Use of statistical process control in quality improvement projects in abdominal surgery: a PRISMA systematic review.

BACKGROUND: The use of quality improvement methodology has increased in recent years due to a perceived benefit in effectively reducing morbidity, mortality and length of stay. Statistical process control (SPC) is an important tool to evaluate these actions, but its use has been limited in abdominal surgery. Previous systematic reviews have examined the use of SPC in healthcare, but relatively few surgery-related articles were found at that time. OBJECTIVE: To perform a systematic review (SR) to evaluate the application of SPC on abdominal surgery specialties between 2004 and 2019. METHODS: An SR following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram was completed using Embase and Ovid Medline with terms related to abdominal surgery and SPC. RESULTS: A total of 20 articles were selected after applying the exclusion criteria. Most of the articles came from North America, Europe and Australia, and half have been published in the last 5 years. The most common outcome studied was surgical complications. Urology, colorectal and paediatric surgery made up most of the articles. Articles show the application of SPC in various outcomes and the use of different types of graphs, demonstrating flexibility in using SPC. However, some studies did not use SPC in a robust way and these studies were of variable quality. CONCLUSION: This study shows that SPCs are being applied increasingly for most surgical specialties; however, it is still less used than in other fields, such as anaesthesia. We identified conceptual errors in several studies, such as issues with the design or incorrect data analysis. SPCs can be used to increase the quality of surgical care; the use should increase, but critically, the analysis needs to improve to prevent erroneous conclusions being drawn.

Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input.

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and 'top-up'. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally.

How Safety Culture Surveys Influence the Quality and Safety of Healthcare Organisations.

Objectives Safety culture surveys have been widely used in healthcare for more than two decades predominantly as a tool for measuring the level of safety culture (as defined as the beliefs and attitudes that staff express about how their organisation ought to work and how it does in fact work). However, there is the potential for the survey process itself to influence the safety culture and working practices in departments and organisations. The objective of this study was to identify the mechanism by which these changes might occur. Design, setting and participants Mixed methods combining qualitative semi-structured interviews and quantitative scores from patient safety surveys. This evaluation was conducted across general practice, community and acute hospitals in two NHS regions in England; South West and Greater Manchester. The study was undertaken between 2015 and 2018 during the implementation of a series of Patient Safety Collaboratives. Safety, Communication, Operational Reliability, and Engagement (SCORE) surveys were administered in 15 units, followed by a staff debriefing and a second SCORE survey. Semi-structured interviews were conducted with clinicians (n=61). Results from the first and second surveys were compared in order to test for differences in responses. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed.  Analysis and results Results from the first and second surveys were compared using chi-squared and Fisher's exact tests. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed.  There was little change in responses between the first and second SCORE surveys. Within general practice there was some improvement in responses in three survey domains; however, these differences were not conclusive. The qualitative interview data demonstrated a beneficial effect on safety culture. Staff stated that the survey debriefings created a new safe space where problems could be discussed and improvement plans created.  Conclusions Safety culture surveys can improve safety culture within departments if they are followed by a process that includes debriefing the staff and working with them to develop improvement plans.

Adherence to Post-polypectomy Surveillance Guidelines at a Large District General Hospital.

Introduction In 2020, the British Society of Gastroenterologists (BSG), the Association of Coloproctology of Great Britain and Ireland (ACPGBI), and Public Health England (PHE) published joint guidelines regarding post-polypectomy surveillance. This study aimed to establish clinician adherence at the Royal Devon University Healthcare NHS Foundation Trust to the 2020 guidelines compared to the now-retired 2010 guidelines. Materials and Methods Data on 152 patients treated under the 2010 guidelines and 133 patients treated under the 2020 guidelines were collected retrospectively from the hospital's colonoscopy database. Data were analysed to determine whether patients who had a colonoscopy fulfilled BSG/ACPGBI/PHE guidelines for follow-up. Costs were estimated using the price of colonoscopy in the NHS National Schedule. Results Approximately 41.4% (63/152) of patients were adherent to the 2010 guidelines while 66.2% (88/133) of patients were adherent to the 2020 guidelines. The difference in adherence rate was 24.7% (95% confidence interval 13.5% - 35.9%, p<0.0001). Nearly 37% (35/95) of patients who would have been followed up under the 2010 guidelines did not receive any follow-up as a result of the 2020 guidelines. This represents a cost saving of £36,892.28 per year in our hospital. Approximately 47% (28/60) of patients treated under the 2020 guidelines had surveillance colonoscopy planned when the guidelines recommended no follow-up. If every clinician were fully adherent to the 2020 guidelines, then a further £29,513.82 per year would have been saved. Discussion and Conclusion Following the introduction of the 2020 guidelines, adherence to polyp surveillance guidelines increased in our hospital. However, nearly half of the colonoscopies were performed unnecessarily due to non-adherence. Furthermore, our results demonstrate that the 2020 guidelines have decreased the need for follow-up.

