Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network.

BACKGROUND: Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research. METHODS: In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations. RESULTS: Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic. CONCLUSIONS: Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Evaluation of an infection control link nurse program: an analysis using the RE-AIM framework.

BACKGROUND: Important elements of programs that train and support infection control link nurses (ICLN) are the engagement of stakeholders, support from hospital and ward management and a structure for iterative improvement. The effects of programs, that combine all these elements, are unknown. We evaluated such a comprehensive program to explore its impact on link nurses and infection prevention practices and routines. METHODS: We used the RE-AIM framework, a robust, evidence-based framework within the field of Implementation Science, to evaluate the impact of our ICLN training and support program. We used a mixed methods approach and organized the outcomes along its five dimensions: Reach, Effectiveness, Adoption, Implementation and Maintenance. RESULTS: Between 2014 and 2018, on average 91% of the inpatient wards and 58% of the outpatient clinics participated in the program (Reach) and impacted guideline adherence in inpatient wards. Link nurses felt engaged and empowered, and perceived their contribution to these results as pivotal. Ward managers confirmed the value of ICLN to help with implementing IPC practices (Effectiveness). The program was adopted both at the hospital and at the ward level (Adoption). Based on ongoing evaluations, the program was adapted by refining education, training and support strategies with emphasis on ward specific aspects (Implementation). The ICLN program was described as a key component of the infection prevention policy to sustain its effects (Maintenance). CONCLUSIONS: Our infection control link nurse program helped ICLN to improve infection prevention practices, especially in inpatient wards. The key to these improvements lay within the adaptability of our link nurse program. The adjustments to the program led to a shift of focus from hospital goals to goals tailored to the ward level. It allowed us to tailor activities to align them with the needs specific to each ward.

A pragmatic approach for implementation of value-based healthcare in Amsterdam UMC, the Netherlands.

BACKGROUND: The emphasis on implementation of value-based healthcare (VBHC) has increased in the Dutch healthcare system. Yet, the translation of the theoretical principles of VBHC towards actual implementation in daily practice has been rarely described. Our aim is to present a pragmatic step-by-step approach for VBHC implementation, developed and applied in Amsterdam UMC, to share our key elements. The approach may inspire others and can be used as a template for implementing VBHC principles in other hospitals. METHODS: The local approach is developed in a major academic hospital in the Netherlands, based at two locations with 15,000 employees in total. Experience-based co-design is used, building on our learning experiences from implementing VBHC for 14 specific patient groups. The described steps and activities devolved from iterative and participative co-design sessions with various experienced stakeholders involved in the implementation of one or more VBHC pathways. RESULTS: The approach includes five phases; preparation, design (team introduction, outcome selection, action agenda), building (outcome set integration in daily practice), implementation (training, outcome registration and implementation) and the continuous improvement cycle. We described two cases for illustration of the approach; the Cleft Lip and Palate and the Chronic Kidney Disease patient groups. For a good start, involvement of a clinical leader as driving force, ensuring participation of patient representatives and sufficient resources are needed. CONCLUSION: We have experienced that several defining features of the development and implementation of this approach may have contributed to its completeness and applicability. Key elements for success have been organisational readiness and clinical leadership. In conclusion, the approach has provided a first step towards VBHC in our hospital. Further research is needed for evaluation of its effectiveness including impact on value for patients.

How do studies assess the preventability of readmissions? A systematic review with narrative synthesis.

BACKGROUND: A large number of articles examined the preventability rate of readmissions, but comparison and interpretability of these preventability rates is complicated due to the large heterogeneity of methods that were used. To compare (the implications of) the different methods used to assess the preventability of readmissions by means of medical record review. METHODS: A literature search was conducted in PUBMED and EMBASE using "readmission" and "avoidability" or "preventability" as key terms. A consensus-based narrative data synthesis was performed to compare and discuss the different methods. RESULTS: Abstracts of 2504 unique citations were screened resulting in 48 full text articles which were included in the final analysis. Synthesis led to the identification of a set of important variables on which the studies differed considerably (type of readmissions, sources of information, definition of preventability, cause classification and reviewer process). In 69% of the studies the cause classification and preventability assessment were integrated; meaning specific causes were predefined as preventable or not preventable. The reviewers were most often medical specialist (67%), and 27% of the studies added interview as a source of information. CONCLUSION: A consensus-based standardised approach to assess preventability of readmission is warranted to reduce the unwanted bias in preventability rates. Patient-related and integrated care related factors are potentially underreported in readmission studies.

