Fixed dose ketamine for prehospital management of hyperactive delirium with severe agitation.

INTRODUCTION: Patients exhibiting signs of hyperactive delirium with severe agitation (HDSA) may require sedating medications for stabilization and safe transport to the hospital. Determining the patient's weight and calculating the correct weight-based dose may be challenging in an emergency. A fixed dose ketamine protocol is an alternative to the traditional weight-based administration, which may also reduce dosing errors. The objective of this study was to evaluate the frequency and characteristics of adverse events following pre-hospital ketamine administration for HDSA. METHODS: Emergency Medical Services (EMS) records from four agencies were searched for prehospital ketamine administration. Cases were included if a 250 mg dose of ketamine was administered on standing order to an adult patient for clinical signs consistent with HDSA. Protocols allowed for a second 250 mg dose of ketamine if the first dose was not effective. Both the 250 mg initial dose and the total prehospital dose were analyzed for weight based dosing and adverse events. RESULTS: Review of 132 cases revealed 60 cases that met inclusion criteria. Patients' median weight was 80 kg (range: 50-176 kg). No patients were intubated by EMS, one only requiring suction, three required respiratory support via bag valve mask (BVM). Six (10%) patients were intubated in the emergency department (ED) including the three (5%) supported by EMS via BVM, three (5%) others who were sedated further in the ED prior to requiring intubation. All six patients who were intubated were discharged from the hospital with a Cerebral Performance Category (CPC) 1 score. The weight-based dosing equivalent for the 250 mg initial dose (OR: 2.62, CI: 0.67-10.22) and the total prehospital dose, inclusive of the 12 patients that were administered a second dose, (OR: 0.74, CI: 0.27, 2.03), were not associated with the need for intubation. CONCLUSION: The 250 mg fixed dose of ketamine was not >5 mg/kg weight-based dose equivalent for all patients in this study. Although a second 250 mg dose of ketamine was permitted under standing orders, only 12 (20%) of the patients were administered a second dose, none experienced an adverse event. This indicates that the 250 mg initial dose was effective for 80% of the patients. Four patients with prehospital adverse events likely related to the administration of ketamine were found. One required suction, three (5%) requiring BVM respiratory support by EMS were subsequently intubated upon arrival in the ED. All 60 patients were discharged from the hospital alive. Further research is needed to determine an optimal single administration dose for ketamine in patients exhibiting signs of HDSA, if employing a standardized fixed dose medication protocol streamlines administration, and if the fixed dose medication reduces the occurrence of dosage errors.

A Qualitative Analysis of the Experiences of EMS Clinicians in Recognizing and Treating Witnessed Cardiac Arrests.

BACKGROUND: Survival from out of hospital cardiac arrest (OHCA) increases when effective cardiopulmonary resuscitation (CPR) and defibrillation are performed early. Patients who suffer OHCA in front of emergency medical services (EMS) clinicians have greater likelihood of survival, but little is known about how EMS clinicians think about and experience those events. We sought to understand how EMS clinicians assessed patients who devolved to cardiac arrest in their presence and uncover the perceived barriers and facilitators associated with recognizing and treating witnessed OHCAs. METHODS: EMS clinicians who had attended an EMS-witnessed OHCA and consented to participate were interviewed within 72 hours of the index case. Transcripts of the interviews were coded through the consolidated framework for implementation research to understand enabling and constraining factors involved and the predictability and anticipation of OHCA and subsequent management of patient care. Utstein data points, interventions, and associated times were extracted from the medical records. RESULTS: We interviewed 29 EMS clinicians who attended 27 EMS-witnessed OHCAs. Twenty-six (96.3%) of the EMS-witnessed OHCAs were preceded by prodromal symptoms and were classified as predictable. Of the predictable cases, clinicians anticipated 53.8% of them and attributed the prodromes of other cases to serious but not peri-arrest etiologies. Participants described various environmental, crew, and intrapersonal enabling and constraining factors associated with recognizing and treating EMS-witnessed OHCAs. Environmental elements included issues of safety and physical locations, crew elements included familiarity with their partners and working with them in the past, and intrapersonal elements included abilities to collect information and stress associated with responding to and managing the calls. CONCLUSION: Recognition and treatment of EMS-witnessed OHCAs are influenced by numerous environmental, crew, and intrapersonal factors. Future training and education on OHCA should include diverse locations, situations, and crew make-up, along with nontraditional patient complaints to broaden experiences associated with cardiac arrest management.

