Exploring the relation between clinician ratings and patient-reported experience and outcomes.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important ways for patients to be more actively involved in their treatment and enhance shared decision-making. OBJECTIVE: The current study investigated the associations between PROMs, PREMs and various symptoms measures reported by clinicians and psychiatric patients. METHOD: One hundred and twenty people admitted to a psychiatric hospital completed two PREMs, one PROM (the shortened version of the Manchester Short Assessment of Quality of Life scale) and Effects of Symptoms on Daily Functioning (the Sheehan Disability Scale), the Patient Clinical Global Impression and the Modified Colorado Symptom Index. Their psychiatrists rated them using the Global Assessment of Functioning scale, the Health of the Nation Outcome Scales and the Therapist Clinical Global Impression. RESULTS: There was a strong correlation between patient's evaluation of their quality of life (PROM), experience of their care (PREM) and the overall severity of their condition and their progress. The pattern of correlation between patients' and clinicians' measures revealed a three-layer structure representing a continuum from inner experience to external presentation of experiences. CONCLUSION: Together these findings help identify and emphasize various domains of subjective experiences and their relation to external ratings.

Evaluating the implementation and use of patient-reported outcome measures in a mental health hospital in Denmark: a qualitative study.

BACKGROUND: Reporting of barriers and successes associated with the implementation and use of patient-reported outcomes (PROs) is limited as a means to ensure enhanced patient involvement, shared decision-making and improved treatment and care. We set out to evaluate the implementation and use of the PRO-Psychiatry initiative on patient-reported outcome measures in Danish mental health care. We aimed to described four specific areas: the quality of the clinical consultations before and after the implementation of PRO-Psychiatry as perceived by the patients (objective A), the motivation for participating in PRO-Psychiatry as perceived by patients and clinicians (objective B), the implementation process as perceived by patients, clinicians and managers (objective C) and suggestions for improvement (objective D). METHODS: The PRO-Psychiatry initiative was evaluated through a participatory approach, including patients, clinicians and managers. A repeated cross-sectional interview-based survey explored the quality of the clinical consultation before and after the implementation of PRO-Psychiatry. A three-step semi-structured group interview, inspired by the modified mini-Delphi method, was used to establish consensus on the evaluation of the implementation and use of the initiative. RESULTS: The evaluation pointed at PRO-Psychiatry as a meaningful initiative, which motivated patients and supported clinicians. The patients emphasised the importance of PROs, but they also found that PROs were not used enough. Clinically relevant improvements were detected after the implementation of the initiative; more patients felt heard and experienced that clinicians took a greater interest in their problems. The clinicians valued the easily accessible real-time graphical display of the PRO responses in the electronic health record (EHR). Clinicians and managers agreed that clinical PRO practices, patient compliance and use of PROs in treatment and care should be supported during implementation. CONCLUSION: The evaluation was overall positive. Patients and clinicians were willing to participate, found the online reporting easy and valued the direct access to PRO responses in the EHR. An essential feature was the integration of well-defined and functional PRO practices into the existing clinical workflow. Using PROs in the clinical sessions in a way that was palpable to the patient was found to be a significant improvement need. At the individual level, PRO-Psychiatry can use patient outcome information to support dialogue, encourage shared decision-making and promote self-management during recovery. At the aggregated patient level, the PROs can be used for monitoring the patient-perceived quality of care and for research.

Patient-reported outcome measures in mental health clinical research: a descriptive review in comparison with clinician-rated outcome measures.