Using PROMs during routine medical consultations: The perspectives of people with Parkinson's disease and their health professionals.

BACKGROUND: The use of patient-reported outcomes measures (PROMs), such as quality of life or symptoms like pain or fatigue, is increasingly embraced within patient-centred care and shared decision making. OBJECTIVES: To investigate: (a) how patients and health professionals think about using PROMs during routine medical consultations; (b) for which purpose(s), patients and health professionals want to use PROMs during those consultations; and (c) how patients interpret PROMs information presented in various formats. People with Parkinson's disease and their health professionals served as case example. METHODS: We performed semi-structured interviews with patients (N = 13) and professionals (N = 7 neurologists; N = 7 physiotherapists). We also used a survey in which patients (N = 115) were shown six figures displaying different information types. Presentation formats of this information varied (line/bar graphs). Interpretation by patients, perceived usefulness of information, attitude towards using information during routine medical consultations and (hypothetical) decisions were assessed. FINDINGS: Patients and professionals were generally positive about using PROMs during medical consultations. Professionals stressed the opportunity to monitor changes in individual PROMs over time. Patients were primarily positive about aggregated PROMs to make treatment decisions. This information was also most often interpreted correctly, especially when presented through a line graph (90.1% correct). Professionals thought patients should take the initiative in discussing PROMs, whereas patients thought professionals should do so. CONCLUSION/DISCUSSION: When used in routine medical consultations, PROMs seem to have potential to support shared decision making and facilitate patient-professional communication. However, training seems needed for both patients and professionals to facilitate actual discussion and proper interpretation.

Interruptions during intravenous medication administration: A multicentre observational study.

AIMS: The aim of this study was to determine the frequency and cause of interruptions during intravenous medication administration, which factors are associated with interruptions and to what extent interruptions influence protocol compliance. BACKGROUND: Hospital nurses are frequently interrupted during medication administration, which contributes to the occurrence of administration errors. Errors with intravenous medication are especially worrisome, given their immediate therapeutic effects. However, knowledge about the extent and type of interruptions during intravenous medication administration is limited. DESIGN: Multicentre observational study. METHODS: Data were collected during two national evaluation studies (2011 - 2012 & 2015 - 2016). Nurses were directly observed during intravenous medication administration. An interruption was defined as a situation where a break during the administration was needed or where a nurse was distracted but could process without a break. Interruptions were categorized according to source and cause. Multilevel logistic regression analyses were conducted to assess the associations between explanatory variables and interruptions or complete protocol compliance. RESULTS: In total, 2,526 intravenous medication administration processes were observed. During 291 (12%) observations, nurses were interrupted 321 times. Most interruptions were externally initiated by other nurses (19%) or patients (19%). Less interruptions occurred during the evening (odds ratio: 0.23 [95% confidence interval: 0.08-0.62]). Do-not-disturb vests were worn by 61 (2%) nurses. No significant association was found between being interrupted and complete protocol compliance. CONCLUSION: An interruption occurred in every eight observed intravenous medication administration, mainly caused by other nurses or patients. One needs to consider critically which strategies effectively improve safety during the high-risk nursing-task of intravenous medication administration.

Blended learning for postgraduates; an interactive experience.

