therapeutic objectives adapted each one, according to their needs and decisions. The objective of this study is to identify the sufficient existence of records in the Medical Histories of terminal patients, which indicate their situation, such as the information given to the patients, or the LET, No-RCP or Z.51.5 codes, and the statistical relation they have with the sociodemographic and clinical variables. METHODS: Cross-sectional study in a third-level hospital, with patients admitted between January and December 2017, who died with terminal illness criteria. Data were collected from the medical records, and, fundamentally, from the nursing clinical notes. The statistical analysis was performed with the SPSS program, version 22. RESULTS: Participants were 140 people, 54.3% men, of 78.51 (SD=13.5) of middle age. People up to 70 years of age received less information (Odds ratio (OR): 0.077, 95% Confidence interval (CI): 0.015-0.390) and lower sedation (OR: 0.366, 95% CI: 0.149-0.899). Proceeding from city reduced the probability of receiving information (OR: 0.202; IC95%: 0.058-0.705). Presenting dyspnea reduced LTE (OR: 0.44, 95% CI: 0.20-093), No CPR (0.29, 95% CI: 0.12-0.68) and sedation (OR: 0.27; 95% CI: 0.12-060). Fatigue increased the probability of being Non-CPR (OR: 2.77, 95% CI: 1.166-6.627) and of receiving sedation (OR: 2.6, 95% CI: 1.065-6.331). CONCLUSIONS: Efforts to empower the patient in the decision of their process and the management of the information of their diagnosis and prognosis are still lacking. A greater and better clinical records facilitates knowing how actions are developed, allowing to identify and implement ethical and responsible interventions.

OBJETIVO: Los/las pacientes en estado terminal y sus familiares deben conocer su situación y ser tratados según el principio de autonomía, para establecer así objetivos terapéuticos adaptados a cada uno/a de acuerdo a sus necesidades y decisiones. El objetivo de este estudio fue identificar la existencia de registros en las historias clínicas de pacientes terminales que señalen su situación, como la información ofrecida, los códigos de limitación del esfuerzo terapéutico (LET), la no reanimación cardiopulmonar (No-RCP) o Z.51.5, y la relación con las variables sociodemográficas y clínicas. METODOS: Se realizó un estudio descriptivo transversal en un hospital de tercer nivel, con pacientes ingresados entre enero y diciembre de 2017, que fallecieron con criterios de enfermedad terminal. Se recogieron los datos de las historias clínicas y, fundamentalmente, de las notas clínicas de enfermería. El análisis estadístico se realizó con el programa SPSS, versión 22. RESULTADOS: Participaron 140 personas, 54,3% de hombres, de 78,51 años (Desviación estándar -DS-=13,5) de edad media. Las personas menores de 70 años recibieron menos información (Odds Ratio -OR-: 0,077; Intervalo de Confianza -IC- 95%: 0,015-0,390) y menor sedación (OR: 0,366; IC 95%: 0,149-0,899). Proceder de ciudad redujo la probabilidad de recibir información (OR: 0,202; IC 95%: 0,058-0,705). Presentar disnea redujo la LET (OR: 0,44; IC 95%: 0,20-093), el No RCP (0,29; IC 95%: 0,12-0,68) y la sedación (OR:0,27; IC 95%: 0,12-060). La fatiga aumentó la probabilidad de ser No RCP (OR: 2,77; IC 95%: 1,163-6,627) y de recibir sedación (OR:2,6; IC 95%: 1,065-6,331). CONCLUSIONES: Los esfuerzos por empoderar al paciente en la toma de decisiones son todavía escasos. Un mayor y mejor registro facilita conocer cómo se desarrollan las actuaciones, permitiendo identificar y poner en marcha intervenciones éticas y responsables.

Ethics and Collateral Findings in Pragmatic Clinical Trials.

Pragmatic clinical trials (PCTs) offer important benefits, such as generating evidence that is suited to inform real-world health care decisions and increasing research efficiency. However, PCTs also present ethical challenges. One such challenge involves the management of information that emerges in a PCT that is unrelated to the primary research question(s), yet may have implications for the individual patients, clinicians, or health care systems from whom or within which research data were collected. We term these findings as ?pragmatic clinical trial collateral findings,? or ?PCT-CFs?. In this article, we explore the ethical considerations associated with the identification, assessment, and management of PCT-CFs, and how these considerations may vary based upon the attributes of a specific PCT. Our purpose is to map the terrain of PCT-CFs to serve as a foundation for future scholarship as well as policy-making and to facilitate careful deliberation about actual cases as they occur in practice.