Transport Rates and Prehospital Intervals for an EMS Telemedicine Intervention.

INTRODUCTION: Emergency medical services (EMS) facilitated telemedicine encounters have been proposed as a strategy to reduce transports to hospitals for patients who access the 9-1-1 system. It is unclear which patient impressions are most likely able to be treated in place. It is also unknown if the increased time spent facilitating the telemedicine encounter is offset by the time saved from reducing the need for transport. The objective of this study was to determine the association between the impressions of EMS clinicians of the patients' primary problems and transport avoidance, and to describe the effects of telemedicine encounters on prehospital intervals. METHODS: This was a retrospective review of EMS records from two commercial EMS agencies in New York and Tennessee. For each EMS call where a telemedicine encounter occurred, a matched pair was identified. Clinicians' impressions were mapped to the corresponding category in the International Classification of Primary Care, 2nd edition (ICPC-2). Incidence and rates of transport avoidance for each category were determined. Prehospital interval was calculated as the difference between the time of ambulance dispatch and back-in-service time. RESULTS: Of the 463 prehospital telemedicine evaluations performed from March 2021 to April 2022, 312 (67%) avoided transports to the hospital. Respiratory calls were most likely to result in transport avoidance (p = 0.018); no other categories had statistically significant transport rates. Four hundred sixty-one (99.6%) had matched pairs identified and were included in the analysis. When compared to the matched pair, telemedicine without transport was associated with a prehospital interval reduction in 68% of the cases with a median reduction of 16 min; this is significantly higher than telemedicine with transport when compared to the matched pair with a median interval increase in 27 min. Regardless of transport status, the prehospital interval was a median of 4 min shorter for telemedicine encounters than non-telemedicine encounters (p = 0.08). CONCLUSION: In this study, most telemedicine evaluations resulted in ED transport avoidance, particularly for respiratory issues. Telemedicine interventions were associated with a median four-minute decrease in prehospital interval per call. Future research should investigate the long-term effects of telemedicine on patient outcomes.

Patients and relatives as auditors of safe practices in oncology and hematology day hospitals.

BACKGROUND: When there is a gap in professionals' adherence to safe practices during cancer treatment, the consequences can be serious. Identifying these gaps in order to enable improvements in patient safety can be a challenge. This study aimed to assess if cancer patients and their relatives can be given the skills to audit reliably four safe practices, and to explore whether they are willing to play this new role. METHODS: We recruited 136 participants in 2018, from the oncology and haematology day hospital of a tertiary hospital in Spain. Patient identification, hand hygiene, blood or chemotherapy identification, and side effects related to transfusion and chemotherapy, were the safe practices selected for evaluation. The study comprised two parts: an interventional educational program and a cross-sectional design to collect data and assess to what degree participants are able and willing to be auditors depending on their characteristics using multivariate logistic regression models. A participant's auditing skill were assessed pre and post the educational intervention. RESULTS: The model was seeking predictors of being a good auditor. 63 participants (46.3%) were classified as good auditors after the training. To have younger age, higher educational level and to have had an experience of an adverse event were associated with a higher probability of being a good auditor. Additionally, 106 (77.9%) participants said that they would like to audit anonymously the professionals' compliance of at least three of four safe practices. The willingness to audit safe practices differed depending on the safe practice but these differences did not reach statistical significance. CONCLUSIONS: The data gathered by patients and relatives acting as auditors can provide healthcare organizations with valuable information about safety and quality of care that is not accessible otherwise. This new role provides an innovative way to engage patients and their families' in healthcare safety where other methods have not had success. The paper sets out the methods that healthcare organizations need to undertake to enrol and train patients and relatives in an auditor role.

Translating research on quality improvement in five European countries into a reflective guide for hospital leaders: the 'QUASER Hospital Guide'.