BACKGROUND: Blended learning has the potential to stimulate effective learning and to facilitate high quality education. For postgraduate health professionals, blended learning is relatively new. For this group we developed, implemented and evaluated two blended learning modules in a master program on quality and safety in patient care. Aiming for a better preparation compared to traditional textbook homework, the course provided not only web lectures and reading, but also interactive assignments and collaborative learning. Additional goal was saving time for the teachers resulting in a potential cost savings. METHOD: The experiences of 21 postgraduate health professionals were evaluated with two voluntary and anonymous questionnaires beginning of 2017 with a special focus on the added value of online interaction, underexposed in previous research. RESULTS: This evaluation shows that online modules are regarded as being an effective preparation for face-to-face meetings for postgraduate health professionals. Added value of social interactive online preparation was perceived from collaborating and interacting with each other. Both the interaction between the students, and the e-moderator and teachers were well received. CONCLUSIONS: Based on the results of this study, we suggest that blended learning may indeed increase the level of education and stimulate effective learning for postgraduate health care professionals. The professionals experienced added value of social interactive online preparation from collaborating and interacting with each other. We consider better aligning of the online and face-to-face components as one of the highest priorities.

EXPLORING MEDICAL DEVICES: THE USE OF RISK ASSESSMENT TOOLS AND THEIR LINK WITH TRAINING IN HOSPITALS.

OBJECTIVES: The aim of this study was to explore the risk assessment tools and criteria used to assess the risk of medical devices in hospitals, and to explore the link between the risk of a medical device and how those risks impact or alter the training of staff. METHODS: Within a broader questionnaire on implementation of a national guideline, we collected quantitative data regarding the types of risk assessment tools used in hospitals and the training of healthcare staff. RESULTS: The response rate for the questionnaire was 81 percent; a total of sixty-five of eighty Dutch hospitals. All hospitals use a risk assessment tool and the biggest cluster (40 percent) use a tool developed internally. The criteria used to assess risk most often are: the function of the device (92 percent), the severity of adverse events (88 percent) and the frequency of use (77 percent). Forty-seven of fifty-six hospitals (84 percent) base their training on the risk associated with a medical device. For medium- and high-risk devices, the main method is practical training. As risk increases, the amount and type of training and examination increases. CONCLUSIONS: Dutch hospitals use a wide range of tools to assess the risk of medical devices. These tools are often based on the same criteria: the function of the device, the potential severity of adverse events, and the frequency of use. Furthermore, these tools are used to determine the amount and type of training required for staff. If the risk of a device is higher, then the training and examination is more extensive.

Development and validation of a model for the adoption of structured and standardised data recording among healthcare professionals.

BACKGROUND: Healthcare professionals provide care to patients and during that process, record large quantities of data in patient records. Data in an Electronic Health Record should ideally be recorded once and be reusable within the care process as well as for secondary purposes. A common approach to realise this is to let healthcare providers record data in a standardised and structured way at the point of care. Currently, it is not clear to what extent this structured and standardised recording has been adopted by healthcare professionals and what barriers to their adoption exist. Therefore, we developed and validated a multivariable model to capture the concepts underlying the adoption of structured and standardised recording among healthcare professionals. METHODS: Based on separate models from the literature we developed a new theoretical model describing the underlying concepts of the adoption of structured and standardised recording. Using a questionnaire built upon this model we gathered data to perform a summative validation of our model. Validation was done through partial least squares structural equation modelling (PLS-SEM). The quality of both levels defined in PLS-SEM analysis, i.e., the measurement model and the structural model, were assessed on performance measures defined in literature. RESULTS: The theoretical model we developed consists of 29 concepts related to information systems as well as organisational factors and personal beliefs. Based on these concepts, 59 statements with a 5 point Likert-scale (fully disagree to fully agree) were specified in the questionnaire. We received 3584 responses. The validation shows our model is supported to a large extent by the questionnaire data. Intention to record in a structured and standardised way emerged as a significant factor of reported behaviour (ß = 0.305, p < 0.001). This intention is influenced most by attitude (ß = 0.512, p < 0.001). CONCLUSIONS: This model can be used to measure the perceived level of adoption of structured and standardised recording among healthcare professionals and further improve knowledge on the barriers and facilitators of this adoption.