Tipping the balance: A systematic review and meta-ethnography to unfold the complexity of surgical antimicrobial prescribing behavior in hospital settings.

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might 'tip the balance' towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

Improving the uptake of cervical screening in pregnant and recently postnatal women: a quality improvement project.

BACKGROUND: In 2018, cervical screening uptake was at its lowest level since screening began, particularly in those aged 25-35, coinciding with the peak incidence of cervical cancer and average age at first delivery. PROBLEM: Retrospective baseline data of pregnant women found 47.3% (n=123/260) were overdue for screening by delivery, of whom 74% (n=91/123) remained overdue by 6 months postnatal. METHODS: We undertook a quality improvement project from April 2018 to April 2019 to improve cervical screening uptake in pregnant and postnatal women. We mapped out the screening process and canvassed stakeholders. The main theme was inconsistency of advice received by women. From February 2018 to May 2020, we undertook a prospective audit of 10 women per week who gave birth in our maternity department, recording screening status at delivery and 6 months postnatal.Interventions included introducing evidence-based guidelines about cervical screening in pregnancy and the postnatal period, flow charts for maternity staff, multiprofessional teaching for all maternity staff and information dissemination to women (via the HANDiApp platform, a social media campaign and adapting results letters following colposcopy, highlighting dates when screening would be due). Primary care opening hours were extended for screening and women received a letter from their midwives, if they required cervical screening in pregnancy. RESULTS: Locally, the percentage of women overdue for cervical screening by 6 months postnatal improved by 8.0% during this project, compared with a 1.6% change in national screening rates in women aged 25-49. CONCLUSIONS: We increased the percentage of local pregnant and postnatal women attending cervical screening by introduction of a package of information, targeted education and widening access to screening appointments.

Exploring two distinct gentamicin prescribing protocols in UK hospitals: a mixed-methods realist evaluation.

OBJECTIVES: Gentamicin is the aminoglycoside antibiotic of choice in the UK. It has a narrow therapeutic index: underdosing results in inefficacy while overdosing is characterised by nephrotoxicity and ototoxicity. To improve patient safety, hospitals have protocols for the prescription of gentamicin, which vary in complexity and approach. This study aimed to explore two distinct protocols for prescribing gentamicin in hospital settings, in order to understand the mechanisms they trigger and the outcomes they achieve. SETTING: A mixed-methods realist evaluation explored gentamicin prescribing protocols in two hospital surgical admissions units in South West England between January and August 2018. Site 1 had a traditional, complex protocol, while site 2 took a simplified protocol. PARTICIPANTS: Testing the initial programme theory (IPT) involved semi-structured audio-recorded interviews of a volunteer sample of healthcare professionals (HCPs) involved in the prescribing and administering process, alongside a clinical audit reviewing accuracy of gentamicin prescribing. OUTCOME MEASURES: Three sequential phases were used to identify factors in a successful protocol: IPT generation; testing; refinement of the IPT. The IPT was generated by literature search and analysis of existing protocols of sites 1 and 2. Refinement of the IPT synthesised the results of the quantitative and qualitative research to identify the key characteristics of a successful protocol. RESULTS: One hundred gentamicin prescriptions were reviewed, with a mean accuracy of gentamicin prescribing at site 1 of 65.67% and at site 2 of 78.79% (p<0.01). Thirty HCPs were interviewed. Key contexts were identified including prescriptiveness, experience and availability of patient information. These triggered hidden mechanisms including uncertainty, fear, confidence and frustration leading to both intended outcomes but also unintended outcomes such as deviation from protocol and unnecessary gentamicin levels. CONCLUSIONS: A simplified prescribing protocol for gentamicin is better accepted by prescribers, leading to better adherence to protocol and more accurate prescribing.

