The quality of care delivered to residents in long-term care in Australia: an indicator-based review of resident records (CareTrack Aged study).

BACKGROUND: This study estimated the prevalence of evidence-based care received by a population-based sample of Australian residents in long-term care (LTC) aged ≥ 65 years in 2021, measured by adherence to clinical practice guideline (CPG) recommendations. METHODS: Sixteen conditions/processes of care amendable to estimating evidence-based care at a population level were identified from prevalence data and CPGs. Candidate recommendations (n = 5609) were extracted from 139 CPGs which were converted to indicators. National experts in each condition rated the indicators via the RAND-UCLA Delphi process. For the 16 conditions, 236 evidence-based care indicators were ratified. A multi-stage sampling of LTC facilities and residents was undertaken. Trained aged-care nurses then undertook manual structured record reviews of care delivered between 1 March and 31 May 2021 (our record review period) to assess adherence with the indicators. RESULTS: Care received by 294 residents with 27,585 care encounters in 25 LTC facilities was evaluated. Residents received care for one to thirteen separate clinical conditions/processes of care (median = 10, mean = 9.7). Adherence to evidence-based care indicators was estimated at 53.2% (95% CI: 48.6, 57.7) ranging from a high of 81.3% (95% CI: 75.6, 86.3) for Bladder and Bowel to a low of 12.2% (95% CI: 1.6, 36.8) for Depression. Six conditions (skin integrity, end-of-life care, infection, sleep, medication, and depression) had less than 50% adherence with indicators. CONCLUSIONS: This is the first study of adherence to evidence-based care for people in LTC using multiple conditions and a standardised method. Vulnerable older people are not receiving evidence-based care for many physical problems, nor care to support their mental health nor for end-of-life care. The six conditions in which adherence with indicators was less than 50% could be the focus of improvement efforts.

Four System Enablers of Large-System Transformation in Health Care: A Mixed Methods Realist Evaluation.

Policy Points The implementation of large-scale health care interventions relies on a shared vision, commitment to change, coordination across sites, and a spanning of siloed knowledge. Enablers of the system should include building an authorizing environment; providing relevant, meaningful, transparent, and timely data; designating and distributing leadership and decision making; and fostering the emergence of a learning culture. Attention to these four enablers can set up a positive feedback loop to foster positive change that can protect against the loss of key staff, the presence of lone disruptors, and the enervating effects of uncertainty. CONTEXT: Large-scale transformative initiatives have the potential to improve the quality, efficiency, and safety of health care. However, change is expensive, complex, and difficult to implement and sustain. This paper advances system enablers, which will help to guide large-scale transformation in health care systems. METHODS: A realist study of the implementation of a value-based health care program between 2017 and 2021 was undertaken in every public hospital (n = 221) in New South Wales (NSW), Australia. Four data sources were used to elucidate initial program theories beginning with a set of literature reviews, a program document review, and informal discussions with key stakeholders. Semistructured interviews were then conducted with 56 stakeholders to confirm, refute, or refine the theories. A retroductive analysis produced a series of context-mechanism-outcome (CMO) statements. Next, the CMOs were validated with three health care quality expert panels (n = 51). Synthesized data were interrogated to distill the overarching system enablers. FINDINGS: Forty-two CMO statements from the eight initial program theory areas were developed, refined, and validated. Four system enablers were identified: (1) build an authorizing environment; (2) provide relevant, authentic, timely, and meaningful data; (3) designate and distribute leadership and decision making; and (4) support the emergence of a learning culture. The system enablers provide a nuanced understanding of large-system transformation that illustrates when, for whom, and in what circumstances large-system transformation worked well or worked poorly. CONCLUSIONS: System enablers offer nuanced guidance for the implementation of large-scale health care interventions. The four enablers may be portable to similar contexts and provide the empirical basis for an implementation model of large-system value-based health care initiatives. With concerted application, these findings can pave the way not just for a better understanding of greater or lesser success in intervening in health care settings but ultimately to contribute higher quality, higher value, and safer care.