PURPOSE: To review how patient-reported outcome (PRO) measures in mental health clinical research complement traditional clinician-rated outcome (CRO) measures. DATA SOURCES: Medline, Embase, PsycInfo and Scopus. STUDY SELECTION: Latest update of the literature search was conducted in August 2019, using a specified set of search terms to identify controlled and uncontrolled studies (published since 1996) of pharmacological or non-pharmacological interventions in adults (≥18 years) in hospital-based mental health care. DATA EXTRACTION: Two authors extracted data independently using a pre-designed extraction form. RESULTS OF DATA SYNTHESIS: Among the 2962 publications identified, 257 were assessed by full text reading. A total of 24 studies reported in 26 publications were included in this descriptive review. We identified subjective and objective outcome measures, classified these according to the pharmacopsychometric triangle and compared them qualitatively in terms of incremental information added to the clinical study question. The data reviewed here from primarily depression and schizophrenia intervention studies show that results from PRO measures and CRO measures generally point in the same direction. There was a relative lack of PRO measures on functioning and medication side effects compared with PRO measures on symptom burden and health-related quality of life. CONCLUSION: PROs and CROs supplement each other and at most times support identical study conclusions. Future studies would benefit from a more systematic approach toward use of PROs and a clearer rationale of how to weigh and report the results in comparison with CROs.

Using patient-reported outcome measures in psychiatric hospital care: an observational study describing an iterative implementation process in Denmark.

BACKGROUND: Patient-reported outcomes (PROs) are increasingly recognized as valuable sources of information to enhance our understanding of the quality of healthcare from the patient's perspective. OBJECTIVE: This study aimed to describe the implementation process of the Danish nationwide PRO-Psychiatry project, including iterative tests of previously developed PRO measurement concept and an online data collection tool. Additional aims were to identify the 'best practice' for the routine use of PROs in hospital-based psychiatry and design information material about the project. METHODS: We conducted an action-oriented observational study to explore the pilot implementation of the PRO-Psychiatry project, which was initiated in February 2018. The study was based on an iterative plan-do-learn approach. An inpatient unit and an outpatient unit from the same psychiatric department in the North Denmark Region were selected for the pilot implementation. The implementation was anchored in multidisciplinary implementation teams at unit level. These teams managed the implementation process according to four tasks defined by the department management. RESULTS: The teams designed, tested, evaluated and adjusted the localized work practices relating to the use of PRO-Psychiatry. The comprehensibility of the predesigned PROs, the usability of the Information Technology(IT) system and the routine use of PROs during clinical consultations were repeatedly tested and adjusted until the functionality was satisfactory. Furthermore, the teams designed information material for patients (emails, posters, handouts and webpages) and clinicians (online clinical guidelines). The team members informed their colleagues about the progress of PRO-Psychiatry at staff meetings and rolled out the initiative through one-to-one teaching. CONCLUSIONS: The pilot implementation was deemed successful. PRO-Psychiatry was rolled out to other units in the region, and a national decision was made to pilot implement the initiative in the other four Danish regions.

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.

Patient-reported indicators in mental health care: towards international standards among members of the OECD.

BACKGROUND: Achieving people-centred health care systems requires new and innovative strategies to capture information about whether, and to what degree, health care is successful in improving health from the perspective of the patient. Patient-reported outcome measures (PROMs) and Patient-reported experience measures (PREMs) can bring some of these new insights, and are increasingly used in research, clinical care, and policymaking. METHODS: This paper reflects the ongoing discussions and findings of the OECD PaRIS Working Group on Patient-reported Indicators for Mental Health Care. RESULTS: The OECD has been measuring quality of care for mental health conditions over the last 14 years through the Health Care Quality and Outcomes (HCQO) program; nonetheless, information on how persons with mental health problems value the services they receive, and impact of the services, remains limited. As of 2018, a survey from the OECD showed that only five of the twelve countries surveyed (Australia, Israel, Netherlands, Sweden, United Kingdom) reported PROMs and PREMs collection on a regular basis in mental health settings. The paper details some of the challenges specific to the collection and use of PROMs and PREMs in mental health care, and examples from countries which have implemented comprehensive programmes to gather information about PROMs and PREMs for individuals receiving mental health services. CONCLUSIONS: Given the health and economic impact of mental ill-health across all OECD countries, there is significant value to being able to assess the quality and outcomes of care in this area using internationally-comparable measures. Continued international harmonisation of PROMs and PREMs for mental health through international coordination is a key way to facilitate the sharing of national experiences, promote the use of PROMs and PREMs, and create meaningful indicators for national and international benchmarking.

