Patients' and clinicians' views of comparing the performance of providers of surgery: a qualitative study.

OBJECTIVES: Comparison of providers' outcomes is intended to encourage patient choice and stimulate clinicians to improve the quality of their services. Given that success will depend on how patients and clinicians respond, our aim was to explore their views of using outcome data to compare providers. METHOD: Qualitative data from six focus groups with patients (n = 45) and seven meetings with surgical clinicians (n = 107) were collected during autumn 2010. Discussions audio-taped, transcribed and a thematic analysis carried out. RESULTS: Patients and clinicians confirmed the value of making comparisons of the outcomes of providers publicly available. However, both groups harboured three principal concerns: the validity of the data; fears that the data would be misinterpreted by the media, politicians and commissioners, and the focus should not just be on providers but also on the performance of individual surgeons. In addition, patients felt that information on providers' outcomes would only ever have a limited impact on their choice because there were other important factors to be taken into account: accessibility, waiting time, the size of the provider and the quality of other aspects such as cleanliness and nursing. Also patients acknowledged the importance of friends' and relatives' experiences and that they would seek their GP's advice. CONCLUSIONS: While comparisons of providers' outcomes should be available to patients to stimulate improvements in performance, information should be directed principally to hospital clinicians and to GPs. Impact may be enhanced by providing data on individual clinicians rather than providers. The extent to which these findings are generalizable to other areas of health care is uncertain.

Clinicians' and patients' views of metrics of change derived from patient reported outcome measures (PROMs) for comparing providers' performance of surgery.

BACKGROUND: Patient reported outcome measures (PROMs) are increasingly being used to compare the performance of health care providers. Our objectives were to determine the relative frequency of use of different metrics that can be derived from PROMs, explore clinicians' and patients' views of the options available, and make recommendations. METHODS: First a rapid review of the literature on metrics derived from two generic (EQ-5D and EQ-VAS) and three disease-specific (Oxford Hip Score; Oxford Knee Score; Aberdeen Varicose Vein Questionnaire) PROMs was conducted. Next, the findings of the literature review were mapped onto our typology of metrics to determine their relative frequency of use, Finally, seven group meetings with surgical clinicians (n = 107) and six focus groups with patients (n = 45) were held which were audio-taped, transcribed and analysed thematically. RESULTS: Only nine studies (9.3% of included papers) used metrics for comparing providers. These were derived from using either the follow-up PROM score (n = 3) or the change in score as an outcome (n = 5), both adjusted for pre-intervention score. There were no recorded uses of the proportion reaching a specified ('good') threshold and only two studies used the proportion reaching a minimally important difference (MID).Surgical clinicians wanted multiple outcomes, with most support expressed for the mean change in score, perceiving it to be more interpretable; there was also some support for the MID. For patients it was apparent that rather than the science behind these measures, the most important aspects were the use of language that would make the metrics personally meaningful and linking the metric to a familiar scale. CONCLUSIONS: For clinicians the recommended metrics are the mean change in score and the proportion achieving a MID, both adjusted for pre-intervention score. Both need to be clearly described and explained. For patients we recommend the proportion achieving a MID or proportion achieving a significant improvement in hip function, both adjusted for pre-intervention score.

Impact of format and content of visual display of data on comprehension, choice and preference: a systematic review.

PURPOSE: Displays comparing the performance of healthcare providers are largely based on commonsense. To review the literature on the impact of compositional format and content of quantitative data displays on people's comprehension, choice and preference. DATA SOURCES: Ovid databases, expert recommendations and snowballing techniques. STUDY SELECTION: Evaluations of the impact of different formats (bar charts, tables and pictographs) and content (ordering, explanatory visual cues, etc.) of quantitative data displays meeting defined quality criteria. Data extraction Type of decision; decision-making domains; audiences; formats; content; methodology; findings. RESULTS OF DATA SYNTHESIS: Most of the 30 studies used quantitative (n= 26) methods with patients or public groups (n= 28) rather than with professionals (n= 2). Bar charts were the most frequent format, followed by pictographs and tables. As regards format, tables and pictographs appeared better understood than bar charts despite the latter being preferred. Although accessible to less numerate and older populations, pictographs tended to lead to more risk avoidance. Tables appeared accessible to all. Aspects of content enhancing the impact of data displays included giving visual explanatory cues and contextual information while still attempting simplicity ('less is more'); ordering data; consistency. Icons rather than numbers were more user-friendly but could lead to over-estimation of risk. Uncertainty was not widely understood, nor well represented. CONCLUSIONS: Though heterogeneous and limited in scope, there is sufficient research evidence to inform the presentation of quantitative data that compares the performance of healthcare providers. The impact of new formats, such as funnel plots, needs to be evaluated.

Taking one step further: five equity principles for hospitals to increase their value as anchor institutions.

Hospitals have the potential to create value beyond the direct clinical care that they provide through tackling the social determinants of health as an 'anchor institution': shifting the way in which they employ staff; procure goods and services; use their physical and environmental resources and assets; and partner with others. However, the societal value of this work is not automatically or accidentally created, it must be intentionally designed and delivered, particularly if it is to tackle inequities. This article proposes five equity principles for healthcare leaders to consider in their hospitals' anchor institution work. There have already been important shifts from the 'traditional way' of conceiving of a hospital's role in the community, but going 'one step further' could help to maximise the equity impact.

Designing the careful and kind clinic: an evidence-based approach.