OBJECTIVE: The aim was to translate the findings of the QUASER study into a reflective, dialogic guide to help senior hospital leaders develop an organization wide QI strategy. DESIGN: The QUASER study involved in depth ethnographic research into QI work and practices in two hospitals in each of five European countries. Three translational stakeholder workshops were held to review research findings and advise on the design of the Guide. An extended iterative process involving researchers from each participant country was then used to populate the Guide. SETTING: The research was carried out in two hospitals in each of five European countries. PARTICIPANTS: In total, 389 interviews with healthcare practitioners and 803 hours of observations. INTERVENTION: None. MAIN OUTCOME MEASURE: None. RESULTS: The QUASER Hospital Guide was designed for leadership teams to diagnose their organization's strengths and weaknesses in the eight QI challenges. The Guide supports organizational dialogue about QI challenges, enables leaders to share perspectives, and helps teams to develop solutions to their situated problems. The Guide includes extensive examples of QI strategies drawn from the data and is published online and on paper. CONCLUSIONS: The QUASER Hospital Guide is empirically based, draws on a dialogical approach to Organizational Development and complexity science and can facilitate hospital leadership teams to identify the best solutions for their organization.

Talking about quality: exploring how 'quality' is conceptualized in European hospitals and healthcare systems.

BACKGROUND: Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study. METHODS: This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics). RESULTS: The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided. CONCLUSION: The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

Prospects for comparing European hospitals in terms of quality and safety: lessons from a comparative study in five countries.

PURPOSE: Being able to compare hospitals in terms of quality and safety between countries is important for a number of reasons. For example, the 2011 European Union directive on patients' rights to cross-border health care places a requirement on all member states to provide patients with comparable information on health-care quality, so that they can make an informed choice. Here, we report on the feasibility of using common process and outcome indicators to compare hospitals for quality and safety in five countries (England, Portugal, The Netherlands, Sweden and Norway). MAIN CHALLENGES IDENTIFIED: The cross-country comparison identified the following seven challenges with respect to comparing the quality of hospitals across Europe: different indicators are collected in each country; different definitions of the same indicators are used; different mandatory versus voluntary data collection requirements are in place; different types of organizations oversee data collection; different levels of aggregation of data exist (country, region and hospital); different levels of public access to data exist; and finally, hospital accreditation and licensing systems differ in each country. CONCLUSION: Our findings indicate that if patients and policymakers are to compare the quality and safety of hospitals across Europe, then further work is urgently needed to agree the way forward. Until then, patients will not be able to make informed choices about where they receive their health care in different countries, and some governments will remain in the dark about the quality and safety of care available to their citizens as compared to that available in neighbouring countries.

Social Determinants of Health in EMS Records: A Mixed-methods Analysis Using Natural Language Processing and Qualitative Content Analysis.

Introduction: Social determinants of health (SDoH) are known to impact the health and well-being of patients. However, information regarding them is not always collected in healthcare interactions, and healthcare professionals are not always well-trained or equipped to address them. Emergency medical services (EMS) professionals are uniquely positioned to observe and attend to SDoH because of their presence in patients' environments; however, the transmission of that information may be lost during transitions of care. Documentation of SDoH in EMS records may be helpful in identifying and addressing patients' insecurities and improving their health outcomes. Our objective in this study was to determine the presence of SDoH information in adult EMS records and understand how such information is referenced, appraised, and linked to other determinants by EMS personnel. Methods: Using EMS records for adult patients in the 2019 ESO Data Collaborative public-use research dataset using a natural language processing (NLP) algorithm, we identified free-text narratives containing documentation of at least one SDoH from categories associated with food, housing, employment, insurance, financial, and social support insecurities. From the NLP corpus, we randomly selected 100 records from each of the SDoH categories for qualitative content analysis using grounded theory. Results: Of the 5,665,229 records analyzed by the NLP algorithm, 175,378 (3.1%) were identified as containing at least one reference to SDoH. References to those SDoH were centered around the social topics of accessibility, mental health, physical health, and substance use. There were infrequent explicit references to other SDoH in the EMS records, but some relationships between categories could be inferred from contexts. Appraisals of patients' employment, food, and housing insecurities were mostly negative. Narratives including social support and financial insecurities were less negatively appraised, while those regarding insurance insecurities were mostly neutral and related to EMS operations and procedures. Conclusion: The social determinants of health are infrequently documented in EMS records. When they are included, they are infrequently explicitly linked to other SDoH categories and are often negatively appraised by EMS professionals. Given their unique position to observe and share patients' SDoH information, EMS professionals should be trained to understand, document, and address SDoH in their practice.