Measuring patient voice matters: setting the scene for patient-reported indicators.

BACKGROUND: Achieving people-centred health care systems requires new and innovative strategies to capture information about whether, and to what degree, health care is successful in improving health from the perspective of the patient. Patient-reported outcome measures (PROMs) and Patient-reported experience measures (PREMs) can bring some of these new insights, and are increasingly used in research, clinical care, and policymaking. METHODS: This paper reflects the ongoing discussions and findings of the OECD PaRIS Working Group on Patient-reported Indicators for Mental Health Care. RESULTS: The OECD has been measuring quality of care for mental health conditions over the last 14 years through the Health Care Quality and Outcomes (HCQO) program; nonetheless, information on how persons with mental health problems value the services they receive, and impact of the services, remains limited. As of 2018, a survey from the OECD showed that only five of the twelve countries surveyed (Australia, Israel, Netherlands, Sweden, United Kingdom) reported PROMs and PREMs collection on a regular basis in mental health settings. The paper details some of the challenges specific to the collection and use of PROMs and PREMs in mental health care, and examples from countries which have implemented comprehensive programmes to gather information about PROMs and PREMs for individuals receiving mental health services. CONCLUSIONS: Given the health and economic impact of mental ill-health across all OECD countries, there is significant value to being able to assess the quality and outcomes of care in this area using internationally-comparable measures. Continued international harmonisation of PROMs and PREMs for mental health through international coordination is a key way to facilitate the sharing of national experiences, promote the use of PROMs and PREMs, and create meaningful indicators for national and international benchmarking.

Quality improvement and accountability in the Danish health care system.

Denmark has unique opportunities for quality measurement and benchmarking since Denmark has well-developed health registries and unique patient identifier that allow all registries to include patient-level data and combine data into sophisticated quality performance monitoring. Over decades, Denmark has developed and implemented national quality and patient safety initiatives in the healthcare system in terms of national clinical guidelines, performance and outcome measurement integrated in clinical databases for important diseases and clinical conditions, measurement of patient experiences, reporting of adverse events, national handling of patient complaints, national accreditation and public disclosure of all data on the quality of care. Over the years, Denmark has worked up a progressive and transparent just culture in quality management; the different actors at the different levels of the healthcare system are mutually attentive and responsive in a coordinated effort for quality of the healthcare services. At national, regional, local and hospital level, it is mandatory to participate in the quality initiatives and to use data and results for quality management, quality improvement, transparency in health care and accountability. To further develop the Danish governance model, it is important to expand the model to the primary care sector. Furthermore, a national quality health programme 2015-18 recently launched by the government supports a new development in health care focusing upon delivering high-quality health care-high quality is defined by results of value to the patients.

Quality management and perceptions of teamwork and safety climate in European hospitals.

OBJECTIVE: This study aimed to investigate the associations of quality management systems with teamwork and safety climate, and to describe and compare differences in perceptions of teamwork climate and safety climate among clinical leaders and frontline clinicians. METHOD: We used a multi-method, cross-sectional approach to collect survey data of quality management systems and perceived teamwork and safety climate. Our data analyses included descriptive and multilevel regression methods. SETTING AND PARTICIPANTS: Data on implementation of quality management system from seven European countries were evaluated including patient safety culture surveys from 3622 clinical leaders and 4903 frontline clinicians. MAIN OUTCOME MEASURES: Perceived teamwork and safety climate. RESULTS: Teamwork climate was reported as positive by 67% of clinical leaders and 43% of frontline clinicians. Safety climate was perceived as positive by 54% of clinical leaders and 32% of frontline clinicians. We found positive associations between implementation of quality management systems and teamwork and safety climate. CONCLUSIONS: Our findings, which should be placed in a broader clinical quality improvement context, point to the importance of quality management systems as a supportive structural feature for promoting teamwork and safety climate. To gain a deeper understanding of this association, further qualitative and quantitative studies using longitudinally collected data are recommended. The study also confirms that more clinical leaders than frontline clinicians have a positive perception of teamwork and safety climate. Such differences should be accounted for in daily clinical practice and when tailoring initiatives to improve teamwork and safety climate.

