Peer support by interprofessional health care providers in aftermath of patient safety incidents: A cross-sectional study.

AIM: To investigate the health care professionals' preferences pertaining to support in the aftermath of patient safety incidents and potential variation thereof depending on the degree of harm. BACKGROUND: Peer support systems are available to support health care professionals in the aftermath of patient safety incidents. It is unclear which type of support is best offered by whom. METHODS: A cross-sectional study in 32 Dutch hospitals. RESULTS: In total, 2,362 nurses and 1,404 doctors indicated they were involved in patient safety incidents at any time during their career (86%). Less than 10% of health care providers had spoken with professional support, and less than 20% admitted a need to do so. They used different support. A higher degree of harm related to higher odds of desiring support. Respondents mainly wanted to understand what happened and how it can be prevented. CONCLUSION: The desired support of health care professionals in the aftermath of patient safety incidents depends on the level of harm. IMPLICATION FOR NURSING MANAGEMENT: Health care professionals seem to mostly rely on persons they are close with, and they mainly desire information related to the aftermath of patient safety incidents. This should be taken into account when support programmes are set up.

Prolonged mental health sequelae among doctors and nurses involved in patient safety incidents with formal complaints and lawsuits.

We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.

Cost-effectiveness of a quality improvement collaborative focusing on patients with diabetes.

OBJECTIVE: To investigate the lifelong health effects, costs, and cost-effectiveness of a quality improvement collaborative focusing on improving diabetes management in an integrated care setting. STUDY DESIGN AND METHODS: Economic evaluation from a healthcare perspective with lifetime horizon alongside a nonrandomized, controlled, before-after study in the Netherlands. Analyses were based on 1861 diabetes patients in 6 intervention and 9 control regions, representing 37 general practices and 13 out-patient clinics. Change in the United Kingdom Prospective Diabetes Study score, remaining lifetime, and costs per quality-adjusted life year gained were calculated. Probabilistic life tables were constructed using the United Kingdom Prospective Diabetes Study risk engine, a validated diabetes model, and nonparametric bootstrapping of individual patient data. RESULTS: Annual United Kingdom Prospective Diabetes Study risk scores reduced for cardiovascular events (hazard ratio: 0.83 and 0.98) and cardiovascular mortality (hazard ratio: 0.78 and 0.88) for men and women, respectively. Life expectancy improved by 0.97 and 0.76 years for men and women, and quality-adjusted life years by 0.44 and 0.37, respectively. Higher life expectancy in the intervention group increased lifelong costs by &OV0556;860 for men and &OV0556;645 for women. Initial program costs were about &OV0556;22 per patient. The incremental costs per quality-adjusted life year were &OV0556;1937 for men and &OV0556;1751 for women compared with usual care costs. There is a probability >95% that the collaborative is cost-effective, using a threshold of &OV0556;20,000 per quality-adjusted life year. CONCLUSION: Optimizing integrated and patient-centered diabetes care through a quality-improvement collaborative is cost-effective compared with usual care.

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

OBJECTIVES: To describe healthcare providers' symptoms evoked by patient safety incidents (PSIs), the duration of these symptoms and the association with the degree of patient harm caused by the incident. DESIGN: Cross-sectional survey. SETTING: 32 Dutch hospitals that participate in the 'Peer Support Collaborative'. PARTICIPANTS: 4369 healthcare providers (1619 doctors and 2750 nurses) involved in a PSI at any time during their career. INTERVENTIONS: All doctors and nurses working in direct patient care in the 32 participating hospitals were invited via email to participate in an online survey. PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of symptoms, symptom duration and its relationship with the degree of patient harm. RESULTS: In total 4369 respondents were involved in a PSI and completely filled in the questionnaire. Of these, 462 reported having been involved in a PSI with permanent harm or death during the last 6 months. This had a personal, professional impact as well as impact on effective teamwork requirements. The impact of a PSI increased when the degree of patient harm was more severe. The most common symptom was hypervigilance (53.0%). The three most common symptoms related to teamwork were having doubts about knowledge and skill (27.0%), feeling unable to provide quality care (15.6%) and feeling uncomfortable within the team (15.5%). PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm. CONCLUSION: The impact of PSI remains an underestimated problem. The higher the degree of harm, the longer the symptoms last. Future studies should evaluate how these data can be integrated in evidence-based support systems.

