Adverse events reporting during the COVID-19 pandemic in a Danish region: a retrospective analysis.

The 2020 onset of the COVID-19 pandemic globally strained healthcare. Healthcare systems worldwide had to rapidly reorganize, impacting service delivery, patient care, and care-seeking behaviors. This left little time to assess the pandemic's effects on patient safety. This paper investigates COVID-19's influence on patient safety in a Danish region, using data from the national reporting system for adverse events during the initial COVID-19 surge in early 2020. This retrospective analysis investigated how the early phase of the COVID-19 pandemic (January-September 2020) affected the incidence of adverse events in a Danish Region, comparing it to the same period in 2019. Data were sourced from the Danish Patient Safety Database and regional systems. Adverse events were reported numerically. Descriptive statistics were employed to describe the percentage difference in adverse events and hospital activity, as well as the rate of adverse events per 1000 activities. Additionally, COVID-19-specific adverse events from April 2020 to March 2021 were identified and analyzed, categorizing them into seven risk areas across various healthcare sectors. During Denmark's initial COVID-19 surge in early 2020, the North Denmark Region's hospitals reported a significant decrease in adverse events, with a 42.5% drop in March 2020 compared to March 2019. From January to September 2020, the number of adverse events dropped 8.5% compared to the same period in 2019. In the same period, hospital activity declined by 10.2%. The ratio of reported adverse events per 1000 hospital activities thus decreased in early 2020 but showed only a minor difference overall for January-September compared to 2019. Between April 2020 and March 2021, out of 5703 total adverse events, 324 (5.7%) were COVID-19 related. COVID-19-related events were categorized into seven distinct risk areas, reflecting diverse impacts across healthcare sectors including hospitals, general practices, pre-hospital care, and specialized services. The initial decline in reporting of adverse events likely resulted from rapid healthcare changes and under-prioritization of the reporting system during the acute phase. However, a near return to pre-pandemic reporting levels suggests a resilient reporting system despite the crisis. The study's strength lies in the comprehensive data from Danish reporting systems, though it acknowledges potential underreporting and doesn't measure the pandemic's overall impact on patient safety.

From accreditation to quality improvement-The Danish National Quality Programme.

The Danish government launched a new National Quality Programme (NQP) in healthcare in 2015. It has changed the focus from old public management in terms of accreditation, regulation, rules and standards to new public governance focusing on delivering high quality healthcare and outcomes of value for the patients, health professionals and the Danish healthcare system. The NQP aims to strengthen the focus on continuous quality improvement and the launch of the programme was accompanied by a decision to phase out accreditation of public hospitals. The NQP includes 1) eight specific national quality goals, 2) a national educational programme for quality management, and 3) establishment of quality improvement collaboratives. Since the establishment of the NQP the indicator results have improved in several important clinical areas. However, causal conclusions related to the effect of the NQP cannot yet be made. This perspective on quality paper aims to give a short introduction to the NQP and documented outcomes.

Quality in practice: applying the patient inventory method at a Danish psychiatric hospital.

QUALITY PROBLEM: Patient care pathways should be organized according to the needs of the patients. This requires methods to assess whether the specific pathways ensure the right care for the right person at the right time and in the right setting. INITIAL ASSESSMENT: Previous investigations indicate that ~25% of the patients in Danish hospitals experience inappropriate elements in their care pathways. CHOICE OF SOLUTION: This study applied the Patient Inventory method to identify inappropriate elements in care pathways in 15 psychiatric in-patient wards in Denmark. IMPLEMENTATION: The pathway for 201 patients was systematically evaluated by the clinical staff to identify whether the admission of the patient was avoidable, the hospitalization was unnecessarily prolonged or if the patient could receive more relevant treatment elsewhere. A subsequent meeting between the clinical staff and management qualified the assessment and identified possible solutions to problems. EVALUATION: A total of 54 (26.9%) of the included patients were assessed to have inappropriate elements in their care pathways, some with more than one type, resulting in a total of 65 episodes.Eight of these episodes (13.1%) were admissions considered to be avoidable, 26 (42.2%) were unnecessary prolongation of admissions, and 31 (58.1%) were patients assessed to be able to receive more relevant care elsewhere. LESSONS LEARNED: One out of four assessed patients admitted to a psychiatric ward was exposed to an inappropriate element in their care pathway. The Patient Inventory tool can assist in a structured dialogue between clinical staff and management to identify focus areas for improvement efforts.

Patient Inventory: a quality improvement method.

Providing high quality care requires that patient care pathways are organized according to the needs of the patient. The organization of high-quality integrated patient care requires methods to assess 'appropriateness' of the care pathways to identify challenges in delivering the right procedure, for the right person at the right time and setting and with the most appropriate use of resources. There is a need for methods to assess appropriateness that can easily be implemented in daily clinical practice. The Patient Inventory method is such a method. Patient Inventory is a special type of audit that provides a 'snapshot' of the patient population in an entire hospital, a ward or another clinical unit. It maps the bed occupancy situation, as well as coordination, continuity and communication associated with the individual patient pathway. The aim is to identify inappropriate or wasteful events and to facilitate reflections on the underlying causes. These reflections are used to identify focus areas for quality improvement efforts. The method answers the question: 'Is it the right patient in the right place at the right time, and is the correct pathway for the patient organized with the most appropriate use of resources?' The aim of this method paper is to describe the background, definitions and methodologies for Patient Inventory, to offer a practical guidance for application of the method and to describe the current experiences with the method.

