What matters to medical ward patients, and do we measure it? A qualitative comparison of patient priorities and current practice in quality measurement, on UK NHS medical wards.

OBJECTIVES: To compare the quality metrics selected for public display on medical wards to patients' and carers' expressed quality priorities. METHODS: Multimodal qualitative evaluation of general medical wards and semi-structured interviews. SETTING: UK tertiary National Health Service (public) hospital. PARTICIPANTS: Fourteen patients and carers on acute medical wards and geriatric wards. RESULTS: Quality metrics on public display evaluated hand hygiene, hospital-acquired infections, nurse staffing, pressure ulcers, falls and patient feedback. The intended audience for these metrics was unclear, and the displays gave no indication as to whether performance was improving or worsening. Interviews identified three perceived key components of high-quality ward care: communication, staff attitudes and hygiene. These aligned poorly with the priorities on display. Suboptimal performance reporting had the potential to reduce patients' trust in their medical teams. More philosophically, patients' and carers' ongoing experiences of care would override any other evaluation, and they felt little need for measures relating to previous performance. The display of performance reports only served to emphasise patients' and carers' lack of control in this inpatient setting. CONCLUSIONS: There is a gap between general medical inpatients' care priorities and the aspects of care that are publicly reported. Patients and carers do not act as 'informed choosers' of healthcare in the inpatient setting, and tokenistic quality measurement may have unintended consequences.

Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial.

OBJECTIVES: Frontline insights into care delivery correlate with patients' clinical outcomes. These outcomes might be improved through near-real time identification and mitigation of staff concerns. We evaluated the effects of a prospective frontline surveillance system on patient and team outcomes. DESIGN: Prospective, stepped wedge, non-randomised, cluster controlled trial; prespecified per protocol analysis for high-fidelity intervention delivery. PARTICIPANTS: Seven interdisciplinary medical ward teams from two hospitals in the UK. INTERVENTION: Prospective clinical team surveillance (PCTS): structured daily interdisciplinary briefings to capture staff concerns, with organisational facilitation and feedback. MAIN MEASURES: The primary outcome was excess length of stay (eLOS): an admission more than 24 hours above the local average for comparable patients. Secondary outcomes included safety and teamwork climates, and incident reporting. Mixed-effects models adjusted for time effects, age, comorbidity, palliation status and ward admissions. Safety and teamwork climates were measured with the Safety Attitudes Questionnaire. High-fidelity PCTS delivery comprised high engagement and high briefing frequency. RESULTS: Implementation fidelity was variable, both in briefing frequency (median 80% working days/month, IQR 65%-90%) and engagement (median 70 issues/ward/month, IQR 34-113). 1714/6518 (26.3%) intervention admissions had eLOS versus 1279/4927 (26.0%) control admissions, an absolute risk increase of 0.3%. PCTS increased eLOS in the adjusted intention-to-treat model (OR 1.32, 95% CI 1.10 to 1.58, p=0.003). Conversely, high-fidelity PCTS reduced eLOS (OR 0.79, 95% CI 0.67 to 0.94, p=0.006). High-fidelity PCTS also increased total, high-yield and non-nurse incident reports (incidence rate ratios 1.28-1.79, all p<0.002). Sustained PCTS significantly improved safety and teamwork climates over time. CONCLUSIONS: This study highlighted the potential benefits and pitfalls of ward-level interdisciplinary interventions. While these interventions can improve care delivery in complex, fluid environments, the manner of their implementation is paramount. Suboptimal implementation may have an unexpectedly negative impact on performance. TRIAL REGISTRATION NUMBER: ISRCTN 34806867 (http://www.isrctn.com/ISRCTN34806867).

Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards.

OBJECTIVES: To understand how frontline reports of day-to-day care failings might be better translated into improvement. DESIGN: Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS. RESULTS: PCTS fostered psychological safety-a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described. CONCLUSIONS: Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations. TRIAL REGISTRATION: ISRCTN 34806867.

Beyond clinical engagement: a pragmatic model for quality improvement interventions, aligning clinical and managerial priorities.

Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers-particularly middle managers-also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions.

A stepped wedge, cluster controlled trial of an intervention to improve safety and quality on medical wards: the HEADS-UP study protocol.