Evaluation of a culture change program to reduce unprofessional behaviours by hospital co-workers in Australian hospitals.

BACKGROUND: Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program "Ethos" implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for 'reflection' or 'recognition'. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos. METHODS: A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5-3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as 'extreme' (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics. RESULTS: In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P < 0.001) post-Ethos. The odds of experiencing incivility/bullying declined by 24% (adjusted odds ratio [aOR] 0.76; 95% CI 0.66,0.87; P < 0.001) and odds of experiencing extreme behaviours by 32% (aOR 0.68; 95% CI 0.54,0.85; P < 0.001) following Ethos. All four dimensions showed a reduction of 32-41% in prevalence post-Ethos. Non-clinical staff reported the greatest decrease in their experience of unprofessional behaviour (aOR 0.41; 95% CI 0.29, 0.61). Staff attitudes and reported skills to speak-up were significantly more positive at follow-up. Awareness of the program was high (82.1%; 95% CI 80.0, 84.0%); 33% of respondents had sent or received an Ethos message. CONCLUSION: The Ethos program was associated with significant reductions in the prevalence of reported unprofessional behaviours and improved capacity of hospital staff to speak-up. These results add to evidence that staff will actively engage with a system that supports informal feedback to co-workers about their behaviours and is facilitated by trained peer messengers.

Strategies to improve care for older adults who present to the emergency department: a systematic review.

BACKGROUND: The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance. METHODS: A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach. RESULTS: Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience. CONCLUSION: It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability.

BACKGROUND: This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS: We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS: CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS: A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Is it possible to make 'living' guidelines? An evaluation of the Australian Living Stroke Guidelines.

BACKGROUND: Keeping best practice guidelines up-to-date with rapidly emerging research evidence is challenging. 'Living guidelines' approaches enable continual incorporation of new research, assisting healthcare professionals to apply the latest evidence to their clinical practice. However, information about how living guidelines are developed, maintained and applied is limited. The Stroke Foundation in Australia was one of the first organisations to apply living guideline development methods for their Living Stroke Guidelines (LSGs), presenting a unique opportunity to evaluate the process and impact of this novel approach. METHODS: A mixed-methods study was conducted to understand the experience of LSGs developers and end-users. We used thematic analysis of one-on-one semi-structured interview and online survey data to determine the feasibility, acceptability, and facilitators and barriers of the LSGs. Website analytics data were also reviewed to understand usage. RESULTS: Overall, the living guidelines approach was both feasible and acceptable to developers and users. Facilitators to use included collaboration with multidisciplinary clinicians and stroke survivors or carers. Increased workload for developers, workload unpredictability, and limited information sharing, and interoperability of technological platforms were identified as barriers. Users indicated increased trust in the LSGs (69%), likelihood of following the LSGs (66%), and frequency of access (58%), compared with previous static versions. Web analytics data showed individual access by 16,517 users in 2016 rising to 53,154 users in 2020, a threefold increase. There was also a fourfold increase in unique LSG pageviews from 2016 to 2020. CONCLUSIONS: This study, the first evaluation of living guidelines, demonstrates that this approach to stroke guideline development is feasible and acceptable, that these approaches may add value to developers and users, and may increase guideline use. Future evaluations should be embedded along with guideline implementation to capture data prospectively.

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals.