Strategies for sustaining a quality improvement collaborative and its patient safety gains.

OBJECTIVE: To identify strategies to facilitate the sustainability of a quality and safety improvement collaborative: the Safer Patients Initiative (SPI) and its successes. DESIGN: A qualitative interview study with a repeated sample at two time points. SETTING: Twenty organizations participating in the SPI programme in the UK. PARTICIPANTS: Twenty principal SPI programme coordinators took part in interviews towards the end of the supported phase of the programme, 12 of which were interviewed again a year later, along with another three replacement programme coordinators, totalling 35 interviewees across the two time points. MAIN OUTCOME MEASURES: Programme coordinators' perceptions of facilitating strategies to the sustainability of the collaborative and its gains. RESULTS: Qualitative analysis identified three overarching factors for the sustainability of SPI: (i) using programme improvement methodology and measurement of its outcomes; (ii) organizational strategies to ensure sustainability and (iii) alignment of goals with external requirements. Within these were eight themes identified by the coordinators as helping to sustain the efforts of the SPI programme and its successes. CONCLUSIONS: This study has presented what principle programme coordinators across 20 NHS organizations considered to be the key strategies to sustain their own improvement programme and its successes, during the supported phase of the programme and 1 year on. Recommendations are to consider these practical strategies in order to improve chances of maintaining changes and continuing a quality improvement programme beyond the formal cessation of the intervention.

Implementing a Novel Statewide Network to Support Emergency Department-initiated Buprenorphine Treatment.

INTRODUCTION: Medications for opioid use disorder (MOUD), including buprenorphine, represent an evidence-based treatment that supports long-term recovery and reduces risk of overdose death. Patients in crisis from opioid use disorder (OUD) often seek care from emergency departments (ED). The New York Medication for Addiction Treatment and Electronic Referrals (MATTERS) network is designed to support ED-initiated buprenorphine and urgent referrals to long-term care for patients suffering from OUD. METHODS: Using the PRECEDE-PROCEED implementation science framework, we provide an overview of the creation of the MATTERS network in Western New York. We also include an explanation of how the network was designed and launched as a response to the opioid epidemic. Finally, we analyzed the program's outputs and outcomes, thus far, as it continues to grow across the state. RESULTS: The New York MATTERS network was created and implemented in 2019 with a single hospital referring patients with OUD to three local clinics. In the social assessment and situational analysis phase, we describe the opioid epidemic and available resources in the region at the outset of the program. In the epidemiological assessment phase, we quantify the epidemic on the state and regional levels. In the educational and ecological assessment, we review local ED practices and resources. In the administrative and policy assessment and intervention alignment phase, the program's unique framework is reviewed. In the piloting phase, we describe the initial deployment of New York MATTERS. Finally, in the process evaluation phase, we depict the early lessons we learned. By the beginning of 2021, the New York MATTERS network included 35 hospitals that refer to 47 clinics throughout New York State. CONCLUSION: The New York MATTERS network provides a structured approach to reduce barriers to ED-initiated buprenorphine and urgent referral to long-term care. An implementation framework provides a structured means of evaluating this best practice model.

A Board Level Intervention to Develop Organisation-Wide Quality Improvement Strategies: Cost-Consequences Analysis in 15 Healthcare Organisations.

