Implementing a perioperative care of older people undergoing surgery (POPS) service: findings from a multi-site qualitative implementation study.

BACKGROUND: The Perioperative care for Older People undergoing Surgery (POPS) service model is increasingly being implemented across care providers in the English and Welsh National Health Services. OBJECTIVE: The study aimed to produce evidence regarding clinical leaders' activities to implement POPS across different service contexts and to produce generalisable recommendations for future implementation. METHODS: A qualitative interview study was undertaken across six National Health Services hospitals with established POPS services. Interview participants were recruited on the basis of their direct involvement in the implementation and leadership of the service. Data collection involved semi-structured interviews with 26 people carried out between November 2022 and May 2023. RESULTS: The implementation of POPS is often hampered by a lack of managerial and financial support, and apprehension amongst surgeons and anaesthetist about new ways of working. POPS leaders address these through five interconnected activities, each targeted at a combination of implementation factors. (i) Securing management and financial support. (ii) Professional engagement. (iii) Evidence building as a resource for demonstrating the clinical and operational benefits of POPS. (iv) Communication and engagement activities to promote and legitimise POPS to stakeholder groups. (v) Designated and distributed leadership to promote and coordinate implementation activities and to spread the service to new pathways. CONCLUSIONS: Through a combination of activities POPS can be effectively implemented across different organisational contexts. Some aspects of these activities can be guided by shared resources and learning across sites, but others require adaption to local contextual barriers and drivers.

Overruling uncertainty about preventative medications: the social organisation of healthcare professionals' knowledge and practices.

In this article, we draw on an institutional ethnographic (IE) study of cardiovascular disease prevention in general practice, exploring the work of healthcare professionals who introduce a discussion of risk and preventative medications into consultations with patients. Our aim is to explicate, using IE's theoretical ontology and analytical tools, how troubling patient experiences in this clinical context are coordinated institutionally. We focus our attention on the social organisation of healthcare professionals' knowledge and front-line practices, highlighting the textual processes through which they overrule patients' concerns and uncertainties about taking preventative medication, such that some patients feel unable to openly discuss their health needs in preventative consultations. We show how healthcare professionals activate knowledge of 'evidence-based risk reduction' to frame patients' queries as 'barriers' to be overcome. Our analysis points not to deficiencies of healthcare professionals who lack the expertise or inclination to adequately 'share decisions' with patients, but to the ways in which their work is institutionally orientated towards performance measures which will demonstrate to local and national policymakers that they are tackling the 'burden of (cardiovascular) disease'.

How the Availability of Observation Status Affects Emergency Physician Decisionmaking.

STUDY OBJECTIVE: This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking. METHODS: We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding. RESULTS: We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty. CONCLUSION: Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.

Use or Abuse? A Qualitative Study of Emergency Physicians' Views on Use of Observation Stays at Three Hospitals in the United States and England.

STUDY OBJECTIVE: Accumulating evidence has shown increasing use of observation stays for patients presenting to emergency departments and requiring diagnostic evaluation or time-limited treatment plans, but critics suggest that this expansion arises from hospitals' concerns to maximize revenue and shifts costs to patients. Perspectives of physicians making decisions to admit, observe, or discharge have been absent from the debate. We examine the views of emergency physicians in the United States and England on observation stays, and what influences their decisions to use observation services. METHODS: We undertook in-depth, qualitative interviews with a purposive sample of physicians in 3 hospitals across the 2 countries and analyzed these using an approach based on the constant-comparison method. Limitations include the number of sites, whose characteristics are not generalizable to all institutions, and the reliance on self-reported interview accounts. RESULTS: Physicians used observation status for the specific presentations for which it is well evidenced but acknowledged administrative and financial considerations in their decisionmaking. They also highlighted an important role for observation not described in the literature: as a "safe space," relatively immune from the administrative gaze, where diagnostic uncertainties, sociomedical problems, and medicolegal challenges could be contained. CONCLUSION: Observation status increases the options available to admitting physicians in a way that they valued for its potential benefits to patient safety and quality of care, but some of these have been neglected in the literature to date. Reform to observation status should address these important but previously unacknowledged functions.