A key component of professional accountability programmes is online reporting tools that allow hospital staff to report co-worker unprofessional behaviour. Few studies have analysed data from these systems to further understand the nature or impact of unprofessional behaviour amongst staff. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system. Ethos has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. This study included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. Submissions that indicated the behaviour increased the risk to patient safety were identified. Descriptive summary statistics were presented for reporters and subjects of submissions about unprofessional behaviour. Logistic regression was applied to examine the association between each unprofessional behaviour (of the six most frequently reported in the Ethos submissions) and patient safety risk reported in the submissions. The descriptions in the reports were reviewed and the patient safety risks were coded using a framework aligned with the World Health Organization's International Classification for Patient Safety. Of 1310 submissions about unprofessional behaviour, 395 (30.2%) indicated that there was a risk to patient safety. Nurses made the highest number of submissions that included a patient safety risk [3.47 submissions per 100 nursing staff, 95% confidence interval (CI): 3.09-3.9] compared to other professional groups. Medical professionals had the highest rate as subjects of submissions for unprofessional behaviour with a patient safety risk (5.19 submissions per 100 medical staff, 95% CI: 4.44-6.05). 'Opinions being ignored' (odds ratio: 1.68; 95% CI: 1.23-2.22; P < .001) and 'someone withholding information which affects work performance' were behaviours strongly associated with patient safety risk in the submissions (odds ratio: 2.50; 95% CI: 1.73-3.62; P < .001) compared to submissions without a patient safety risk. The two main types of risks to patient safety described were related to clinical process/procedure and clinical administration. Commonly reported events included staff not following policy or protocol; doctors refusing to review a patient; and interruptions and inadequate information during handover. Our findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organizations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.

Programme theories to describe how different general practitioner service models work in different contexts in or alongside emergency departments (GP-ED): realist evaluation.

BACKGROUND: Addressing increasing patient demand and improving ED patient flow is a key ambition for NHS England. Delivering general practitioner (GP) services in or alongside EDs (GP-ED) was advocated in 2017 for this reason, supported by £100 million (US$130 million) of capital funding. Current evidence shows no overall improvement in addressing demand and reducing waiting times, but considerable variation in how different service models operate, subject to local context. METHODS: We conducted mixed-methods analysis using inductive and deductive approaches for qualitative (observations, interviews) and quantitative data (time series analyses of attendances, reattendances, hospital admissions, length of stay) based on previous research using a purposive sample of 13 GP-ED service models (3 inside-integrated, 4 inside-parallel service, 3 outside-onsite and 3 with no GPs) in England and Wales. We used realist methodology to understand the relationship between contexts, mechanisms and outcomes to develop programme theories about how and why different GP-ED service models work. RESULTS: GP-ED service models are complex, with variation in scope and scale of the service, influenced by individual, departmental and external factors. Quantitative data were of variable quality: overall, no reduction in attendances and waiting times, a mixed picture for hospital admissions and length of hospital stay. Our programme theories describe how the GP-ED service models operate: inside the ED, integrated with patient flow and general ED demand, with a wider GP role than usual primary care; outside the ED, addressing primary care demand with an experienced streaming nurse facilitating the 'right patients' are streamed to the GP; or within the ED as a parallel service with most variability in the level of integration and GP role. CONCLUSION: GP-ED services are complex . Our programme theories inform recommendations on how services could be modified in particular contexts to address local demand, or whether alternative healthcare services should be considered.

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study.

BACKGROUND: The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. METHODS: We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript. RESULTS: We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose. CONCLUSIONS: We have scrutinised the meaningful use of the PISA classification system's application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Feasibility and pilot testing of a personalized eHealth intervention for pain science education and self-management for breast cancer survivors with persistent pain: a mixed-method study.

PURPOSE: Here, we describe the development and pilot study of a personalized eHealth intervention containing a pain science education program and self-management support strategies regarding pain and pain-related functioning in female survivors of breast cancer. First, we aimed to evaluate the eHealth intervention's acceptability, comprehensibility, and satisfaction; second, we aimed to assess its preliminary efficacy. METHODS: A mixed-method study design was used. Breast cancer survivors with persistent pain were recruited. After 6 weeks of engagement with the eHealth intervention, acceptability, comprehensibility, and satisfaction were measured quantitatively with a self-constructed questionnaire and described qualitatively using focus groups. A joint display was used to present the meta-interferences between data. Efficacy was assessed via mixed effects models with repeated measures (outcomes assessed at baseline, 6 weeks, and 12 weeks). RESULTS: Twenty-nine women with persistent pain after breast cancer surgery participated. Overall, the eHealth program was well received and experienced as easy to use and helpful. The eHealth intervention seems useful as an adjunct to comprehensive cancer aftercare. Efficacy estimates suggested a significant improvement in pain-related functioning, physical functioning, and quality of life. CONCLUSION: A personalized eHealth intervention appears valuable for persistent pain management after breast cancer surgery. A large controlled clinical trial to determine effectiveness, and a full process evaluation, seems warranted.

