Hospice care in Calgary: Survey of family physicians on their knowledge, experience, and attitudes.

OBJECTIVE: To explore Calgary family physicians' knowledge about hospices, their attitudes toward the referral process, and their understanding of barriers to referral for hospice care. DESIGN: Surveys were mailed to 400 randomly selected participants. The survey contained 18 questions related to hospice care, physician experience, attitudes, and perceived barriers to making a hospice referral. SETTING: Calgary, Alta. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Survey responses were analyzed quantitatively using the (2) goodness-of-fit test, Kruskal-Wallis tests, and logistic regression analyses to examine univariate associations. Qualitative analysis of open-ended questions was done by content analysis and thematic coding. RESULTS: In total, 104 surveys were mailed back. Family physicians agreed that palliative care in a hospice setting can greatly improve quality of life for patients, but only 2 of 6 knowledge questions about hospice care were answered correctly by most. Family physicians with special areas of interest or subspecialties were more likely to feel well-informed about hospice referrals (P = .017), indicated a higher comfort level discussing hospice and palliative care (P = .030), and were less likely to defer discussing it with patients (P = .023). Physicians with a special interest in palliative medicine were more likely to correctly answer the knowledge questions (P < .034) and to be familiar with the referral process (P < .001), patient eligibility (P < .001), and the palliative home care program (P = .003). Qualitative analysis revealed support for palliative home care and consultation services but concerns about caregiver coping and family issues. Concerns about disengagement of family physicians and uncertainty about the referral process are obstacles to referral. CONCLUSION: While Calgary family physicians are appreciative of hospice care, there are knowledge gaps. It is important to engage family physicians in the referral process.

Beyond bricks and mortar: a rural network approach to preclinical medical education.

BACKGROUND: Countries with expansive rural regions often experience an unequal distribution of physicians between rural and urban communities. A growing body of evidence suggests that the exposure to positive rural learning experiences has an influence on a physician's choice of practice location. Capitalizing on this observation, many medical schools have developed approaches that integrate rural exposure into their curricula during clerkship. It is postulated that a preclinical rural exposure may also be effective. However, to proceed further in development, accreditation requirements must be considered. In this investigation, academic equivalence between a preclinical rural community based teaching method and the established education model was assessed. METHOD: Two separate preclinical courses from the University of Calgary's three year Undergraduate Medical program were taught at two different rural sites in 2010 (11 students) and 2012 (12 students). The same academic content was delivered in the pilot sites as in the main teaching centre. To ensure consistency of teaching skills, faculty development was provided at each pilot site. Academic equivalence between the rural based learners and a matched cohort at the main University of Calgary site was determined using course examination scores, and the quality of the experience was evaluated through learner feedback. RESULTS: In both pilot courses there was no significant difference between examination scores of the rural distributed learners and the learners at the main University of Calgary site (p > 0.05). Feedback from the participating students demonstrated that the preceptors were very positively rated and, relative to the main site, the small group learning environment appeared to provide strengthened social support. CONCLUSION: These results suggest that community distributed education in pre-clerkship may offer academically equivalent training to existing traditional medical school curricula while also providing learners with positive rural social learning environments. The approach described may offer the potential to increase exposure to rural practice without the cost of constructing additional physical learning sites.

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.

INTRODUCTION: The WHO Surgical Safety Checklist (SSC) is a communication tool that improves teamwork and patient outcomes. SSC effectiveness is dependent on implementation fidelity. Administrative audits fail to capture most aspects of SSC implementation fidelity (ie, team communication and engagement). Existing research tools assess behaviours during checklist performance, but were not designed for routine quality assurance and improvement. We aimed to create a simple tool to assess SSC implementation fidelity, and to test its reliability using video simulations, and usability in clinical practice. METHODS: The Checklist Performance Observation for Improvement (CheckPOINT) tool underwent two rounds of face validity testing with surgical safety experts, clinicians and quality improvement specialists. Four categories were developed: checklist adherence, communication effectiveness, attitude and engagement. We created a 90 min training programme, and four trained raters independently scored 37 video simulations using the tool. We calculated intraclass correlation coefficients (ICC) to assess inter-rater reliability (ICC>0.75 indicating excellent reliability). We then trained two observers, who tested the tool in the operating room. We interviewed the observers to determine tool usability. RESULTS: The CheckPOINT tool had excellent inter-rater reliability across SSC phases. The ICC was 0.83 (95% CI 0.67 to 0.98) for the sign-in, 0.77 (95% CI 0.63 to 0.92) for the time-out and 0.79 (95% CI 0.59 to 0.99) for the sign-out. During field testing, observers reported CheckPOINT was easy to use. In 98 operating room observations, the total median (IQR) score was 25 (23-28), checklist adherence was 7 (6-7), communication effectiveness was 6 (6-7), attitude was 6 (6-7) and engagement was 6 (5-7). CONCLUSIONS: CheckPOINT is a simple and reliable tool to assess SSC implementation fidelity and identify areas of focus for improvement efforts. Although CheckPOINT would benefit from further testing, it offers a low-resource alternative to existing research tools and captures elements of adherence and team behaviours.

Adapting the World Health Organization's Surgical Safety Checklist to High-Income Settings: A Hybrid Effectiveness-Implementation Trial Protocol.