Building the Bridge to Quality: An Urgent Call to Integrate Quality Improvement and Patient Safety Education With Clinical Care.

Current models of quality improvement and patient safety (QIPS) education are not fully integrated with clinical care delivery, representing a major impediment toward achieving widespread QIPS competency among health professions learners and practitioners. The Royal College of Physicians and Surgeons of Canada organized a 2-day consensus conference in Niagara Falls, Ontario, Canada, called Building the Bridge to Quality, in September 2016. Its goal was to convene an international group of educational and health system leaders, educators, frontline clinicians, learners, and patients to engage in a consensus-building process and generate a list of actionable strategies that individuals and organizations can use to better integrate QIPS education with clinical care.Four strategic directions emerged: prioritize the integration of QIPS education and clinical care, build structures and implement processes to integrate QIPS education and clinical care, build capacity for QIPS education at multiple levels, and align educational and patient outcomes to improve quality and patient safety. Individuals and organizations can refer to the specific tactics associated with the 4 strategic directions to create a road map of targeted actions most relevant to their organizational starting point.To achieve widespread change, collaborative efforts and alignment of intrinsic and extrinsic motivators are needed on an international scale to shift the culture of educational and clinical environments and build bridges that connect training programs and clinical environments, align educational and health system priorities, and improve both learning and care, with the ultimate goal of achieving improved outcomes and experiences for patients, their families, and communities.

What does 'quality' add? Towards an ethics of healthcare improvement.

In this paper, we argue that there are important ethical questions about healthcare improvement which are underexplored. We start by drawing on two existing literatures: first, the prevailing, primarily governance-oriented, application of ethics to healthcare 'quality improvement' (QI), and second, the application of QI to healthcare ethics. We show that these are insufficient for ethical analysis of healthcare improvement. In pursuit of a broader agenda for an ethics of healthcare improvement, we note that QI and ethics can, in some respects, be treated as closely related concerns and not simply as externally related agendas. To support our argument, we explore the gap between 'quality' and 'ethics' discourses and ask about the possible differences between 'good quality healthcare' and 'good healthcare'. We suggest that the word 'quality' both adds to and subtracts from the idea of 'good healthcare', and in particular that the technicist inflection of quality discourses needs to be set in the context of broader conceptualisations of healthcare improvement. We introduce the distinction between quality as a measurable property and quality as an evaluative judgement, suggesting that a core, but neglected, question for an ethics of healthcare improvement is striking the balance between these two conceptions of quality.

Virtue ethics and the commitment to learn: overcoming disparities faced by transgender individuals.

The purpose of this paper is to utilize virtue ethics as the appropriate paradigm by which to improve health care delivery to transgender individuals. Health disparities for transgender individuals occur external to the medical environment as well as internal to the medical profession. A commitment to virtue ethics should be undertaken to improve the care to transgender individuals.In this manuscript I call on virtue ethics to address the intersectionality of such environmental structures for the promotion of the good of the patient as per the telos of medicine by Edmund Pellegrino, consistent with the eudaimonia of Aristotle's Nicomachean Ethics. Virtue ethics is the appropriate paradigm for which bioethics can address the framework that poses barriers to access to health care and maintenance of health through a lack of competent, knowledgeable and compassionate providers for the transgender population.Further, I pose that ascribing to improving the care to the individual transgender patient involves a call to action to overcome social ecological spheres of influence that are affecting the health of the individual and thereby the population of the transgender individuals as a whole. Through virtue ethics, the virtuous physician improves the health of the transgender individual and the character of themselves and the profession of medicine.

The ethical oversight of learning health care activities in Switzerland: a qualitative study.