Evidence-based organization and patient safety strategies in European hospitals.

OBJECTIVE: To explore how European hospitals have implemented patient safety strategies (PSS) and evidence-based organization of care pathway (EBOP) recommendations and examine the extent to which implementation varies between countries and hospitals. DESIGN: Mixed-method multilevel cross-sectional design in seven countries as part of the European Union-funded project 'Deepening our Understanding of Quality improvement in Europe' (DUQuE). SETTING AND PARTICIPANTS: Seventy-four acute care hospitals with 292 departments managing acute myocardial infarction (AMI), hip fracture, stroke, and obstetric deliveries. Main outcome measure Five multi-item composite measures-one generic measure for PSS and four pathway-specific measures for EBOP. RESULTS: Potassium chloride had only been removed from general medication stocks in 9.4-30.5% of different pathways wards and patients were adequately identified with wristband in 43.0-59.7%. Although 86.3% of areas treating AMI patients had immediate access to a specialist physician, only 56.0% had arrangements for patients to receive thrombolysis within 30 min of arrival at the hospital. A substantial amount of the total variance observed was due to between-hospital differences in the same country for PSS (65.9%). In EBOP, between-country differences play also an important role (10.1% in AMI to 57.1% in hip fracture). CONCLUSIONS: There were substantial gaps between evidence and practice of PSS and EBOP in a sample of European hospitals and variations due to country differences are more important in EBOP than in PSS, but less important than within-country variations. Agencies supporting the implementation of PSS and EBOP should closely re-examine the effectiveness of their current strategies.

Deepening our understanding of quality improvement in Europe (DUQuE): overview of a study of hospital quality management in seven countries.

INTRODUCTION AND OBJECTIVE: This paper provides an overview of the DUQuE (Deepening our Understanding of Quality Improvement in Europe) project, the first study across multiple countries of the European Union (EU) to assess relationships between quality management and patient outcomes at EU level. The paper describes the conceptual framework and methods applied, highlighting the novel features of this study. DESIGN: DUQuE was designed as a multi-level cross-sectional study with data collection at hospital, pathway, professional and patient level in eight countries. SETTING AND PARTICIPANTS: We aimed to collect data for the assessment of hospital-wide constructs from up to 30 randomly selected hospitals in each country, and additional data at pathway and patient level in 12 of these 30. MAIN OUTCOME MEASURES: A comprehensive conceptual framework was developed to account for the multiple levels that influence hospital performance and patient outcomes. We assessed hospital-specific constructs (organizational culture and professional involvement), clinical pathway constructs (the organization of care processes for acute myocardial infarction, stroke, hip fracture and deliveries), patient-specific processes and outcomes (clinical effectiveness, patient safety and patient experience) and external constructs that could modify hospital quality (external assessment and perceived external pressure). RESULTS: Data was gathered from 188 hospitals in 7 participating countries. The overall participation and response rate were between 75% and 100% for the assessed measures. CONCLUSIONS: This is the first study assessing relation between quality management and patient outcomes at EU level. The study involved a large number of respondents and achieved high response rates. This work will serve to develop guidance in how to assess quality management and makes recommendations on the best ways to improve quality in healthcare for hospital stakeholders, payers, researchers, and policy makers throughout the EU.

Review: application of the Safety Attitudes Questionnaire (SAQ) in primary care - a systematic synthesis on validity, descriptive and comparative results, and variance across organisational units.