Pathways to professionalism? Quality improvement, care pathways, and the interplay of standardisation and clinical autonomy.

Care pathways are a prominent feature of efforts to improve healthcare quality, outcomes and accountability, but sociological studies of pathways often find professional resistance to standardisation. This qualitative study examined the adoption and adaptation of a novel pathway as part of a randomised controlled trial in an unusually complex, non-linear field - emergency general surgery - by teams of surgeons and physicians in six theoretically sampled sites in the UK. We find near-universal receptivity to the concept of a pathway as a means of improving peri-operative processes and outcomes, but concern about the impact on appropriate professional judgement. However, this concern translated not into resistance and implementation failure, but into a nuancing of the pathways-as-realised in each site, and their use as a means of enhancing professional decision-making and inter-professional collaboration. We discuss our findings in the context of recent literature on the interplay between managerialism and professionalism in healthcare, and highlight practical and theoretical implications.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems.

OBJECTIVE: To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies. SUMMARY BACKGROUND DATA: Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs. METHODS: Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3. RESULTS: The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach. CONCLUSIONS: Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Running a hospital patient safety campaign: a qualitative study.

PURPOSE: Research on patient safety campaigns has mostly concentrated on large-scale multi-organisation efforts, yet locally led improvement is increasingly promoted. The purpose of this paper is to characterise the design and implementation of an internal patient safety campaign at a large acute National Health Service hospital trust with a view to understanding how to optimise such campaigns. DESIGN/METHODOLOGY/APPROACH: The authors conducted a qualitative study of a campaign that sought to achieve 12 patient safety goals. The authors interviewed 19 managers and 45 frontline staff, supplemented by 56 hours of non-participant observation. Data analysis was based on the constant comparative method. FINDINGS: The campaign was motivated by senior managers' commitment to patient safety improvement, a series of serious untoward incidents, and a history of campaign-style initiatives at the trust. While the campaign succeeded in generating enthusiasm and focus among managers and some frontline staff, it encountered three challenges. First, though many staff at the sharp end were aware of the campaign, their knowledge, and acceptance of its content, rationale, and relevance for distinct clinical areas were variable. Second, the mechanisms of change, albeit effective in creating focus, may have been too limited. Third, many saw the tempo of the campaign as too rapid. Overall, the campaign enjoyed some success in raising the profile of patient safety. However, its ability to promote change was mixed, and progress was difficult to evidence because of lack of reliable measurement. ORIGINALITY/VALUE: The study shows that single-organisation campaigns may help in raising the profile of patient safety. The authors offer important lessons for the successful running of such campaigns.

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023.

BACKGROUND: Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear. AIM: To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment. METHODS: We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality. RESULTS: We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident. CONCLUSIONS: Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.

What can Safety Cases offer for patient safety? A multisite case study.

BACKGROUND: The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. We examined the first documented attempt to apply the Safety Case methodology to clinical pathways. METHODS: Data are drawn from a mixed-methods evaluation of the Safer Clinical Systems programme. The development of a Safety Case for a defined clinical pathway was a centrepiece of the programme. We base our analysis on 143 interviews covering all aspects of the programme and on analysis of 13 Safety Cases produced by clinical teams. RESULTS: The principles behind a proactive, systematic approach to identifying and controlling risk that could be curated in a single document were broadly welcomed by participants, but was not straightforward to deliver. Compiling Safety Cases helped teams to identify safety hazards in clinical pathways, some of which had been previously occluded. However, the work of compiling Safety Cases was demanding of scarce skill and resource. Not all problems identified through proactive methods were tractable to the efforts of front-line staff. Some persistent hazards, originating from institutional and organisational vulnerabilities, appeared also to be out of the scope of control of even the board level of organisations. A particular dilemma for organisational senior leadership was whether to prioritise fixing the risks proactively identified in Safety Cases over other pressing issues, including those that had already resulted in harm. CONCLUSIONS: The Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.

Improving quality and safety of care using "technovigilance": an ethnographic case study of secondary use of data from an electronic prescribing and decision support system.