Quality and safety in residential aged care: an evaluation of a national quality indicator programme.

BACKGROUND: In Australia, 243 000 individuals live in approximately 2700 residential aged care facilities yearly. In 2019, a National Aged Care Mandatory Quality Indicator programme (QI programme) was implemented to monitor the quality and safety of care in facilities. AIM: To examine the validity of the QI programme indicators using explicit measure review criteria. METHODS: The QI programme manual and reports were reviewed. A modified American College of Physicians Measure Review Criteria was employed to examine the QI programme's eight indicators. Five authors rated each indicator on importance, appropriateness, clinical evidence, specifications and feasibility using a nine-point scale. A median score of 1-3 was considered to not meet criteria, 4-6 to meet some criteria and 7-9 to meet criteria. RESULTS: All indicators, except polypharmacy, met criteria (median scores = 7-9) for importance, appropriateness and clinical evidence. Polypharmacy met some criteria for importance (median = 6, range 2-8), appropriateness (median = 5, range 2-8) and clinical evidence (median = 6, range 3-8). Pressure injury, physical restraints, significant unplanned weight loss, consecutive unplanned weight loss, falls and polypharmacy indicators met some criteria for specifications validity (all median scores = 5) and feasibility and applicability (median scores = 4 to 6). Antipsychotic use and falls resulting in major injury met some criteria for specifications (median = 6-7, range 4-8) and met criteria for feasibility and applicability (median = 7, range 4-8). CONCLUSIONS: Australia's National QI programme is a major stride towards a culture of quality promotion, improvement and transparency. Measures' specifications, feasibility and applicability could be improved to ensure the programme delivers on its intended purposes.

What are the experiences of team members involved in root cause analysis? A qualitative study.

BACKGROUND: Conducting root cause analysis (RCA) is complex and challenging. The aim of this study was to better understand the experiences of RCA team members and how they value their involvement in the RCA to inform future recruitment, conduct and implementation of RCA findings into clinical practice. METHODS: The study was set in a health network in Adelaide, South Australia. A qualitative exploratory descriptive approach was undertaken to provide an in-depth understanding of team member's experience in participating in an RCA. Eight of 27 RCA team members who conducted RCAs in the preceding 3-year period were included in one of three semi-structured focus groups. Thematic analysis was used to synthesise the transcribed data into themes. RESULTS: We derived four major themes: Experiences and perceptions of the RCA team, Limitations of RCA recommendations, Facilitators and barriers to conducting an RCA, and Supporting colleagues involved in the adverse event. Participants' mixed experience of RCAs ranged from enjoyment and the perception of worth and value to concerns about workload and lack of impact. Legislative privilege protecting RCAs from disclosure was both a facilitator and a barrier. Concern and a desire to better support their colleagues was widely reported. CONCLUSIONS: Clinicians perceived value in reviewing significant adverse events. Improvements can be made in sharing learnings to make effective improvements in health care. We have proposed a process to better support interviewees and strengthen post interview follow up.

Is there an association between out-of-pocket hospital costs, quality and care outcomes? A systematic review of contemporary evidence.

BACKGROUND: Out of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking. METHODS: The current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763). FINDINGS: A total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes. INTERPRETATION: The review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs. FUNDING: This study was funded by Medibank Better Health Foundation.

Retrospective analysis of factors influencing the implementation of a program to address unprofessional behaviour and improve culture in Australian hospitals.

