A framework for engaging physicians in quality and safety.

BACKGROUND: Physicians should be engaged in quality-improvement activities to make the systems in which they work safer and more reliable. However, many physicians are still unable to contribute to patient safety initiatives that lead to safer, high-quality care for their patients. OBJECTIVE: To survey 10 high-performing hospitals in the USA to determine how they engage their physicians in quality and safety. DESIGN: Qualitative study that used site visits and a semistructured 20-question interview. SETTING: Ten high-performing US hospitals were chosen from the 2010 US News and World Report Best Hospitals and the Leapfrog Group on Patient Safety. PARTICIPANTS: Forty two interviews were conducted with forty-six quality leaders including CEO's, Chief Medical Officers, Vice Presidents for Quality and Safety and physicians. MEASUREMENTS: Site visits and in-person interviews were conducted during 2010-2011. The interviews were transcribed and coded using the constant comparative method for further analysis by the team. RESULTS: The authors developed a six-point framework for physician engagement in quality and safety as a constellation of the best strategies being used across the country. The framework consists of engaged leadership, a physician compact, appropriate compensation, realignment of financial incentives, data plus enablers and promotion. LIMITATION: The qualitative design and the small number of hospitals surveyed mean that the results may not be generalisable. CONCLUSION: There remain many ongoing barriers to physician engagement in quality and safety. Some high-performing hospitals in the USA have made significant improvements in engaging their physicians in quality and safety. The proposed framework can assist organisations in the development of strategies to engage physicians in quality-and-safety activities.

Use of the Internet by parents of paediatric patients.

AIM: We aimed to determine the rate of Internet use for obtaining medical information by health-care patients at a tertiary paediatric hospital, whether the Internet may influence patients' attitudes to health-care services and health-care providers and whether patients would prefer the assistance of a professional informatics officer. METHODS: An anonymous questionnaire randomly distributed to 450 subjects at Sydney Children's Hospital, Sydney, Australia. RESULTS: A total of 294 (65%) questionnaires were returned. Overall Internet use for medical information was 64% (189/294). Most (97%; 183/189) respondents reported 'wanting to know more' as the reason they sought information on the Internet. Eighty-eight per cent (167/189) of respondents reported that they trust their doctor more than the Internet. Twenty-one per cent (39/189) had presented their doctor with information about which he/she was unaware and 18% (34/189) had altered a health-care decision because of information found on the Internet. The Internet had influenced questions asked of doctors in 83% (156/189). Eighty-six per cent (252/294) of all respondents were in favour of professional assistance to obtain medical information. CONCLUSION: A large number of patients use the Internet to find information that influences their attitudes to health care. The services of a medical informatics professional would likely benefit both patients and doctors.

Lack of Supervision and Independent Clinical Decision Making in Postgraduate Pediatric training in Australia.

OBJECTIVE: Evaluation of postgraduate pediatric training is a complex yet critical task. We aimed to review pediatric trainees' attitudes to clinical decision-making, levels of supervision and end of life issues in a tertiary pediatric teaching hospital in Sydney, Australia. METHOD: A questionnaire was devised and distributed to all trainees at Sydney Children's Hospital, Randwick. All responses were anonymous. Results were independently analyzed using SPSS statistical software. RESULTS: Forty percent of trainees spent three hours or less per week face to face with more senior colleagues and 14% spent greater than 10 hours per week with more senior colleagues. Seventy-five percent of trainees spent three hours or less on the phone with more senior colleagues while 10% spent five hours or more on the phone with more senior colleagues. There was no association (or correlation) (p>0.05) between seniority of trainee and the number of times a trainee met face to face or phoned a more senior colleague to discuss a management plan. One in three trainees felt that they made less than 10% of clinical decisions on their own and 54% felt that they made less than half of decisions on their own. There was a statistically significant difference between seniority of training and the percentage of important clinical decisions made (p<0.01). Nearly half the trainees (47.7%) have not had the occasion to inform families of the death or impending death of a child. There was a statistically significant difference between seniority of training and the opportunity of informing families of a death of a child (p<0.01).Greater than two thirds of trainees feel that they have not received formal training in clinical decision-making. At the completion of four years of pediatric training only half the trainees considered themselves to be making the majority of clinical decisions. CONCLUSION: There is a need for closer supervision of pediatric trainees by senior colleagues, who themselves, may require additional ongoing training to supervise appropriately. There should be a balanced environment where trainees can make safe, independent decisions. The perceived absence of clinical decision making training suggests a deficiency in the training program.

Osteochondroma after total body irradiation: an age-related complication.

BACKGROUND: The discovery of a mass lesion in a long-term cancer survivor causes significant anxiety. The causes of such a mass include benign osteochondroma, which has been reported following focal irradiation and total body irradiation (TBI). PROCEDURE: To establish the incidence of osteochondromas following TBI, the medical records of all children treated at the Sydney Children's Hospital who received TBI as part of the conditioning prior to bone-marrow transplantation between 1978 and 1997 were reviewed. RESULTS: Five of 58 children who received TBI as part of the conditioning therapy for bone-marrow transplantation and who have been followed for at least 30 months post-irradiation, developed osteochondromas. All five of the patients had been under 5 years of age when they received TBI (mean 2.4 years), giving an incidence of osteochondroma of 24% in those who received TBI in the first 5 years of life. No osteochondromas have been diagnosed among the 37 patients who were aged between 5 years and 15 years at the time of receiving TBI. The mean latent time to diagnosis of osteochondroma was 4.6 years (range 2.5-9 years). Two patients developed multiple osteochondromas. Two patients required resection of their osteochondromas because of symptoms. Neither showed malignant degeneration. CONCLUSIONS: Younger patients are at increased risk of osteochondroma following TBI. Review of the available literature suggests a low malignant potential of radiation-induced osteochondromas. Knowledge about the behaviour of post-irradiation osteochondromas will help clinicians manage patients appropriately.

Making the Most of Medical Orientation - A New Approach.

Orientating new junior medical staff can be a complex and time consuming task. Traditional models have typically involved a day or longer of lectures. This involves a large number of senior staff being available on the first day of term. It also means that junior staff not present on the first day had any access to an orientation program at all. Evaluation of our program confirmed the belief that the day was dull and that there was simply too much information for new staff to absorb. As a result of this feedback we extensively updated our orientation program. Pre-reading of the junior staff manual became compulsory. We departed from the traditional lecture style program and devised a new ten- station scenario based interactive program. The stations were designed to cover aspects of the hospital's mandatory education and key educational requirements in order to function effectively on our campus. Station leaders were selected and trained in the goals of the new process. Several of our secondment sites were engaged in the development of the project topics. We hoped that our secondment sites would be relieved of some orientation responsibility if core material was delivered centrally. The strength of the new orientation is that it is portable, reproducible and uniform. It is also available via video conferencing. A single person can educate new staff in three hours if the need arises. Most importantly all new staff will have access to the program within a week of starting a term at our hospital. Key words: medical orientation; junior staff; interactive.