CONTEXT: "Meaningful use" of electronic health records to improve quality of care has remained understudied. We evaluated an approach to improving patients' safety and quality of care involving the secondary use of data from a hospital electronic prescribing and decision support system (ePDSS). METHODS: We conducted a case study of a large English acute care hospital with a well-established ePDSS. Our study was based on ethnographic observations of clinical settings (162 hours) and meetings (28 hours), informal conversations with clinical staff, semistructured interviews with ten senior executives, and the collection of relevant documents. Our data analysis was based on the constant comparative method. FINDINGS: This hospital's approach to quality and safety could be characterized as "technovigilance." It involved treating the ePDSS as a warehouse of data on clinical activity and performance. The hospital converted the secondary data into intelligence about the performance of individuals, teams, and clinical services and used this as the basis of action for improvement. Through a combination of rapid audit, feedback to clinical teams, detailed and critical review of apparent omissions in executive-led meetings, a focus on personal professional responsibility for patients' safety and quality care, and the correction of organizational or systems defects, technovigilance was-based on the hospital's own evidence-highly effective in improving specific indicators. Measures such as the rate of omitted doses of medication showed marked improvement. As do most interventions, however, technovigilance also had unintended consequences. These included the risk of focusing attention on aspects of patient safety made visible by the system at the expense of other, less measurable but nonetheless important, concerns. CONCLUSIONS: The secondary use of electronic data can be effective for improving specific indicators of care if accompanied by a range of interventions to ensure proper interpretation and appropriate action. But care is needed to avoid unintended consequences.

Towards a new paradigm in health research and practice? Collaborations for Leadership in Applied Health Research and Care.

PURPOSE: Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) are a new UK initiative to promote collaboration between universities and healthcare organisations in carrying out and applying the findings of applied health research. But they face significant, institutionalised barriers to their success. This paper seeks to analyse these challenges and discuss prospects for overcoming them. DESIGN/METHODOLOGY/APPROACH: The paper draws on in-depth qualitative interview data from the first round of an ongoing evaluation of one CLAHRC to understand the views of different stakeholders on its progress so far, challenges faced, and emergent solutions. FINDINGS: The breadth of CLAHRCs' missions seems crucial to mobilise the diverse stakeholders needed to succeed, but also produces disagreement about what the prime goal of the Collaborations should be. A process of consensus building is necessary to instil a common vision among CLAHRC members, but deep-seated institutional divisions continue to orient them in divergent directions, which may need to be overcome through other means. ORIGINALITY/VALUE: This analysis suggests some of the key means by which those involved in joint enterprises such as CLAHRCs can achieve consensus and action towards a current goal, and offers recommendations for those involved in their design, commissioning and performance management.

Beyond Received Wisdom and Authorised Accounts: What Knowledge Is Needed to Avoid Repeating History? Comment on "'Attending to History' in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration".

Perry and colleagues' study of a programme to reconfigure cancer surgery provision in Greater Manchester highlights the importance of accounting for history in making successful change. In this short commentary, I expand on some of Perry and colleagues' key findings. I note the way in which those leading change in Greater Manchester combined formal expertise in change management with sensitivity to local context, enhancing their approach to change through attention to details around relationships, events and assumptions that might otherwise have derailed the process. I identify lessons for others in how best to account for history in leading change, highlighting in particular the need to attempt to access and understand forms of history that may be suppressed, difficult-to-articulate, or otherwise marginalised.

Sustaining interventions in care homes initiated by quality improvement projects: a qualitative study.