A baseline assessment by healthcare professionals of Dutch pharmacotherapeutic care for the elderly with polypharmacy.

Background: Polypharmacy is common in the elderly population and is associated with an increased risk of adverse drug events. To diminish this risk, the guideline 'Polypharmacy in the Elderly' has been developed in 2012. This study examines, to what extent Dutch pharmacotherapeutic practice amongst elderly with polypharmacy mirrors the best practice described in this guideline and which barriers threaten it. Methods: An observational study was conducted in 2013/14 using a questionnaire distributed amongst Dutch healthcare professionals and elderly patients with polypharmacy. Healthcare professionals were asked about their current practice and the presence of five significant barriers, selected through a literature review and from expert opinion. These barriers are: inadequate transfer of patient records; insufficient documentation of prescribed drugs; a lack of collaboration between professionals; a failure to take a full control of the medication and insufficient involvement of the patient. The patients were asked about their experience with pharmacotherapeutic care. Results: No more than 26% of the healthcare professionals indicated that they use the guideline. The five barriers threatening the pharmacotherapeutic care were found to be present. Forty-three percent of the patients mentioned that their medication was assessed last year. Conclusion: The guideline is not used frequently by the healthcare professionals, but there is a will to improve the care by following this guideline. However, the presence of the five barriers hampers its implementation. Good management of those barriers is necessary in order to improve the collaboration between primary and secondary care and to enhance the documentation of prescribed drugs.

Association of admission and patient characteristics with quality of discharge letters: posthoc analysis of a retrospective study.

BACKGROUND: A complete, correct and timely discharge letter can communicate important information from the hospital to the general practitioner. The adequacy of the letter may vary with the patient and admission characteristics of the patient. Insight in the association between these characteristics and the presence and quality of the discharge letter will give rise to improvement activities for a better continuity of care after discharge. The objective was to determine the presence, correctness and timeliness of admission information in discharge letters and to determine the association between patient and admission characteristics, including unplanned readmissions and the quality of the discharge letter. METHODS: A post-hoc analysis of a two-staged retrospective patient record review study was performed in 4048 patient records in a random sample of 20 hospitals. RESULTS: Nearly ten percent of the discharge letters are lacking in patient records in Dutch hospitals. In 59.1% of the discharge letters, one or more relevant components are missing. Important laboratory results, relevant information about consultations, answers to the questions of the referrer, changes in medication and follow up are often lacking. Discharge letters are more likely to be missing in elective patient admissions to a hospital, with a shorter length of stay, less comorbidity, and in readmissions. There was a significant variation in missing discharge letters between hospitals and between hospital departments. CONCLUSIONS: The quality of discharge letters varies with patient and admission characteristics.

Excess length of stay and economic consequences of adverse events in Dutch hospital patients.

BACKGROUND: To investigate the average and extrapolated excess length of stay and direct costs of adverse events (AEs) and preventable AEs in Dutch hospitals, and to evaluate patient characteristics associated with excess length of stay and costs. METHODS: Data of a large retrospective patient record review study on AEs was used. A stratified sample of 20 Dutch hospitals was included. Excess length of stay and costs attributable to AEs and preventable AEs were calculated and extrapolated to a national estimate. The association between patient characteristics and excess length of stay (and costs thereof) attributable to AEs and preventable AEs was investigated through multilevel linear regression analyses. RESULTS: A total of 2975 patient records were included in the analysis, of which 325 experienced one or more AEs. Hospital patients experiencing an AE stayed 5.11 (95% CI 3.91-6.30) more days in hospital and cost €2600 (95% CI €1968-€3232) more compared to those without an AE. There was no significant difference in days and costs between preventable and non-preventable AEs. Extrapolated to a national level, AEs cost more than €300 million, which was 1.3% of the national hospital care budget. Patients with hospital-acquired infections had a statistically significant longer length of stay compared to the reference group (patients with AEs on the cardiovascular system). CONCLUSIONS: This study showed that AEs lead to substantial excess length of stay and increased costs. Special attention should be paid to patients with AEs due to an hospital-acquired infection.