Factors that influence the stroke care team's effectiveness in reducing the length of hospital stay.

BACKGROUND AND PURPOSE: The purpose of this study was to explore the effects of a quality improvement program for improving stroke care and the determinants of success at the team and hospital levels. Method- For 16 months, 23 multidisciplinary stroke service teams participated in a quality improvement collaborative designed to set up stroke services and reduce the length of hospital stay (LOHS). We monitored the LOHS and the discharge delay during the project and measured indicators of well organized stroke services at baseline and after the intervention. A multiple and multilevel regression model was used to relate the outcome variables to the team and hospital characteristics. National LOHS figures served as reference data. RESULTS: Data regarding 4549 stroke patients were included in the analyses. The LOHS decreased significantly from 18.3 to 13.3 days. The mean LOHS varied substantially (9.2 to 20.9 days) after the intervention. Teams with higher team functioning scores showed lower LOHS scores and higher scores for the indicators of well organized stroke services. Team characteristics explain almost 40% of the variance in LOHS and 53% in the indicators of well organized stroke care. CONCLUSIONS: Participation in a national quality improvement collaborative effected a significant decrease of the LOHS and a significant increase in the presence of key features of stroke services. Variation in ability to reduce the LOHS and increase key features of stroke services were related to team functioning. The data suggest that the composite of team functioning is pivotal in quality-of-care improvement and may need specific attention in any quality improvement program.

Determinants of success of quality improvement collaboratives: what does the literature show?

CONTEXT: The apparent inconsistency between the widespread use of quality improvement collaboratives and the available evidence heightens the importance of thoroughly understanding the relative strength of the approach. More insight into factors influencing outcome would mean future collaboratives could be tailored in ways designed to increase their chances of success. This review describes potential determinants of team success and how they relate to effectiveness. METHOD: We searched Medline, CINAHL, Embase, Cochrane, and PsycINFO databases from January 1995 to June 2006. The 1995-2006 search was updated in June 2009. Reference lists of included papers were reviewed to identify additional papers. We included papers that were written in English, contained data about the effectiveness of collaboratives, had a healthcare setting, met our definition for collaborative, and quantitatively assessed a relationship between any determinant and any effect parameter. FINDINGS: Of 1367 abstracts identified, 23 papers (reporting on 26 collaboratives) provided information on potential determinants and their relationship with effectiveness. We categorised potential determinants of success using the definition for collaboratives as a template. Numerous potential determinants were tested, but only a few related to empirical effectiveness. Some aspects of teamwork and participation in specific collaborative activities enhanced short-term success. If teams remained intact and continued to gather data, chances of long-term success were higher. There is no empirical evidence of positive effects of leadership support, time and resources. CONCLUSIONS: These outcomes provide guidance to organisers, participants and researchers of collaboratives. To advance knowledge in this area we propose a more systematic exploration of potential determinants by applying theory and practice-based knowledge and by performing methodologically sound studies that clearly set out to test such determinants.

Factors influencing success in quality-improvement collaboratives: development and psychometric testing of an instrument.