INTRODUCTION: Inadequate and varied quality of care in care homes has led to a proliferation of quality improvement (QI) projects. This study examined the sustainability of interventions initiated by such projects. METHOD: This qualitative study explored the sustainability of seven interventions initiated by three QI projects between 2016 and 2018 in UK care homes and explored the perceived influences to the sustainability of interventions. QI projects were followed up in 2019. Staff leading QI projects (n=9) and care home (n=21, from 13 care homes) and healthcare (n=2) staff took part in semi-structured interviews. Interventions were classified as sustained if the intervention was continued at the point of the study. Thematic analysis of interview data was performed, drawing on the Consolidated Framework for Sustainability (CFS), a 40-construct model of sustainability of interventions. RESULTS: Three interventions were sustained and four interventions were not. Seven themes described perceptions around what influenced sustainability: monitoring outcomes and regular check-in; access to replacement intervention materials; staff willingness to dedicate time and effort towards interventions; continuity of staff and thorough handover/inductions in place for new staff; ongoing communication and awareness raising; perceived effectiveness; and addressing care home priorities. All study themes fell within 18 of the 40 CFS constructs. DISCUSSION: Our findings resonate with the CFS and are also consistent with implementation theories, suggesting sustainability is best addressed during implementation rather than treated as a separate process which follows implementation. Commissioning and funding QI projects should address these considerations early on, during implementation.

What are the features of high-performing quality improvement collaboratives? A qualitative case study of a state-wide collaboratives programme.

OBJECTIVES: Despite their widespread use, the evidence base for the effectiveness of quality improvement collaboratives remains mixed. Lack of clarity about 'what good looks like' in collaboratives remains a persistent problem. We aimed to identify the distinctive features of a state-wide collaboratives programme that has demonstrated sustained improvements in quality of care in a range of clinical specialties over a long period. DESIGN: Qualitative case study involving interviews with purposively sampled participants, observations and analysis of documents. SETTING: The Michigan Collaborative Quality Initiatives programme. PARTICIPANTS: 38 participants, including clinicians and managers from 10 collaboratives, and staff from the University of Michigan and Blue Cross Blue Shield of Michigan. RESULTS: We identified five features that characterised success in the collaboratives programme: learning from positive deviance; high-quality coordination; high-quality measurement and comparative performance feedback; careful use of motivational levers; and mobilising professional leadership and building community. Rigorous measurement, securing professional leadership and engagement, cultivating a collaborative culture, creating accountability for quality, and relieving participating sites of unnecessary burdens associated with programme participation were all important to high performance. CONCLUSIONS: Our findings offer valuable learning for optimising collaboration-based approaches to improvement in healthcare, with implications for the design, structure and resourcing of quality improvement collaboratives. These findings are likely to be useful to clinicians, managers, policy-makers and health system leaders engaged in multiorganisational approaches to improving quality and safety.

Patients as team members: opportunities, challenges and paradoxes of including patients in multi-professional healthcare teams.

Current healthcare policy emphasises the need for more collaborative, team-based approaches to providing care, and for a greater voice for service users in the management and delivery of care. Increasingly, policy encourages 'partnerships' between users and professionals so that users, too, effectively become team members. In examining this phenomenon, this paper draws on insights from the organisational-sociological literature on team work, which highlights the challenges of bringing together diverse professional groups, but which has not, to date, been applied in contexts where users, too, are included in teams. Using data from a qualitative study of five pilot cancer-genetics projects, in which service users were included in teams responsible for managing and developing new services, it highlights the difficulties involved in making teams of such heterogeneous members-and the paradoxes that arise when this task is achieved. It reveals how the tension between integration and specialisation of team members, highlighted in the literature on teams in general, is especially acute for service users, the distinctiveness of whose contribution is more fragile, and open to blurring.

Uncovering, creating or constructing problems? Enacting a new role to support staff who raise concerns about quality and safety in the English National Health Service.

Employee voice is an important source of organizational intelligence about possible problems in quality and patient safety, but effective systems for encouraging and supporting those who seek to speak up have remained elusive. In the English National Health Service, a novel role known as the 'Freedom to Speak Up Guardian' has been introduced to address this problem. We critically examine the role and its realization in practice, drawing on semi-structured interviews with 51 key individuals, including Guardians, clinicians, managers, policymakers, regulators and others. Operationalizing the new role in organizations was not straightforward, since it had to sit in a complex set of existing systems and processes. One response was to seek to bound the scope of Guardians, casting them in a signposting or coordinating role in relation to quality and safety concerns. However, the role proved hard to delimit, not least because the concerns most frequently voiced in practice differed in character from those anticipated in the role's development. Guardians were tasked with making sense of and dealing with issues that could not always straightforwardly be classified, deflected to the right system or escalated to the appropriate authority. Our analysis suggests that the role's potential contribution might be understood less as supporting whistleblowers who bear witness to clear-cut wrongdoing, and more as helping those with lower-level worries to construct their concerns and what to do with them. These findings have implications for how voice is understood, imagined and addressed in healthcare organizations.

Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualitative study.

Healthcare organisations' responses to concerns and complaints often fall short of the expectations of patients and staff who raise them, and substandard responses to concerns and complaints have been implicated in organisational failures. Informed by Habermas's systems theory, we offer new insights into the features of organisations' responses to concerns and complaints that give rise to these problems. We draw on a large qualitative dataset, comprising 88 predominantly narrative interviews with people raising and responding to concerns and complaints in six English NHS organisations. In common with past studies, many participants described frustrations with systems and processes that seemed ill-equipped to deal with concerns of the kinds they raised. Departing from existing analyses, we identify the influence of functional rationality, as conceptualised by Habermas, and embodied in procedures, pathways and scripts for response, in producing this dissatisfaction. Functionally rational processes were well equipped to deal with simple, readily categorised concerns and complaints. They were less well placed to respond adequately to concerns and complaints that were complex, cross-cutting, or irreducible to predetermined criteria for redress and resolution. Drawing on empirical examples and on Habermas's theory of communicative action, we offer suggestions for alternative and supplementary approaches to responding to concerns and complaints that might better address both the expectations of complainants and the improvement of services.

The role of the informal and formal organisation in voice about concerns in healthcare: A qualitative interview study.

The importance of employee voice-speaking up and out about concerns-is widely recognised as fundamental to patient safety and quality of care. However, failures of voice continue to occur, often with disastrous consequences. In this article, we argue that the enduring sociological concepts of the informal organisation and formal organisation offer analytical purchase in understanding the causes of such problems and how they can be addressed. We report a qualitative study involving 165 interviews across three healthcare organisations in two high-income countries. Our analysis emphasises the interdependence of the formal and informal organisation. The formal organisation describes codified and formalised elements of structures, procedures and processes for the exercise of voice, but participants often found it frustrating, ambiguous, and poorly designed. The informal organisation-the informal practices, social connections, and methods for making decisions that are key to coordinating organisational activity-could facilitate voice through its capacity to help people to understand complex processes, make sense of their concerns, and frame them in ways likely to prompt an appropriate organisational response. Sometimes the informal organisation compensated for gaps, ambiguities and inconsistencies in formal policies and systems. At the same time, the informal organisation had a dark side, potentially subduing voice by creating informal hierarchies, prioritising social cohesion, and providing opportunities for retaliation. The formal and the informal organisation are not exclusive or independent: they interact with and mutually reinforce each other. Our findings have implications for efforts to improve culture and processes in relation to voice in healthcare organisations, pointing to the need to address deficits in the formal organisation, and to the potential of building on strengths in the informal organisation that are crucial in supporting voice.

The relationship between staff skill mix, costs and outcomes in intermediate care services.

BACKGROUND: The purpose of this study was to assess the relationship between skill mix, patient outcomes, length of stay and service costs in older peoples' intermediate care services in England. METHODS: We undertook multivariate analysis of data collected as part of the National Evaluation of Intermediate Care Services. Data were analysed on between 337 and 403 older people admitted to 14 different intermediate care teams. Independent variables were the numbers of different types of staff within a team and the ratio of support staff to professionally qualified staff within teams. Outcome measures include the Barthel index, EQ-5D, length of service provision and costs of care. RESULTS: Increased skill mix (raising the number of different types of staff by one) is associated with a 17% reduction in service costs (p = 0.011). There is weak evidence (p = 0.090) that a higher ratio of support staff to qualified staff leads to greater improvements in EQ-5D scores of patients. CONCLUSIONS: This study provides limited evidence on the relationship between multidisciplinary skill mix and outcomes in intermediate care services.