Exploring the treatment delay in the care of patients with ST-elevation myocardial infarction undergoing acute percutaneous coronary intervention: a cross-sectional study.

BACKGROUND: A short delay between diagnosis and treatment for patients diagnosed with ST-elevation myocardial infarction (STEMI) is vital to prevent cardiac damage and mortality. The objective of this study was to explore the treatment delay and associated factors in the management of patients diagnosed with STEMI going for percutaneous coronary intervention (PCI). METHODS: In a cross-sectional multicenter study, the treatment delay (time between first electrocardiogram and start of PCI procedure) of STEMI patients in seven PCI centers in the Netherlands was measured. Data were analyzed by means of multivariable generalized linear models, accounting for a non-normally distributed outcome and clustering of patients within centers. RESULTS: In total, 1017 patient charts were included. The majority of the patients (78.7%) were treated within the guideline recommended time target of 90 min. Overall, the median treatment delay was 64 min (interquartile range 47-82). A significantly prolonged delay was found among patients of whom their first electrocardiogram was performed at a general practitioner's practice (+23.9 min; 95% confidence interval 9.9-40.8) or in-hospital (+9.5 min; 95% confidence interval 2.5-17.3), patients requiring interhospital transfer (+14.6 min; 95% confidence interval 7.6-22.4) or presenting with acute heart failure on admission (+17.6 min; 95% confidence interval 7.9-28.7). CONCLUSIONS: Despite a short median delay between first electrocardiogram and PCI, the time targets are occasionally exceeded for patients diagnosed with STEMI. To further improve the process of care, PCI centers should focus on improving regional STEMI care networks, involving general practitioners, emergency departments and referring hospitals.

Understanding factors that influence the use of risk scoring instruments in the management of patients with unstable angina or non-ST-elevation myocardial infarction in the Netherlands: a qualitative study of health care practitioners' perceptions.

BACKGROUND: Cardiac risk scores estimate a patient's risk of future cardiac events or death. They are developed to inform treatment decisions of patients diagnosed with unstable angina or non-ST-elevation myocardial infarction. Despite recommending their use in guidelines and evidence of their prognostic value, they seem underused in practice. The purpose of the study was to gain insight in the motivation for implementing cardiac risk scores, and perceptions of health care practitioners towards the use of these instruments in clinical practice. METHODS: This qualitative study involved semi-structured interviews with 31 health care practitioners at 11 hospitals throughout the Netherlands. Participants were approached through purposive sampling to represent a broad range of participant- and hospital characteristics, and included cardiologists, medical residents, medical interns, nurse practitioners and an emergency physician. The Pettigrew and Whipp Framework for strategic change was used as a theoretical basis. Data were initially analysed through open coding to avoid forcing data into categories predetermined by the framework. RESULTS: Cardiac risk score use was dependent on several factors, including IT support, clinical relevance for daily practice, rotation of staff and workload. Both intrinsic and extrinsic drivers for implementation were identified. Reminders, feedback and IT solutions were strategies used to improve and sustain the use of these instruments. The scores were seen as valuable support systems in improving uniformity in treatment practices, educating interns, conducting research and quantifying a practitioner's own risk assessment. However, health care practitioners varied in their perceptions regarding the influence of cardiac risk scores on treatment decisions. CONCLUSIONS: Health care practitioners disagree on the value of cardiac risk scores for clinical practice. Practitioners driven by intrinsic motivations predominantly experienced benefits in policy-making, education and research. Practitioners who were forced to use cardiac risk scores were less likely to take into account the risk score in their treatment decisions. The results of this study can be used to develop strategies that stimulate or sustain cardiac risk score use in practice, while taking into account barriers that affect cardiac risk score use, and possibly reduce practice variation in the management of unstable angina and non-ST-elevation myocardial infarction patients.

The ecometric properties of a measurement instrument for prospective risk analysis in hospital departments.