BACKGROUND: Hospital boards have statutory responsibility for upholding the quality of care in their organisations. International research on quality in hospitals resulted in a research-based guide to help senior hospital leaders develop and implement quality improvement (QI) strategies, the QUASER Guide. Previous research has established a link between board practices and quality of care; however, to our knowledge, no board-level intervention has been evaluated in relation to its costs and consequences. The aim of this research was to evaluate these impacts when the QUASER Guide was implemented in an organisational development intervention (iQUASER). METHODS: We conducted a 'before and after' cost-consequences analysis (CCA), as part of a mixed methods evaluation. The analysis combined qualitative data collected from 66 interviews, 60 hours of board meeting observations and documents from 15 healthcare organisations, of which 6 took part on iQUASER, and included direct and opportunity costs associated with the intervention. The consequences focused on the development of an organisation-wide QI strategy, progress on addressing 8 dimensions of QI (the QUASER challenges), how organisations compared to benchmarks, engagement with the intervention and progress in the implementation of a QI project. RESULTS: We found that participating organisations made greater progress in developing an organisation-wide QI strategy and became more similar to the high-performing benchmark than the comparators. However, progress in addressing all 8 QUASER challenges was only observed in one organisation. Stronger engagement with the intervention was associated with the implementation of a QI project. On average, iQUASER costed £23 496 per participating organisation, of which approximately 44% were staff time costs. Organisations that engaged less with the intervention had lower than average costs (£21 267 per organisation), but also failed to implement an organisation-wide QI project. CONCLUSION: We found a positive association between level of engagement with the intervention, development of an organisation-wide QI strategy and the implementation of an organisation-wide QI project. Support from the board, particularly the chair and chief executive, for participation in the intervention, is important for organisations to accrue most benefit. A board-level intervention for QI, such as iQUASER, is relatively inexpensive as a proportion of an organisation's budget.

Missing clinical information in NHS hospital outpatient clinics: prevalence, causes and effects on patient care.

BACKGROUND: In Britain over 39,000 reports were received by the National Patient Safety Agency relating to failures in documentation in 2007 and the UK Health Services Journal estimated in 2008 that over a million hospital outpatient visits each year might take place without the full record available. Despite these high numbers, the impact of missing clinical information has not been investigated for hospital outpatients in the UK.Studies in primary care in the USA have found 13.6% of patient consultations have missing clinical information, with this adversely affecting care in about half of cases, and in Australia 1.8% of medical errors were found to be due to the unavailability of clinical information.Our objectives were to assess the frequency, nature and potential impact on patient care of missing clinical information in NHS hospital outpatients and to assess the principal causes. This is the first study to present such figures for the UK and the first to look at how clinicians respond, including the associated impact on patient care. METHODS: Prospective descriptive study of missing information reported by surgeons, supplemented by interviews on the causes.Data were collected by surgeons in general, gastrointestinal, colorectal and vascular surgical clinics in three teaching hospitals across the UK for over a thousand outpatient appointments. Fifteen interviews were conducted with those involved in collating clinical information for these clinics.The study had ethics approval (Hammersmith and Queen Charlotte's & Chelsea Research Ethics Committee), reference number (09/H0707/27). Participants involved in the interviews signed a consent form and were offered the opportunity to review and agree the transcript of their interview before analysis. No patients were involved in this research. RESULTS: In 15% of outpatient consultations key items of clinical information were missing. Of these patients, 32% experienced a delay or disruption to their care and 20% had a risk of harm. In over half of cases the doctor relied on the patient for the information, making a clinical decision despite the information being missing in 20% of cases. Hospital mergers, temporary staff and non-integrated IT systems were contributing factors. CONCLUSIONS: If these findings are replicated across the NHS then almost 10 million outpatients are seen each year without key clinical information, creating over a million unnecessary appointments, and putting nearly 2 million patients at risk of harm. There is a need for a systematic, regular audit of the prevalence of missing clinical information. Only then will we know the impact on clinical decision making and patient care of new technology, service reorganisations and, crucially given the present financial climate, temporary or reduced staffing levels. Further research is needed to assess the relationship between missing clinical information and diagnostic errors; to examine the issue in primary care; and to consider the patients perspective.

Prescribing errors in hospital inpatients: a three-centre study of their prevalence, types and causes.