BACKGROUND: There is evidence that creating a 'healthy workplace' can be of profound importance for clinicians, team members and patients. Yet there have been few papers that have proposed mechanisms to take decades of research and translate this into a practical list of options for leaders and managers to take into account when structuring a clinic based on care and kindness to achieve optimal health. EVIDENCE: We bring together 20 years of scholarship linking care of the caregivers with outcomes for caregivers and patients. The data are used to support both structures and cultures that will result in satisfied and thriving healthcare team members, as well as satisfied and healthy patients. RESULTS: The clinic based on care of the caregivers will be structured to address key aspects of worklife that are known to cause either satisfaction or burnout. Aspects of care, such as time pressure, chaotic environments and worker control of their workplace, will be taken into account in clinical design; organisational culture will be supportive and cohesive, emphasising quality, values and communication. Experiences based on gender and race will be measured and continuously improved; and performance will be evaluated in a new, human-centred manner. OUTCOMES: The careful and kind clinic will be a remarkable place to work; in contrast to industrialised healthcare, this will be an environment where health can indeed be optimised, for both workers and patients.

Changes in recruitment to public health consultant posts and hospital consultant posts in England: potential impact on the sustainability of the Public Health system.

BACKGROUND: The UK government has proposed major changes to the Public Health system in England. This study aims quantify increasing anecdotal concern that the number of Public Health consultant posts advertised has plummeted since the publication of these plans. METHODS: The archives of BMJ careers were interrogated for hospital and Public Health consultant posts advertised October 2008 and May 2011. Statistical process control charts were used to compare differences in recruitment over time and the ratio of Public Health:hospital consultant posts. RESULTS: We found a highly significant reduction in the mean number of advertisements for Public Health consultant posts from 27.9 posts per month in the period October 2008-Novermber 2009 to 6.3 posts per month between December 2009 and May 2010 (P< 0.005). The ratio of Public Health:hospital consultant posts fell from 3.3 to 0.9 Public Health consultant posts per 100 hospital consultant posts (P< 0.005). CONCLUSIONS: This study confirms the anecdotal concern that there has been a significant reduction in the advertisement, and by extrapolation, recruitment to Public Health consultants posts in England around the time of the publication of the government's reform plans. Public Health consultant posts have been disproportionately affected by this reduction compared to hospital consultant posts.

Integrated health and care systems in England: can they help prevent disease?

Objectives: Over the past 12 months, there has been increasing policy rhetoric regarding the role of the National Health Service (NHS) in preventing disease and improving population health. In particular, the NHS Long Term Plan sees integrated care systems (ICSs) and sustainability and transformation partnerships (STPs) as routes to improving disease prevention. Here, we place current NHS England integrated care plans in their historical context and review evidence on the relationship between integrated care and prevention. We ask how the NHS Long Term Plan may help prevent disease and explore the role of the 2019 ICS and STP plans in delivering this change. Methods: We reviewed the evidence underlying the relationship between integrated care and disease prevention, and analysed 2016 STP plans for content relating to disease prevention and population health. Results: The evidence of more integrated care leading to better disease prevention is weak. Although nearly all 2016 STP plans included a prevention or population health strategy, fewer than half specified how they will work with local government public health teams, and there was incomplete coverage across plans about how they would meet NHS England prevention priorities. Plans broadly focused on individual-level approaches to disease prevention, with few describing interventions addressing social determinants of health. Conclusions: For ICSs and STPs to meaningfully prevent disease and improve population health, they need to look beyond their 2016 plans and fill the gaps in the Long Term Plan on social determinants.

Moving improvement research closer to practice: the Researcher-in-Residence model.

The traditional separation of the producers of research evidence in academia from the users of that evidence in healthcare organisations has not succeeded in closing the gap between what is known about the organisation and delivery of health services and what is actually done in practice. As a consequence, there is growing interest in alternative models of knowledge creation and mobilisation, ones which emphasise collaboration, active participation of all stakeholders, and a commitment to shared learning. Such models have robust historical, philosophical and methodological foundations but have not yet been embraced by many of the people working in the health sector. This paper presents an emerging model of participation, the Researcher-in-Residence. The model positions the researcher as a core member of a delivery team, actively negotiating a body of expertise which is different from, but complementary to, the expertise of managers and clinicians. Three examples of in-residence models are presented: an anthropologist working as a member of an executive team, operational researchers working in a front-line delivery team, and a Health Services Researcher working across an integrated care organisation. Each of these examples illustrates the contribution that an embedded researcher can make to a service-based team. They also highlight a number of unanswered questions about the model, including the required level of experience of the researcher and their areas of expertise, the institutional facilitators and barriers to embedding the model, and the risk that the independence of an embedded researcher might be compromised. The Researcher-in-Residence model has the potential to engage both academics and practitioners in the promotion of evidence-informed service improvement, but further evaluation is required before the model should be routinely used in practice.

Clinicians' views of formats of performance comparisons.

RATIONALE, AIMS AND OBJECTIVES: Comparisons of the performance of health care providers are increasingly being used. Despite one key audience being clinicians, there has been little research on the format and content of such comparisons. Our aim was to explore clinicians' comprehension and preferences of format and content in displaying provider outcomes using comparisons of patient reported outcome measures data. METHOD: A qualitative study, based on seven meetings involving 107 clinicians (mostly consultant and junior doctors, and nurses), revealed their views on nine formats and five aspects of content. RESULTS: Key findings were the desire for data in more than one format, explicit display of comparative performance (rank order) and the need for explanations (e.g. of unfamiliar formats and of statistical uncertainty). CONCLUSIONS: Several themes were identified that shaped clinicians' views. Results were sufficiently clear to permit recommendations for the form and content of standard reports for the National Health Service.