BACKGROUND: Safety management systems have been set up in healthcare institutions to reduce the number of adverse events. Safety management systems use a combination of activities, such as identifying and assessing safety risks in the organizational processes through retrospective and prospective risk assessments. A complementary method to already existing prospective risk analysis methods is Tripod, which measures latent risk factors in organizations through staff questionnaires. The purpose of this study is to investigate whether Tripod can be used as a method for prospective risk analysis in hospitals and whether it can assess differences in risk factors between hospital departments. METHODS: Tripod measures risk factors in five organizational domains: (1) Procedures, (2) Training, (3) Communication, (4) Incompatible Goals and (5) Organization. Each domain is covered by 15 items in the questionnaire. A total of thirteen departments from two hospitals participated in this study. All healthcare staff working in the participating departments were approached. The multilevel method ecometrics was used to evaluate the validity and reliability of Tripod. Ecometrics was needed to ensure that the differences between departments were attributable to differences in risk at the departmental level and not to differences between individual perceptions of the healthcare staff. RESULTS: A total of 626 healthcare staff completed the questionnaire, resulting in a response rate of 61.7%. Reliability coefficients were calculated for the individual level and department level. At the individual level, reliability coefficients ranged from 0.78 to 0.87, at the departmental level they ranged from 0.55 to 0.73. Intraclass correlations at the departmental level ranged from 3.7% to 8.5%, which indicate sufficient clustering of answers within departments. At both levels the domains from the questionnaire were positively interrelated and all significant. CONCLUSIONS: The results of this study show that Tripod can be used as a method for prospective risk analysis in hospitals. Results of the questionnaire provide information about latent risk factors in hospital departments. However, this study also shows that there are indications that the method is not sensitive enough to detect differences between hospital departments. Therefore, it is important to be careful when interpreting differences in potential risks between departments when using Tripod.

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial.

BACKGROUND: The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective. METHODS: In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs. RESULTS: Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly). CONCLUSIONS: Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant. TRIAL REGISTRATION: Current Controlled trials: ISRCTN66124817.

Is culture associated with patient safety in the emergency department? A study of staff perspectives.

OBJECTIVE: To describe the patient safety culture of Dutch emergency departments (EDs), to examine associations between safety culture dimensions and patient safety grades as reported by ED staff and to compare these associations between nurses and physicians. DESIGN: Cross-sectional survey conducted in 2007. SETTING: Thirty-three non-academic EDs in the Netherlands. PARTICIPANTS: Four hundred and eighty nurses, 159 physicians and 91 other professionals. MAIN OUTCOME MEASURE: Self-reported level of patient safety. RESULTS: In unadjusted analyses, all dimensions of safety culture were positively associated with the reported level of patient safety and six of these associations with patient safety were statistically significant after adjustment ('teamwork across units', 'frequency of event reporting', communication openness', 'feedback about and learning from errors', 'hospital management support for patient safety'). Differences between nurses and physicians were found on two dimensions ('frequency of event reporting' and ' hospital management support for patient safety'). Physicians tended to grade patient safety higher than nurses whilst having equal judgements on these two dimensions. CONCLUSIONS: Staff identified several dimensions of safety culture that are associated with staff-reported safety in the ED. Physicians and nurses identified distinct dimensions of safety culture as associated with reported level of patient safety.

Barriers and facilitators for taking action after classroom-based crew resource management training at three ICUs.