OBJECTIVE: This study aims to identify the key issues regarding the ethical oversight of health care improvement activities in Switzerland. DESIGN: Individual semi-structured qualitative interviews, analysed using conventional content analysis. SETTING: Interviews were conducted in Switzerland between July 2017 and February 2018. PARTICIPANTS: A purposive sample of 38 key stakeholders from four different groups: health care improvement researchers and practitioners (n = 19), representatives of clinical trial units (n = 3), clinical ethicists (n = 5), quality heads of university hospitals (n = 5), and cantonal ethics committee members (n = 6). RESULTS: There appears to be widespread uncertainty regarding when certain learning health care activities require ethical review by a research ethics committee in Switzerland. This situation is exacerbated by legislative ambiguity and limited guidance. It was reported that the lack of other oversight mechanisms for activities outside of the Human Research Act is also leading many investigators to submit projects to research ethics committees to avoid barriers to publication. CONCLUSIONS: The continuous, integrated, and dynamic nature of learning health care poses significant challenges to the current regulatory framework. It will be important that more clarification and guidance is provided regarding which activities require ethical review, and that it is considered how the ethical oversight of activities falling outside human research legislation can be strengthened. However, the traditional model of ethical oversight is poorly suited to learning health care and may need to be replaced with new systemic oversight approaches.

Improving safety through speaking up: An ethical and financial imperative.

BACKGROUND: Fostering a culture that empowers staff to speak up when concerned about the quality or safety of patient care is both an ethically1 and economically2 responsible endeavor. The Michigan Health & Hospital Association (MHA) Keystone Center has implemented the Speak-Up! Award program that acknowledges frontline health care staff for voicing their concerns and making care safer. The objective of this effort was to advance patient safety in Keystone Center member organizations through widespread, measurable culture improvement. After extensive data collection and analysis, there was a discernable improvement in culture survey results across a 2-year period coinciding with the launch and sustainment of the award program. Furthermore, in an effort to demonstrate the power of speaking up among staff, the Keystone Center applied a cost-savings framework to the types of harm avoided. Results from the cost-savings analysis suggest that each instance of speaking up by staff saves patients, families, and health care organizations an average of more than $13,000. METHODS: Keystone Center Speak-Up! Award nominations were submitted through an electronic form that collects open, closed, and Likert-type question responses, producing a data array on type and severity of harm prevented, as well as the difficulty and magnitude of the decision to speak up. All data were then coded by harm type and subsequently applied to a tailored version of the cost-savings estimation framework used in the Great Lakes Partnership for Patients Hospital Improvement and Innovation Network. Safety culture was measured through the use of a survey instrument called the Safety, Communication, Operational Reliability, and Engagement (SCORE) instrument. RESULTS: The Keystone Center Speak-Up! Award program received 416 nominations across the 2-year study period, of which 62% (n = 258) were coded as a specific harm type. Adverse drug events (n = 153), imaging errors (n = 42), and specimen errors (n = 27) were the most common harm types prevented by speaking up. After applying the cost-savings framework to these data, it is estimated that for every instance of speaking up, approximately $13,000 in total expenses were avoided, which is in line with the findings from a report on the economic impact of medical errors sponsored by the Society of Actuaries.3 Furthermore, culture survey results improved by 6% between 2015 and 2017, coinciding with the Keystone Center Speak-Up! Award program. CONCLUSIONS: The Keystone Center Speak-Up! Award has proven to be a valuable tool in recognizing staff awareness and willingness to raise concerns about quality and safety in health care. Data analysis from this program presents evidence that fostering a psychologically safe culture of speaking up yields fiscal and humanistic returns, both of which are crucial to sustainable, meaningful progress in safety and quality. However, further research is required to adequately gauge the degree to which safety culture improvement is proportional to cost savings.

Value based competition in health care's ethical drawbacks and the need for a values-driven approach.

Value Based competition in Health Care (VBHC) has become a guiding principle in the quest for high quality health care for acceptable costs. Current literature lacks substantial ethical evaluation of VBHC.In this paper we describe how a single-minded focus on VBHC may cause serious infringements upon at least four medical ethical principles: 1) it tends to neglect patients' personal values; 2) it ignores the intrinsic value of the caring act; 3) it disproportionately replaces trust in professionals with accountability, and 4) it undermines solidarity.Health care needs a next step in VBHC. We suggest a 'Values-Driven Health Care' (VDHC) approach that a) takes patients' personal values as prescriptive and guiding; b) holds a value account that encompasses health care's intrinsic (gift) values; c) is based upon intelligent accountability that supports trust in trustworthy professionals, and d) encourages patients to raise their voices for the shared good of health care.