Patient safety research has focused mostly on the hospital and acute care setting whereas assessments of patient safety climate in primary health care settings are warranted. Valid questionnaires as e.g., the Safety Attitudes Questionnaire (SAQ) may capture staff perceptions of patient safety climate but until now, an overview of the use of SAQ in primary care has not been systematically presented. Thus, the aim of this systematic review is to present an overview of SAQ used in primary care.Methods The electronic databases: PubMed, Embase, Cinahl, PsycInfo and Web of Science were used to find studies that used any version of SAQ in primary care. Studies were excluded if only abstract or poster was available, as the information in abstract and posters was deemed insufficient. Commentaries and nonempirical studies (e.g., study protocols) were excluded. Only English manuscripts were included.Results A total of 43 studies were included and 40 of them fell into four categories: 1) validation analysis, 2) descriptive analysis, 3) variance assessment and 4) intervention evaluation and were included in further analyses. Some studies fell into more than one of the four categories. Seventeen studies aimed to validate different versions of SAQ in a variety of settings and providers. Twenty-five studies from fourteen different countries reported descriptive findings of different versions of SAQ in a variety of settings. Most studies were conducted in primary health care centres, out-of-hours clinics, nursing homes and general practice focusing on greatly varying populations. One study was conducted in home care. Three studies investigated variance of SAQ scores. Only five studies used SAQ to assess the effects of interventions/events. These studies evaluated the effect of electronic medical record implementation, a comprehensive Unit-based Safety Program or COVID-19.Conclusion The synthesis demonstrated that SAQ is valid for use in primary care, but it is important to adapt and validate the questionnaire to the specific setting and participants under investigation. Moreover, differences in SAQ factor scores were related to a variety of descriptive factors, that should be considered in future studies More studies, especially variance and intervention studies, are warranted in primary care.Trial registration This systematic review was not registered in any register.

Rasch analysis of a patient-reported outcome measure for self-perceived health among psychiatric patients in Denmark.

BACKGROUND: Patient-reported outcome measures (PROMs) are valuable and necessary tools for establishing and maintaining patient-centred healthcare. The PRO-Psychiatry initiative was primarily initiated to support the patient's voice in treatment decision-making and secondarily to monitor patient-perceived quality of care. The result of the initiative is a patient-reported instrument developed in collaboration between patients and clinicians. We aimed to validate the PROM developed for measuring self-perceived health among psychiatric patients in North Denmark Region, in terms of internal consistency, criterion validity and responsiveness. METHOD: Patients in contact with a psychiatric hospital in the North Denmark Region from September 2018 to March 2021 were included in the study. The PROM constitutes a scale of 17 items covering various aspects of self-perceived health including well-being (7 items), lack of well-being (5 items) and social functioning (5 items), where the former domain entails the WHO-5 Well-Being Index. The potential range of the total scale score is 0-85. We applied McDonald's omega, average inter-item correlation (AIIC) and differential item functioning (DIF). In addition, we used mixed effects analyses to estimate temporal correlations. The instrument was compared with self-rated overall mental and psychiatric health. RESULTS: The patient population consisted of 1132 unique patients and a total of 2476 responses corresponding to one response per patient pathway. McDonald's omega was found to be 0.92 (95% CI 0.92 to 0.93), while the AIIC was found to be 0.42 (95% CI 0.39 to 0.44). For DIF, the largest systematic variation resulted in a maximum difference of 2.3 points on the total score when adjusting for the latent trait and was found when comparing initial measurements with follow-up measurements. The correlation between the total score and the outcomes regarding overall physical and mental health was 0.52 (95% CI 0.48 to 0.56) and 0.74 (95% CI 0.72 to 0.76). Similar correlations were found for the corresponding changes over time. CONCLUSION: The scale showed high consistency and little systematic variation between the comparison groups. The concurrent correlations and analyses of responsiveness coincided with the prespecified hypotheses. Overall, we deem the Danish PRO-Psychiatry instrument to possess suitable psychometric properties for measuring self-perceived health among a psychiatric population.

Behavioral/Emotional Problems of Preschoolers: Caregiver/Teacher Reports From 15 Societies.