INTRODUCTION: The majority of preventable deaths in healthcare are due to errors on general wards. Staff perceptions of safety correlate with patient survival, but effectively translating ward teams' concerns into tangibly improved care remains problematic. The Hospital Event Analysis Describing Significant Unanticipated Problems (HEADS-UP) trial evaluates a structured, multidisciplinary team briefing, capturing safety threats and adverse events, with rapid feedback to clinicians and service managers. This is the first study to rigorously assess a simpler intervention for general medical units, alongside an implementation model applicable to routine clinical practice. METHODS/ANALYSIS: 7 wards from 2 hospitals will progressively incorporate the intervention into daily practice over 14 months. Wards will adopt HEADS-UP in a pragmatic sequence, guided by local clinical enthusiasm. Initial implementation will be facilitated by a research lead, but rapidly delegated to clinical teams. The primary outcome is excess length of stay (a surplus stay of 24 h or more, compared to peer institutions' Healthcare Resource Groups-predicted length of stay). Secondary outcomes are 30-day readmission or excess length of stay; in-hospital death or death/readmission within 30 days; healthcare-acquired infections; processes of escalation of care; use of traditional incident-reporting systems; and patient safety and teamwork climates. HEADS-UP will be analysed as a stepped wedge cluster controlled trial. With 7840 patients, using best and worst case predictions, the study would achieve between 75% and 100% power to detect a 2-14% absolute risk reduction in excess length of stay (two-sided p<0.05). Regression analysis will use generalised linear mixed models or generalised estimating equations, and a time-to-event regression model. A qualitative analysis will evaluate facilitators and barriers to HEADS-UP implementation and impact. ETHICS AND DISSEMINATION: Participating institutions' Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN34806867.

Effects of Interdisciplinary Team Care Interventions on General Medical Wards: A Systematic Review.

IMPORTANCE: Improving the quality of health care for general medical patients is a priority, but the organization of general medical ward care receives less scrutiny than the management of specific diseases. Optimizing teams' performance improves patient outcomes in other settings, and interdisciplinary practice is a major target for improvement efforts. However, the effect of interdisciplinary team interventions on general medical ward care has not been systematically reviewed. OBJECTIVES: To describe the range of objective patient outcomes used in studies of general medical ward interdisciplinary team care, and to evaluate the performance of interdisciplinary interventions against them. EVIDENCE REVIEW: We searched EMBASE, MEDLINE, and PsycINFO from January 1, 1998, through December 31, 2013, for interdisciplinary team care interventions in adult general medical wards using an objective patient outcome measure. Reference lists of included articles were also searched. The last search was conducted on January 29, 2014, and the narrative and statistical analysis was conducted through December 1, 2014. Study quality was assessed using the Cochrane Effective Practice and Organization of Care group's tool. FINDINGS: Thirty of 6934 articles met the selection criteria. The studies included 66,548 patients, with a mean age of 63 years. Nineteen of 30 (63%) studies reported length of stay, readmission, or mortality rate as their primary outcome, or did not specify the primacy of their outcomes. The most commonly reported objective patient outcomes were length of stay (23 of 30 [77%]), complications of care (10 of 30 [33%]), in-hospital mortality rate (8 of 30 [27%]), and 30-day readmission rate (8 of 30 [27%]). Of 23 interventions, 16 (70%) had no effect on length of stay, 12 of 15 (80%) did not reduce readmissions, and 14 of 15 (93%) did not affect mortality. Five of 10 (50%) interventions reduced complications of care. In an exploratory quantitative analysis, the interventions did not consistently reduce the relative risk of early readmission or early mortality, or the weighted mean difference in length of stay. All studies had a medium or high risk of bias. CONCLUSIONS AND RELEVANCE: Current evidence suggests that interdisciplinary team care interventions on general medical wards have little effect on traditional measures of health care quality. Complications of care or preventable adverse events may merit inclusion as quality indicators for general medical wards. Future study should clarify how best to implement interdisciplinary team care interventions and establish quality metrics that are credible to both health care professionals and patients in this setting.

Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base.

Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.

UK colorectal cancer patients are inadequately assessed for Lynch syndrome.

OBJECTIVE: To establish whether colorectal cancer patients in two centres in the UK are screened appropriately for Lynch syndrome, in accordance with current international guidance. DESIGN: Patients newly diagnosed with colorectal cancer over an 18-month period were identified from the UK National Bowel Cancer Audit Programme. Their records and management were reviewed retrospectively. SETTING: Two university teaching hospitals, Imperial College Healthcare and Oxford Radcliffe Hospitals NHS Trusts. OUTCOMES MEASURED: Whether patients were screened for Lynch syndrome-and the outcome of that evaluation, if it took place-were assessed from patients' clinical records. The age, tumour location and family history of screened patients were compared to those of unscreened patients. RESULTS: Five hundred and fifty three patients with newly diagnosed colorectal cancer were identified. Of these, 97 (17.5%) satisfied the revised Bethesda criteria, and should have undergone further assessment. There was no evidence that those guidelines had been contemporaneously applied to any patient. In practice, only 22 of the 97 (22.7%) eligible patients underwent evaluation. The results for 14 of those 22 (63.6%) supported a diagnosis of Lynch syndrome, but only nine of the 14 (64.3%) were referred for formal mismatch repair gene testing. No factors reliably predicted whether or not a patient would undergo Lynch syndrome screening. CONCLUSIONS: Colorectal teams in the UK do not follow international guidance identifying the patients who should be screened for Lynch syndrome. Patients and their families are consequently excluded from programmes reducing colorectal cancer incidence and mortality. Multidisciplinary teams should work with their local genetics services to develop reliable algorithms for patient screening and referral.