Objectives: The proposed study aims to assess users' perceptions of a surgical safety checklist (SSC) reimplementation toolkit and its impact on SSC attitudes and operating room (OR) culture, meaningful checklist use, measures of surgical safety, and OR efficiency at 3 different hospital sites. Background: The High-Performance Checklist toolkit (toolkit) assists surgical teams in modifying and implementing or reimplementing the World Health Organization's SSC. Through the explore, prepare, implement, and sustain implementation framework, the toolkit provides a process and set of tools to facilitate surgical teams' modification, implementation, training on, and evaluation of the SSC. Methods: A pre-post intervention design will be used to assess the impact of the modified SSC on surgical processes, team culture, patient experience, and safety. This mixed-methods study includes quantitative and qualitative data derived from surveys, semi-structured interviews, patient focus groups, and SSC performance observations. Additionally, patient outcome and OR efficiency data will be collected from the study sites' health surveillance systems. Data analysis: Statistical data will be analyzed using Statistical Product and Service Solutions, while qualitative data will be analyzed thematically using NVivo. Furthermore, interview data will be analyzed using the Consolidated Framework for Implementation Research and reach, effectiveness, adoption, implementation, maintenance implementation frameworks. Setting: The toolkit will be introduced at 3 diverse surgical sites in Alberta, Canada: an urban hospital, university hospital, and small regional hospital. Anticipated impact: We anticipate the results of this study will optimize SSC usage at the participating surgical sites, help shape and refine the toolkit, and improve its usability and application at future sites.

International Perspectives on Modifications to the Surgical Safety Checklist.

Importance: Modification of the World Health Organization's Surgical Safety Checklist (SSC) is a critical component of its implementation. To facilitate the SSC's use, it is important to know how surgical teams modify their SSCs, their reasons for making modifications, and the opportunities and challenges teams face in SSC tailoring. Objective: To study SSC modifications in high-income hospital settings in 5 countries: Australia, Canada, New Zealand, the United States, and the United Kingdom. Design, Setting, and Participants: This qualitative study used semistructured interviews based on the survey used in the quantitative study. Each interviewee was asked a core set of questions and various follow-up questions based on their survey responses. Interviews were conducted from July 2019 to February 2020 in person and online using teleconferencing software. Surgeons, anesthesiologists, nurses, and hospital administrators from the 5 countries were recruited through a survey and snowball sampling. Main Outcomes and Measures: Interviewees' attitudes and perceptions on SSC modifications and their perceived impact on operating rooms. Results: A total of 51 surgical team members and hospital administrators from the 5 countries were interviewed (37 [75%] with >10 years of service; 28 [55%] women). There were 15 (29%) surgeons, 13 (26%) nurses, 15 (29%) anesthesiologists, and 8 (16%) health administrators. Five themes emerged concerning the awareness and involvement in SSC modifications; reasons for modifications; types of modifications; the outcomes of modifications; and perceived barriers to SSC modifications. Based on the interviews, some SSCs may go many years without being revisited or modified. SSCs are modified to ensure they address local issues and standards of practice and that they are fit for purpose. Modifications are also made following adverse events to reduce the risk of reoccurrence. Interviewees described adding, moving, and removing elements from their SSCs, which increased their sense of ownership in their SSC and participation in its performance. Some barriers to modification included leadership and the SSC's inclusion in hospitals' electronic medical record. Conclusions and Relevance: In this qualitative study of surgical team members and administrators, interviewees described addressing contemporary surgical issues through various SSC modifications. The process of SSC modification may improve team cohesion and buy-in in addition to providing opportunities for teams to improve patient safety.

Surgical Teams' Attitudes About Surgical Safety and the Surgical Safety Checklist at 10 Years: A Multinational Survey.

To assess health care professionals' attitudes on the Surgical Safety Checklist ("the Checklist") in resource-rich health systems and provide insights on strategies for optimizing Checklist use. Background: In use for over a decade, the Checklist is a safety instrument aimed at improving operating room communication, teamwork, and evidence-based safety practices. Methods: An online survey was sent to surgeons, nurses, and anesthesiologists in 5 high-income countries (Canada, the United States, the United Kingdom, Australia, and New Zealand). Survey results were analyzed using SPSS. Results: A total of 2032 health care professionals completed the survey. Of these respondents, 47.6% were nurses, 70.5% were women, 65.1% were from the United States, and 50.0% had 20 years of experience or more in their role. Most respondents felt the Checklist positively impacted patient safety (70.9%), team communication (73.1%), and teamwork (58.9%). Only 50.3% of respondents were satisfied their team's use of the Checklist, and only 47.5% reported team members stopping to fully participate in the process. More nurses lacked confidence regarding their role in the Checklist process than surgeons and anesthesiologists combined (8.9% vs 4.3%). Fewer surgeons and anesthesiologists than nurses felt they received adequate training on the Checklist's use (57.8% vs 76.7%). Conclusions: While most respondents perceive the Checklist as enhancing patient safety, not all surgical team members are actively engaging with its use. To enhance buy-in and meaningful use of the Checklist, health systems should provide more training on the Checklist with respect to its purpose and strengthening teamwork.