This study tested societal effects on caregiver/teacher ratings of behavioral/emotional problems for 10,521 preschoolers from 15 societies. Many societies had problem scale scores within a relatively narrow range, despite differences in language, culture, and other characteristics. The small age and gender effects were quite similar across societies. The rank orders of mean item ratings were similar across diverse societies. For 7,380 children from 13 societies, ratings were also obtained from a parent. In all 13 societies, mean Total Problems scores derived from parent ratings were significantly higher than mean Total Problems scores derived from caregiver/teacher ratings, although the size of the difference varied somewhat across societies. Mean cross-informant agreement for problem scale scores varied across societies. Societies were very similar with respect to which problem items, on average, received high versus low ratings from parents and caregivers/teachers. Within every society, cross-informant agreement for item ratings varied widely across children. In most respects, results were quite similar across 15 very diverse societies.

Patient safety culture improvements depend on basic healthcare education: a longitudinal simulation-based intervention study at two Danish hospitals.

BACKGROUND: A growing body of evidence supports the existence of an association between patient safety culture (PSC) and patient outcomes. PSC refers to shared perceptions and attitudes towards norms, policies and procedures related to patient safety. Existing literature shows that PSC varies among health professionals depending on their specific profession and specialty. However, these studies did not investigate whether PSC can be improved. This study investigates whether length of education is associated with improvements in PCS following a simulation intervention. METHODS: From April 2017 to November 2018, a cross-sectional intervention study was conducted at two regional hospitals in Denmark. Two groups with altogether 1230 health professionals were invited to participate. One group included nurses, midwives and radiographers; the other group included doctors. A train-the-trainer intervention approach was applied consisting of a 4-day simulation instructor course that emphasised team training, communication and leadership. Fifty-three healthcare professionals were trained as instructors. After the course, instructors performed in situ simulation in their own hospital environment. OUTCOMES: The Safety Attitude Questionnaire (SAQ), which has 6 dimensions and 32 items, was used to collect main outcome variables. All employees from both groups were surveyed before the intervention and again four and nine months after the intervention. RESULTS: Mean baseline scores were higher among doctors than among nurses, midwives and radiographers for all SAQ dimensions. At the second follow-up, four of six dimensions improved significantly (p ≤ 0.05) among nurses, midwives and radiographers, whereas no dimensions improved significantly among doctors. CONCLUSION: Over time, nurses, midwives and radiographers improved more in PSC attitudes than doctors did.

Patient safety culture and associated factors in secondary health care of the Capital Region of Denmark: influence of specialty, healthcare profession and gender.

BACKGROUND: We aimed to explore (1) the influence of healthcare professionals' (HCPs') specialty, profession, gender and length of employment on their perception of six dimensions of patient safety culture (PSC) and (2) the relation between these characteristics and the two dimensions of safety climate and perception of management. METHODS: In a cross-sectional study, a Danish version of the Safety Attitudes Questionnaire was sent to all HCPs at a large regional hospital organisation. This included hospitals, the Emergency Services, the Regional Pharmacy and the Centre for Diabetes corporations. A total of 30 230 HCPs received the survey. Differences between specialties, professions, gender and years of employment were tested for each dimension of PSC. Differences in mean attitude scores were tested using analysis of variance and differences in having a positive attitude were tested using logistic regression. RESULTS: In total, 15 119 (50%) HCPs returned the survey. Significant differences are seen across hospitals and corporations for all dimensions of PSC. The proportion of HCPs with a positive attitude was largest regarding job satisfaction (74.8%) and lowest regarding perception of management (43.9%). Significant differences are seen in physicians' and nurses' perception of PSC in the different specialties within all dimensions of PSC except for the dimension of recognition of stress. Significant differences in positive perception of teamwork climate are seen between anaesthesiologists' (69.4%) and surgeons' (41.7%). No significant gender differences were found between physicians' and nurses' perception of safety climate and of management. In addition, we found an influence of years of employment on PSC. DISCUSSION: Significant differences were found in HCPs' perception of PSC between corporations, specialties and professions. The lowest proportion of HCPs with a positive perception of PSC was found within the dimensions of safety climate and perception of management. These differences may have implications for teamwork and patient safety.