BACKGROUND: Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. METHOD: Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. RESULTS: Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool ('Design quality and packaging'), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos ('Goals and Feedback', 'Access to Knowledge and Information'). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. CONCLUSION: Aspects of the inner setting (e.g., 'Leadership Engagement', 'Tension for Change') had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

The diversity of providers' and consumers' views of virtual versus inpatient care provision: a qualitative study.

BACKGROUND: A broad-based international shift to virtual care models over recent years has accelerated following COVID-19. Although there are increasing numbers of studies and reviews, less is known about clinicians' and consumers' perspectives concerning virtual modes in contrast to inpatient modes of delivery. METHODS: We conducted a mixed-methods study in late 2021 examining consumers' and providers' expectations of and perspectives on virtual care in the context of a new facility planned for the north-western suburbs of Sydney, Australia. Data were collected via a series of workshops, and a demographic survey. Recorded qualitative text data were analysed thematically, and surveys were analysed using SPSS v22. RESULTS: Across 12 workshops, 33 consumers and 49 providers from varied backgrounds, ethnicities, language groups, age ranges and professions participated. Four advantages, strengths or benefits of virtual care reported were: patient factors and wellbeing, accessibility, better care and health outcomes, and additional health system benefits, while four disadvantages, weaknesses or risks of virtual care were: patient factors and wellbeing, accessibility, resources and infrastructure, and quality and safety of care. CONCLUSIONS: Virtual care was widely supported but the model is not suitable for all patients. Health and digital literacy and appropriate patient selection were key success criteria, as was patient choice. Key concerns included technology failures or limitations and that virtual models may be no more efficient than inpatient care models. Considering consumer and provider views and expectations prior to introducing virtual models of care may facilitate greater acceptance and uptake.

What do consumer and providers view as important for integrated care? A qualitative study.

BACKGROUND: Integrated care is a model recognised internationally, however, there is limited evidence about its usability in the community. This study aimed to elicit community and provider views about integrated care and how implementation could meet their healthcare needs in a new hospital. METHODS: Using a qualitative approach, consumer and provider views on the strengths, barriers and enablers for integrated care were collected via a series of online workshops and supplementary interviews. RESULTS: A total of 22 consumers and 49 providers participated in 11 focus groups; all perceived integrated care to be an accessible and efficient model that offers a high level of care which enhanced staff and patient well-being. Providers expressed concerns about longer waiting times and safety risks associated with communication gaps and insufficient staff. Enablers include supporting consumers in navigating the integrated care process, co-ordinating and integrating primary care into the model as well as centralising patient electronic medical records. DISCUSSION: Primary, tertiary and community linkages are key for integrated care. Successful interoperability of services and networks requires an investment in resources and infrastructure to build the capability for providers to seamlessly access information at all points along the patient pathway. CONCLUSION: Integrated care is perceived by consumers and providers to be a flexible and patient-focused model of healthcare that offers benefits for a hospital of the future.

Comparing rates of adverse events detected in incident reporting and the Global Trigger Tool: a systematic review.

Many hospitals continue to use incident reporting systems (IRSs) as their primary patient safety data source. The information IRSs collect on the frequency of harm to patients [adverse events (AEs)] is generally of poor quality, and some incident types (e.g. diagnostic errors) are under-reported. Other methods of collecting patient safety information using medical record review, such as the Global Trigger Tool (GTT), have been developed. The aim of this study was to undertake a systematic review to empirically quantify the gap between the percentage of AEs detected using the GTT to those that are also detected via IRSs. The review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies published in English, which collected AE data using the GTT and IRSs, were included. In total, 14 studies met the inclusion criteria. All studies were undertaken in hospitals and were published between 2006 and 2022. The studies were conducted in six countries, mainly in the USA (nine studies). Studies reviewed 22 589 medical records using the GTT across 107 institutions finding 7166 AEs. The percentage of AEs detected using the GTT that were also detected in corresponding IRSs ranged from 0% to 37.4% with an average of 7.0% (SD 9.1; median 3.9 and IQR 5.2). Twelve of the fourteen studies found <10% of the AEs detected using the GTT were also found in corresponding IRSs. The >10-fold gap between the detection rates of the GTT and IRSs is strong evidence that the rate of AEs collected in IRSs in hospitals should not be used to measure or as a proxy for the level of safety of a hospital. IRSs should be recognized for their strengths which are to detect rare, serious, and new incident types and to enable analysis of contributing and contextual factors to develop preventive and corrective strategies. Health systems should use multiple patient safety data sources to prioritize interventions and promote a cycle of action and improvement based on data rather than merely just collecting and analysing information.

