Regional needs assessment for emergency physician audit and feedback.

OBJECTIVES: Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region. METHODS: We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups. RESULTS: A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners. CONCLUSION: This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

How do emergency departments and emergency leaders catalyze positive change through quality improvement collaborations?

OBJECTIVES: Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration. METHODS: An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback. RESULTS: Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program. CONCLUSION: A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

OBJECTIF: L'amélioration de la qualité et la sécurité des patients (AQSP) joue un rôle important dans la correction des lacunes observées dans la prestation optimale de soins. Toutefois, les équipes de soins au service des urgences (SU) disposent de peu de documentation sur la conception de leurs propres programmes d'AQSP. L'étude avait donc pour objectif l'élaboration de recommandations conçues à l'intention des chefs de file, nouveaux ou confirmés, au SU, et présentées comme une voie à emprunter pour améliorer les soins aux patients, par l'application d'activités programmatiques d'AQSP, tout d'abord au sein du service, puis entre services, grâce à la collaboration. MÉTHODE: Un groupe d'experts composé de 10 cliniciens en médecine d'urgence, ayant des compétences particulières en AQSP et en pouvoir d'influence, a été mis sur pied. Un examen de cadrage a été entrepris à la recherche de publications sur l'établissement de programmes d'AQSP et de cadres de travail s'y rapportant, en soins de santé. Des consultations ont été menées avec les parties intéressées parmi les chefs de file en soins de santé au Canada, et le groupe d'experts a rédigé une version préliminaire de recommandations fondées sur l'ensemble de l'information recueillie. Celles-ci ont été examinées et améliorées durant le Symposium sur les affaires universitaires 2018 de l'ACMU, à Calgary, à la suite de rétroactions communiquées en personne ou par voie électronique. RÉSULTATS: Les recommandations portaient sur : l'éveil d'un sentiment d'urgence à l'égard de l'amélioration; la mobilisation d'intervenants et de chefs de file compétents; la mise sur pied d'un comité local structuré d'AQSP; l'obtention de financement et de ressources; la disponibilité de données locales pour orienter le travail; le soutien de la formation des membres d'équipe en AQSP; la promotion de la collaboration entre professions, entre services et avec les patients; l'utilisation d'un cadre de travail d'AQSP déjà établi afin d'orienter le travail; l'élaboration d'un système de récompenses et de structures incitatives; la possibilité d'entreprendre, au début, des initiatives à petite échelle, soit des projets plutôt que des programmes. CONCLUSION: Les dix recommandations ont été présentées à titre de principes directeurs en vue de l'élaboration d'activités d'AQSP et de leur mise en œuvre durable dans les SU, au Canada et ailleurs dans le monde. Les chefs de file dans les SU sont invités à appliquer ces recommandations dans le but d'améliorer les soins aux patients.

Evidence-based medicine: A cornerstone for clinical care but not for quality improvement.

Quality improvement (QI) as a clinical improvement science has been criticized for failing to deliver broad patient outcome improvement and for being a top-down regulatory and compliance construct. These critics have argued that the focus of QI should be on increasing adherence to clinical practice guidelines (CPGs) and, as a result, should be consolidated into research structures with the science of evidence-based medicine (EBM) at the helm. We argue that EBM often overestimates the role of knowledge as the root cause of quality problems and focuses almost exclusively on the effectiveness of care while often neglecting the domains of safety, efficiency, patient-centredness, and equity. Successfully addressing quality problems requires a much broader, systems-based view of health-care delivery. Although essential to clinical decision-making and practice, EBM cannot act as the cornerstone of health system improvement.