BACKGROUND: To increase the effectiveness of quality-improvement collaboratives (QICs), it is important to explore factors that potentially influence their outcomes. For this purpose, we have developed and tested the psychometric properties of an instrument that aims to identify the features that may enhance the quality and impact of collaborative quality-improvement approaches. The instrument can be used as a measurement instrument to retrospectively collect information about perceived determinants of success. In addition, it can be prospectively applied as a checklist to guide initiators, facilitators, and participants of QICs, with information about how to perform or participate in a collaborative with theoretically optimal chances of success. Such information can be used to improve collaboratives. METHODS: We developed an instrument with content validity based on literature and the opinions of QIC experts. We collected data from 144 healthcare professionals in 44 multidisciplinary improvement teams participating in two QICs and used exploratory factor analysis to assess the construct validity. We used Cronbach's alpha to ascertain the internal consistency. RESULTS: The 50-item instrument we developed reflected expert-opinion-based determinants of success in a QIC. We deleted nine items after item reduction. On the basis of the factor analysis results, one item was dropped, which resulted in a 40-item questionnaire. Exploratory factor analysis showed that a three-factor model provided the best fit. The components were labeled 'sufficient expert team support', 'effective multidisciplinary teamwork', and 'helpful collaborative processes'. Internal consistency reliability was excellent (alphas between .85 and .89). CONCLUSIONS: This newly developed instrument seems a promising tool for providing healthcare workers and policy makers with useful information about determinants of success in QICs. The psychometric properties of the instrument are satisfactory and warrant application either as an objective measure or as a checklist.

Short- and long-term effects of a quality improvement collaborative on diabetes management.

INTRODUCTION: This study examined the short- and long-term effects of a quality improvement collaborative on patient outcomes, professional performance, and structural aspects of chronic care management of type 2 diabetes in an integrated care setting. METHODS: Controlled pre- and post-intervention study assessing patient outcomes (hemoglobin A1c, cholesterol, blood pressure, weight, blood lipid levels, and smoking status), professional performance (guideline adherence), and structural aspects of chronic care management from baseline up to 24 months. Analyses were based on 1,861 patients with diabetes in six intervention and nine control regions representing 37 general practices and 13 outpatient clinics. RESULTS: Modest but significant improvement was seen in mean systolic blood pressure (decrease by 4.0 mm Hg versus 1.6 mm Hg) and mean high density lipoprotein levels (increase by 0.12 versus 0.03 points) at two-year follow up. Positive but insignificant differences were found in hemoglobin A1c (0.3%), cholesterol, and blood lipid levels. The intervention group showed significant improvement in the percentage of patients receiving advice and instruction to examine feet, and smaller reductions in the percentage of patients receiving instruction to monitor blood glucose and visiting a dietician annually. Structural aspects of self-management and decision support also improved significantly. CONCLUSIONS: At a time of heightened national attention toward diabetes care, our results demonstrate a modest benefit of participation in a multi-institutional quality improvement collaborative focusing on integrated, patient-centered care. The effects persisted for at least 12 months after the intervention was completed. TRIAL NUMBER: http://clinicaltrials.gov Identifier: NCT 00160017.

Evidence for the impact of quality improvement collaboratives: systematic review.

OBJECTIVE: To evaluate the effectiveness of quality improvement collaboratives in improving the quality of care. DATA SOURCES: Relevant studies through Medline, Embase, PsycINFO, CINAHL, and Cochrane databases. STUDY SELECTION: Two reviewers independently extracted data on topics, participants, setting, study design, and outcomes. DATA SYNTHESIS: Of 1104 articles identified, 72 were included in the study. Twelve reports representing nine studies (including two randomised controlled trials) used a controlled design to measure the effects of the quality improvement collaborative intervention on care processes or outcomes of care. Systematic review of these nine studies showed moderate positive results. Seven studies (including one randomised controlled trial) reported an effect on some of the selected outcome measures. Two studies (including one randomised controlled trial) did not show any significant effect. CONCLUSIONS: The evidence underlying quality improvement collaboratives is positive but limited and the effects cannot be predicted with great certainty. Considering that quality improvement collaboratives seem to play a key part in current strategies focused on accelerating improvement, but may have only modest effects on outcomes at best, further knowledge of the basic components effectiveness, cost effectiveness, and success factors is crucial to determine the value of quality improvement collaboratives.