Kenyan health stakeholder views on individual consent, general notification and governance processes for the re-use of hospital inpatient data to support learning on healthcare systems.

BACKGROUND: Increasing adoption of electronic health records in hospitals provides new opportunities for patient data to support public health advances. Such learning healthcare models have generated ethical debate in high-income countries, including on the role of patient and public consent and engagement. Increasing use of electronic health records in low-middle income countries offers important potential to fast-track healthcare improvements in these settings, where a disproportionate burden of global morbidity occurs. Core ethical issues have been raised around the role and form of information sharing processes for learning healthcare systems, including individual consent and individual and public general notification processes, but little research has focused on this perspective in low-middle income countries. METHODS: We conducted a qualitative study on the role of information sharing and governance processes for inpatient data re-use, using in-depth interviews with 34 health stakeholders at two public hospitals on the Kenyan coast, including health managers, providers and researchers. Data were collected between March and July 2016 and analysed using a framework approach, with Nvivo 10 software to support data management. RESULTS: Most forms of clinical data re-use were seen as an important public health good. Individual consent and general notification processes were often argued as important, but contingent on interrelated influences of the type of data, use and secondary user. Underlying concerns were linked to issues of patient privacy and autonomy; perceived risks to trust in health systems; and fairness in how data would be used, particularly for non-public sector re-users. Support for engagement often turned on the anticipated outcomes of information-sharing processes, as building or undermining trust in healthcare systems. CONCLUSIONS: As reported in high income countries, learning healthcare systems in low-middle counties may generate a core ethical tension between supporting a public good and respecting patient autonomy and privacy, with the maintenance of public trust acting as a core requirement. While more evidence is needed on patient and public perspectives on learning healthcare activities, greater collaboration between public health and research governance systems is likely to support the development of efficient and locally responsive learning healthcare activities in LMICs.

Defining What is Good: Pluralism and Healthcare Quality.

'Quality' is a widely invoked concept in healthcare, which broadly captures how good or bad a healthcare service is. While quality has long been thought to be multidimensional, and thus constitutively plural, we suggest that quality is also plural in a further sense, namely that different conceptions of quality are appropriately invoked in different contexts, for different purposes. Conceptual diversity in the definition and specification of quality in healthcare is, we argue, not only inevitable but also valuable. To treat one conception of healthcare quality as universally definitive of good healthcare unjustifiably constrains the ways in which healthcare can be understood to be better or worse. This indicates that there are limits to the extent to which improvement activities should be coordinated or standardized across the healthcare sector. While there are good reasons to advocate greater coordination in healthcare improvement activities, harmonization efforts should not advance conceptual uniformity about quality.

Aseguramiento de la calidad educacional en las universidades de América Latina / Assurance of the teaching quality in the universities of Latin America

El aseguramiento de la calidad de la educación superior en la región latinoamericana ha conllevado el despliegue de medidas provenientes del sector estatal, que conducen a la búsqueda de alternativas en los centros universitarios, con las cuales no siempre se alcanzan los resultados esperados. En este artículo se presenta esta problemática desde la perspectiva del factor humano, expresado en el profesor como actor clave en la construcción de instituciones donde se labora en función de desarrollar la calidad educacional como propuesta a su contexto social concreto

The assurance of the higher education quality in Latin American region has motivated the implementation of measures coming from the state sector that guide to the search of alternatives in the university centers, with which the prospective results are not always reached. In this article this problem is presented from the perspective of the human factor, expressed in the professor as key actor in the building of institutions where it is worked for the aim of developing the teaching quality as proposal to its concrete social context

Ethics Review of Projects (ERoP): A Conceptual Framework.

Ethical risks are routinely assessed and mitigated in research studies. The same risks can exist in program evaluations and quality improvement initiatives and yet may not be routinely and comprehensively addressed. The authors present a conceptual framework that can help organizations develop comprehensive ethics review processes for non-research knowledge-generating projects (NRKGPs). They provide strategies that can be implemented in three progressive domains and illustrate the framework's application using two examples of health organizations with existing NRKGP ethics review processes. They conclude the article by discussing some lessons learned.