Improving patient safety governance and systems through learning from successes and failures: qualitative surveys and interviews with international experts.

Patient harm is a leading cause of global disease burden with considerable morbidity, mortality, and economic impacts for individuals, families, and wider society. Large bodies of evidence exist for strategies to improve safety and reduce harm. However, it is not clear which patient safety issues are being addressed globally, and which factors are the most (or least) important contributors to patient safety improvements. We aimed to explore the perspectives of international patient safety experts to identify: (1) the nature and range of patient safety issues being addressed, and (2) aspects of patient safety governance and systems that are perceived to provide value (or not) in improving patient outcomes. English-speaking Fellows and Experts of the International Society for Quality in Healthcare participated in a web-based survey and in-depth semistructured interview, discussing their experience in implementing interventions to improve patient safety. Data collection focused on understanding the elements of patient safety governance that influence outcomes. Demographic survey data were analysed descriptively. Qualitative data were coded, analysed thematically (inductive approach), and mapped deductively to the System-Theoretic Accident Model and Processes framework. Findings are presented as themes and a patient safety governance model. The study was approved by the University of South Australia Human Research Ethics Committee. Twenty-seven experts (59% female) participated. Most hailed from Africa (n = 6, 22%), Australasia, and the Middle East (n = 5, 19% each). The majority were employed in hospital settings (n = 23, 85%), and reported blended experience across healthcare improvement (89%), accreditation (76%), organizational operations (64%), and policy (60%). The number and range of patient safety issues within our sample varied widely with 14 topics being addressed. Thematically, 532 textual segments were grouped into 90 codes (n = 44 barriers, n = 46 facilitators) and used to identify and arrange key patient safety governance actors and factors as a 'system' within the System-Theoretic Accident Model and Processes framework. Four themes for improved patient safety governance were identified: (1) 'safety culture' in healthcare organizations, (2) 'policies and procedures' to investigate, implement, and demonstrate impact from patient safety initiatives, (3) 'supporting staff' to upskill and share learnings, and (4) 'patient engagement, experiences, and expectations'. For sustainable patient safety governance, experts highlighted the importance of safety culture in healthcare organizations, national patient safety policies and regulatory standards, continuing education for staff, and meaningful patient engagement approaches. Our proposed 'patient safety governance model' provides policymakers and researchers with a framework to develop data-driven patient safety policy.

Unsafe care in residential settings for older adults: a content analysis of accreditation reports.