BACKGROUND: Given growing awareness of the crucial role of nontechnical skills in providing safe patient care, crew resource management (CRM) training is being increasingly used to improve them. Implementing the plans of action that are formulated during CRM training may constitute an important first step in the successful uptake of skills. Accordingly, understanding the factors that determine why participants do or do not carry out those plans should help improve CRM training and enhance its impact. A study was conducted to examine the impact of pretraining readiness factors and posttraining barriers and facilitators on follow-up on plans of action. METHODS: Three ICUs, each at a different nonacademic teaching hospital in The Netherlands, received two-day classroom-based CRM training in 2010. During the training, new ideas for safety initiatives were documented as concrete plans of action. All plans were categorized as individual (for example, "Always ask a colleague to double-check your medication"), team, or organizational. Two months before and three months after the CRM training, all ICU employees were asked to fill out a set of questionnaires. RESULTS: Management support for patient safety before the training was a positive determinant of the number of perceived facilitators. A significant relationship was found between the perceived barriers and facilitators after CRM training and Taking Action. More barriers were negatively associated, while more facilitators were positively associated, with Taking Action. When assessed separately, none of the readiness factors were significantly associated with taking action, while when assessed together, the readiness factors were positive related to Taking Action. DISCUSSION: To overcome the barriers and profit from the facilitators, they should be considered during the training and in regular CRM meetings afterward.

"Something we must be proud of": An interview and document study of team improvisation in the Dutch convalescent plasma project group.

Background and Aims: The COVID-19 pandemic has revealed the importance of organizational resilience, the ability to effectively respond to a disruptive event before, during, and after it occurs. Team improvisation is an important component of organizational resilience as it describes characteristics of team skills and contextual qualities to create order from chaos. In Spring 2020, the Dutch national blood bank, began the convalescent plasma project (CCP). We aimed to study which elements of team improvisation in the CCP group were found and how lessons learned can contribute towards a non-crisis situation for blood establishments. Methods: Using Vera and Crossan's framework of improvisation, semi-structured interviews with eight members of the CCP group were conducted. This was simultaneous to performing a document analysis of 21 Intranet posts and seven internal reports. MAXDA 2020 was used to conduct deductive and inductive thematic analyses. Results: The CCP group showed strong characteristics of expertise and memory, teamwork quality, experimental culture, and real-time information and communication that enabled them to improvise in all aspects of the donation process. Improvisation examples included comprehensive communication methods to identify and obtain new donors, asking additional intake questions and collecting additional aliquots to store while waiting for an internal antibody test to be developed, and regulatory respondents allowing a flexible change control procedure to meet the pace of the crisis. Training was evident to a lesser degree. Conclusion: While improvisation impacted set routines and procedures, the safety and quality of the product were not affected. Regarding organizational resilience, our results showed that the CCP group "coped" well using elements of team improvisation. Blood establishments may consider introducing improvisational training and innovation teams throughout the organization for future preparedness and improving organizational resilience.

Building towards organisational resilience and complexity leadership: a case study of impacts and changes in a Dutch blood establishment during COVID-19.

OBJECTIVES: This study examined how one large blood-related establishment coped and adapted during the first 1.5 years of the pandemic by evaluating the impacts and changes on its resources, communication, collaborations, and monitoring and feedback. Furthermore, we explored whether elements of complexity leadership emerged during this time. DESIGN: Duchek's organisational resilience framework was primarily used. We followed a three-step sequential approach: (1) a document analysis of over 150 intranet, internet and internal reports; (2) 31 semistructured interviews with employees and (3) four feedback sessions. SETTING: Sanquin is known as the Dutch national blood bank and a large multidivisional expertise organisation in the Netherlands. RESULTS: Sanquin coped well. Respondents accepted the crisis and catalysed many collaborations to implement solutions, which were communicated to the public. There were many positive aspects related to internal collaborations, yet challenges remained related to its historical siloed structure and culture. Sanquin adapted partially. Many respondents experienced the organisation becoming more connected and flexible during the pandemic. However, Sanquin was not permanently changed due to significant leadership changes and organisational restructuring occurring simultaneously. Respondents reflected on lessons learnt, including the need for continual collaboration and improvements in Sanquin's culture. An important driver in the successful coping was management's enabling attitude and the adaptations occurring within and through the collaborative groups. CONCLUSIONS: Sanquin improved its organisational resilience by exhibiting elements of adaptive spaces, enabling leadership and (temporary) emergence from complexity leadership. This illuminates how the organisation could continue benefiting from complexity leadership for non-crises and for future uncertainties.