Patient safety culture in an orthopaedic surgery centre in Denmark.

INTRODUCTION: Measuring and developing patient safety culture (PSC) is a focal point in creating a highly reliable organisation, and patient safety is the cornerstone of quality healthcare. The purpose of this study was to describe PSC in an elective orthopaedic surgery centre in Denmark. METHODS: A total of 445 healthcare workers were invited to participate. A cross-sectional study design using the Safety Attitudes Questionnaire (SAQ) was applied. RESULTS: A total of 356 invitees (80%) answered the SAQ. The proportion of employees with a positive perception of the PSC was above the anticipated 60% threshold in five out of six dimensions. Perceptions of PSC varied by gender across four of six dimensions. Thus, significantly more female than male participants had a positive perception of the PSC. A significant variation was observed in the proportion of employees with a positive perception of PSC at the unit level except for teamwork climate and stress recognition. CONCLUSIONS: This is the first Danish study of PSC in an elective orthopaedic surgical setting. Across dimensions, % positive were more favourable than reported in the international literature. FUNDING: none. TRIAL REGISTRATION: not relevant.

International comparisons of behavioral and emotional problems in preschool children: parents' reports from 24 societies.

International comparisons were conducted of preschool children's behavioral and emotional problems as reported on the Child Behavior Checklist for Ages 1½-5 by parents in 24 societies (N = 19,850). Item ratings were aggregated into scores on syndromes; Diagnostic and Statistical Manual of Mental Disorders-oriented scales; a Stress Problems scale; and Internalizing, Externalizing, and Total Problems scales. Effect sizes for scale score differences among the 24 societies ranged from small to medium (3-12%). Although societies differed greatly in language, culture, and other characteristics, Total Problems scores for 18 of the 24 societies were within 7.1 points of the omnicultural mean of 33.3 (on a scale of 0-198). Gender and age differences, as well as gender and age interactions with society, were all very small (effect sizes < 1%). Across all pairs of societies, correlations between mean item ratings averaged .78, and correlations between internal consistency alphas for the scales averaged .92, indicating that the rank orders of mean item ratings and internal consistencies of scales were very similar across diverse societies.

Patient safety culture improves during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites.

OBJECTIVES: This study aimed to investigate staff's perceptions of patient safety culture (PSC) in two Danish hospitals before and after an in situ simulation intervention. DESIGN: A repeated cross-sectional intervention study. SETTING: Two Danish hospitals. Hospital 1 performs emergency functions, whereas hospital 2 performs elective functions. PARTICIPANTS: A total of 967 healthcare professionals were invited to participate in this study. 516 were employed in hospital 1 and 451 in hospital 2. Of these, 39 were trained as simulation instructors. INTERVENTION: A 4-day simulation instructor course was applied. Emphasis was put on team training, communication and leadership. After the course, instructors performed simulation in the hospital environment. No systematic simulation was performed prior to the intervention. MAIN OUTCOME MEASURES: The Safety Attitude Questionnaire investigating PSC was applied prior to the intervention and again 4 and 8 weeks after intervention. The proportion of participants with a positive attitude and mean scale scores were measured as main outcomes. RESULTS: The response rate varied from 63.6% to 72.0% across surveys and hospitals. Baseline scores were generally lower for hospital 1. The proportion of staff with positive attitudes in hospital 1 improved by ≥5% in five of six safety culture dimensions, whereas only two dimensions improved by ≥5% in hospital 2. The mean scale scores improved significantly in five of six safety culture dimensions in hospital 1, while only one dimension improved significantly in hospital 2. CONCLUSIONS: Safety attitude outcomes indicate an improvement in PSC from before to after the in situ simulation intervention period. However, it is possible that an effect is more profound in an acute care hospital versus an elective setting.