Can quality improvement improve the quality of care? A systematic review of reported effects and methodological rigor in plan-do-study-act projects.

BACKGROUND: The Plan-Do-Study-Act (PDSA) method is widely used in quality improvement (QI) strategies. However, previous studies have indicated that methodological problems are frequent in PDSA-based QI projects. Furthermore, it has been difficult to establish an association between the use of PDSA and improvements in clinical practices and patient outcomes. The aim of this systematic review was to examine whether recently published PDSA-based QI projects show self-reported effects and are conducted according to key features of the method. METHODS: A systematic literature search was performed in the PubMed, Embase and CINAHL databases. QI projects using PDSA published in peer-reviewed journals in 2015 and 2016 were included. Projects were assessed to determine the reported effects and the use of the following key methodological features; iterative cyclic method, continuous data collection, small-scale testing and use of a theoretical rationale. RESULTS: Of the 120 QI projects included, almost all reported improvement (98%). However, only 32 (27%) described a specific, quantitative aim and reached it. A total of 72 projects (60%) documented PDSA cycles sufficiently for inclusion in a full analysis of key features. Of these only three (4%) adhered to all four key methodological features. CONCLUSION: Even though a majority of the QI projects reported improvements, the widespread challenges with low adherence to key methodological features in the individual projects pose a challenge for the legitimacy of PDSA-based QI. This review indicates that there is a continued need for improvement in quality improvement methodology.

Multi-morbid patients with co-existing mental and physical illness.

This review investigates the mortality gap that exists between people with or people without mental illness. Poor physical health is the leading cause of excess mortality among people with mental illness. Mental disorders increase the risk of developing a broad range of physical diseases and the risk of death caused by somatic diseases is increased. Also, mental disorder is associated with less optimal treatment in the somatic healthcare system, which is also evident within a broad spectrum of somatic diseases. The role of structural factors such as the design of the healthcare system and stigma are developing.

Inequities in Mental Health Care Quality and Clinical Outcomes Among Inpatients with Depression Within a Tax-Financed Universal Health Care System.

Purpose: The objective was to examine potential socioeconomic inequities in guideline recommended quality of care as well as several clinical outcomes among first-time inpatients with major depressive disorder (MDD) in a tax-financed universal health care system. Patients and Methods: A nationwide cohort study was performed based on individual-level record linkage of public registers in Denmark. The study included all adult incident inpatients with MDD at Danish psychiatric hospitals in the period 2011-2017 (n=10,949). Socioeconomic position was assessed according to the level of education and income. Outcomes included quality of depression care for inpatients as reflected by the fulfillment of guideline recommended quality of care measures as well as clinical outcomes in terms of all-cause mortality, suicidal behavior, readmission for depression and all-cause readmission. Results: Patients with low-level education or low-level income were statistically significantly less likely to receive high quality of in-hospital care, defined as fulfillment of at least 70% of relevant performance measures (adjusted relative risk (RR) 0.92 and 0.87, respectively). In addition, the same patients had a higher all-cause mortality (adjusted RR 1.22 and 1.41, respectively). Patients with low education or middle income were associated with a higher risk of suicidal behavior (adjusted RR 1.28 and 1.19, respectively). While no differences were found in the risk of all-cause readmission, low-level education and income was associated with a lower risk of readmission due to MDD (adjusted RR 0.91 and 0.87, respectively). Conclusion: Inequities in quality of care and clinical outcomes were observed among MDD inpatients in a tax-financed universal health care system, indicating that lack of access to care and insurance is not the only explanation for inequity in health.

Differences in quality of care, mortality, suicidal behavior, and readmissions among migrants and Danish-born inpatients with major depressive disorder.

BACKGROUND: The increasing global migration has made migrants' health a pertinent topic. This article aimed to examine whether migrants were less likely than Danish-born residents to receive guideline recommended care when hospitalized for major depressive disorder (MDD) and potential differences in clinical outcomes, including all-cause mortality, suicidal behavior, and readmissions during 1-year follow-up after first-time admission. METHODS: A national cohort study was performed, including all adult MDD inpatients at mental care units in the period 2011-2017. Migrants and two migrant subgroups (non-Western and Western) were compared with Danish-born patients. Quality of care was examined using multivariable Poisson and linear regression models. Clinical outcomes were examined using Cox proportional hazards regression analysis. RESULTS: Migrant-status was associated with a non-significantly lower chance of receiving high-quality care (relative risk [RR] = 0.93, confidence interval [CI] 0.86:1.01) and lower readmission rates for depression (hazard rate ratio [HR] = 0.93, CI 0.86:1.01), and significantly higher all-cause mortality (HR = 1.55, CI 1.19:2.01) and lower all-cause readmission rate (HR = 0.88, CI 0.83:0.94). No clear association was found regarding suicidal behavior. While associations were comparable for migrant subgroups regarding readmission, the associations with low quality of care and of all-cause mortality appeared strongest among Western migrants. CONCLUSIONS: Among inpatients with MDD in a universal tax-financed healthcare system, being a migrant was associated with a potential lower quality of in-hospital care and worse clinical outcomes. These results warrant further investigation to clarify the underlying explanation for these inequalities and to develop and test interventions to ensure better quality of care and clinical outcomes for migrant patients.