Residents of aged care services can experience safety incidents resulting in preventable serious harm. Accreditation is a commonly used strategy to improve the quality of care; however, narrative information within accreditation reports is not generally analysed as a source of safety information to inform learning. In Australia, the Aged Care Quality and Safety Commission (ACQSC), the sector regulator, undertakes over 500 accreditation assessments of residential aged care services against eight national standards every year. From these assessments, the Aged Care Quality and Safety Commission generates detailed Site Audit Reports. In over one-third (37%) of Site Audit Reports, standards relating to Personal and Clinical Care (Standard 3) are not being met. The aim of this study was to identify the types of resident Safety Risks that relate to Personal and Clinical Care Standards not being met during accreditation or re-accreditation. These data could inform priority setting at policy, regulatory, and service levels. An analytical framework was developed based on the World Health Organization's International Classification for Patient Safety and other fields including Clinical Issue (the issue related to the incident impacting the resident, e.g. wound/skin or pain). Information relating to safety incidents in the Site Audit Reports was extracted, and a content analysis undertaken using the analytical framework. Clinical Issue and the International Classification for Patient Safety-based classification were combined to describe a clinically intuitive category ('Safety Risks') to describe ways in which residents could experience unsafe care, e.g. diagnosis/assessment of pain. The resulting data were descriptively analysed. The analysis included 65 Site Audit Reports that were undertaken between September 2020 and March 2021. There were 2267 incidents identified and classified into 274 types of resident Safety Risks. The 12 most frequently occurring Safety Risks account for only 32.3% of all incidents. Relatively frequently occurring Safety Risks were organisation management of infection control; diagnosis/assessment of pain, restraint, resident behaviours, and falls; and multiple stages of wounds/skin management, e.g. diagnosis/assessment, documentation, treatment, and deterioration. The analysis has shown that accreditation reports contain valuable data that may inform prioritization of resident Safety Risks in the Australian residential aged care sector. A large number of low-frequency resident Safety Risks were detected in the accreditation reports. To address these, organizations may use implementation science approaches to facilitate evidence-based strategies to improve the quality of care delivered to residents. Improving the aged care workforces' clinical skills base may address some of the Safety Risks associated with diagnosis/assessment and wound management.

Accreditation and clinical outcomes: shorter length of stay after first-time hospital accreditation in the Faroe Islands.

BACKGROUND: The aim of accreditation is to improve quality of care and patient safety. However, studies on the effectiveness of accreditation on clinical outcomes are limited and inconsistent. Comparative studies have contrasted accredited with non-accredited hospitals or hospitals without a benchmark, but assessments of clinical outcomes of patients treated at hospitals undergoing accreditation are sparse. The Faroe Islands hospitals were accredited for the first time in 2017, making them an ideal place to study the impact of accreditation. OBJECTIVE: We aimed to investigate the association between first-time hospital accreditation and length of stay (LOS), acute readmission (AR) and 30-day mortality in the unique situation of the Faroe Islands. METHODS: We conducted a before and after study based on medical record reviews in relation to first-time accreditation. All three Faroese hospitals were voluntarily accredited using a modified second version of the Danish Healthcare Quality Programme encompassing 76 standards. We included inpatients 18 years or older treated at a Faroese hospital with one of six clinical conditions (stroke/transient ischemic attack (TIA), bleeding gastic ulcer, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture) in 2012-2013 designated 'before accreditation'or 2017-2018' after accreditation'. The main outcome measures were LOS, all-cause AR and all-cause 30-day mortality. We computed adjusted cause-specific hazard rate (HR) ratios using Cox Proportional Hazard regression with before accreditation as reference. The analyses were controlled for age, sex, cohabitant status, in-hospital rehabilitation, type of admission, diagnosis and cluster effect at patient and hospital levels. RESULTS: The mean LOS was 13.4 days [95% confidence interval (95% CI): 10.8, 15.9] before accreditation and 7.5 days (95% CI: 6.10, 8.89) after accreditation. LOS of patients hospitalized after accreditation was significantly shorter [overall, adjusted HR = 1.23 (95% CI: 1.04, 1.46)]. By medical condition, only women in childbirth had a significantly shorter LOS [adjusted HR = 1.30 (95% CI: 1.04, 1.62)]. In total, 12.3% of inpatients before and 9.5% after accreditation were readmitted acutely within 30 days of discharge, and 30-day mortality was 3.3% among inpatients before and 2.8% after accreditation, respectively. No associations were found overall or by medical condition for AR [overall, adjusted HR = 1.34 (95% CI: 0.82, 2.18)] or 30-day mortality [overall, adjusted HR = 1.33 (95% CI: 0.55, 3.21)]) after adjustment for potential confounding factors. CONCLUSION: First-time hospital accreditation in the Faroe Islands was associated with a significant reduction in LOS, especially of women in childbirth. Notably, shorter LOS was not followed by increased AR. There was no evidence that first-time accreditation lowered the risk of AR or 30-day mortality.