AIM: To compare the prevalence and causes of prescribing errors in newly written medication orders and how quickly they were rectified, in three NHS organisations. METHODS: Errors in newly written inpatient and discharge medication orders were recorded in Spring/Summer 2009 by ward pharmacists on medical admissions and surgical wards, as well as the number of erroneous doses administered (or omitted) before errors were corrected. Logistic regression analysis was used to explore the effects of ward (nested within organisation) and clinical specialty, and whether the pharmacist had checked the patient's medication history during data collection. Causes were explored using semistructured interviews with key informants. RESULTS: Overall, 1025 prescribing errors were identified in 974 of 6605 medication orders (14.7%, 95% confidence interval (CI) 13.8% to 15.6%). A mean of 0.9 doses were administered (or omitted) before each error was corrected (range 0-11), with differences between specialties and organisations. The error rate on medical admissions wards (16.3%) was significantly higher than that on surgical wards (12.2%), but this was accounted for by the higher proportion of prescribing being on admission, where omission of patients' usual medication was often identified. There were significant differences among wards (and organisations). Contributing factors included lack of feedback on errors, poor documentation and communication of prescribing decisions, and lack of information about patients' medication histories from primary care. CONCLUSIONS: There were variations among wards, organisations and specialties in error rates and how quickly they were rectified. Exploring reasons for differences between organisations may be useful in identifying best practice and potential solutions.

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol.

BACKGROUND: although there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The 'Quality and Safety in Europe by Research' (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them. The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients. METHODS/DESIGN: in-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features: • a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience • a conceptualisation of quality as a human, social, technical and organisational accomplishment • an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union. Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims). DISCUSSION: the protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the 'organisational and cultural characteristics associated with better quality of care' in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.

Predictors of the perceived impact of a patient safety collaborative: an exploratory study.

OBJECTIVE: The aim of this study was to evaluate the influence of various factors on the perceived impact of a patient safety improvement collaborative in the UK, the Safer Patients Initiative (SPI). STUDY DESIGN: A cross-sectional survey design was used. Study setting Twenty National Health Service organizations from the UK that participated in the main phase of the SPI programme, which ran from September 2007 to 2008. PARTICIPANTS: Senior executive leads, clinical operational leads in the four clinical areas targeted by the programme, programme coordinators and any other staff involved in the SPI (n = 635). INTERVENTION: The SPI is a patient safety improvement intervention based on the Breakthrough Series Collaborative model (Institute of Healthcare Improvement, 2004) aimed at improving patient safety in four clinical areas (general ward care, intensive care, perioperative care and pharmacy) through implementing a number of evidence-based clinical practices and a focus on organizational leadership. Outcome measures Participant perceptions of the impact of the programme on their organizations. RESULTS: Exploratory regression analysis showed that programme management, the value assigned to programme methodology and length of data collection contributed the largest variance in perceived impact of the SPI followed by perceived support from junior doctors, inter-professional collaboration, difference of the programme from existing safety improvement practices and organizational readiness. CONCLUSIONS: The resulting model suggests hierarchical importance for a range of variables to support future research concerning the mechanisms by which large-scale organizational programmes, such as the SPI, impact on the care systems they are designed to influence.

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service.

BACKGROUND: Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis' typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England. METHODS: We conducted fieldwork over a 30-month period as part of an evaluation in six healthcare provider organisations in England. Our data comprised board member interviews (n=54), board meeting observations (24 hours) and relevant documents. RESULTS: Two organisations transformed their processes in a way that was consistent with the objectives of the intervention, and one customised the intervention with positive effects. In two further organisations, the intervention was only loosely coupled with organisational processes, and participation in the intervention stopped when it competed with other initiatives. In the final case, the intervention was corrupted to reinforce existing organisational processes (a focus on external regulatory requirements). The organisational response was contingent on the availability of 'slack'-expressed by participants as the 'space to think' and 'someone to do the doing'-and the presence of a functioning board. CONCLUSIONS: Underperforming organisations, under pressure to improve, have little time or resources to devote to organisation-wide quality improvement initiatives. Our research highlights the need for policy-makers and regulators to extend their focus beyond the choice of intervention, to consider how the chosen intervention will be implemented in public sector hospitals, how this will vary between contexts and with what effects. We provide useful information on the necessary conditions for a board-level quality improvement intervention to have positive effects.