'I've got a little list'-the scourge of a surgical junior. A quality improvement project to change the surgical patient list in a district general hospital.

BACKGROUND: Junior doctors at the Royal Devon and Exeter Hospital spend hours every day creating and updating patient lists for all surgical specialties on Microsoft Excel spreadsheets. This not only consumes time that should be spent on clinical tasks, it allows for human errors, system errors and patient safety concerns. Our aim was to reduce time spent on the list and reduce the chance for error. METHODS: We measured the time junior doctors spent creating and updating the surgical lists for one specialty, and on-call shifts. Our first Plan-Do-Study-Act (PDSA) cycle was to introduce clinical secretaries; this reduced the time spent by ward teams on the list but had no effect on the on-call team. We then worked with the hospital application developer to adapt software currently used to suit all surgical teams. Once completed, this software was rolled out alongside the existing spreadsheet method with a view to a switch after a transition period. RESULTS: The introduction of clinical secretaries reduced the time spent on the colorectal surgery list from 99.22 min a day to 43.38 min. The on-call team however did not benefit from this intervention. Following the introduction of the new software, the day on-call team time spent on the list changed from 121 min a day to 4.66 min. The night on-call team time changed from 91 min to 7.38 min. CONCLUSION: Reducing the time juniors spend compiling surgical lists has clear benefits to patients with extra time for junior doctors to clerk patients. The use of an automated system removes the chance of error in transcription of blood results. Due to the success of this project, colorectal, upper gastrointestinal, urology, vascular and on-call teams have adopted the new list permanently.

Pharmacist-led, video-stimulated feedback to reduce prescribing errors in doctors-in-training: A mixed methods evaluation.

AIMS: To develop and evaluate a feasible, authentic pharmacist-led prescribing feedback intervention for doctors-in-training, to reduce prescribing errors. METHODS: This was a mixed methods study. Sixteen postgraduate doctors-in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi-structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. RESULTS: During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P < .0001). Pharmacist-led video-stimulated prescribing feedback was feasible and positively received by participants, who appreciated the reinforcement of good practice as well as the opportunity to reflect on and improve practice. CONCLUSIONS: Feedback to doctors-in-training tends to be infrequent and often negative, but this feasible feedback strategy significantly reduced prescribing errors and was well received by the target audience as a supportive developmental approach.

Empowering junior doctors: a qualitative study of a QI programme in South West England.

AIM: To explore how the South-West Foundation Doctor Quality Improvement programme affected foundation year 1 (F1) doctors' attitudes and ability to implement change in healthcare. METHODS: Twenty-two qualitative interviews were carried out with two cohorts of doctors. The first F1 group before and after their participation in the QI programme; the second group comprised those who had completed the programme between 1 and 5 years earlier. Qualitative data were analysed using thematic analysis techniques. RESULTS : Prior to taking part in the QI programme, junior doctors' attitudes towards QI were mixed. Although there was agreement on the importance of QI in terms of patient safety, not all shared enthusiasm for engaging in QI, while some were sceptical that they could bring about any change. Following participation in the programme, attitudes towards QI and the ability to effect change were significantly transformed. Whether their projects were considered a success or not, all juniors reported that they valued the skills learnt and the overall experience they gained through carrying out QI projects. Participants reported feeling more empowered in their role as junior doctors, with several describing how they felt 'listened to' and able to 'have a voice', that they were beginning to see things 'at systems level' and learning to 'engage more critically' in their working environment. CONCLUSIONS : Junior doctors are ideally placed to engage in QI. Training in QI at the start of their medical careers may enable a new generation of doctors to acquire the skills necessary to improve patient safety and quality of care.

E-referrals: improving the routine interspecialty inpatient referral system.

Interspecialty referrals are an essential part of most inpatient stays. With over 130 referrals occurring per week at the Royal Devon and Exeter Hospital, the process must be efficient and safe. The current paper-based 'white card' system was felt to be inefficient, and a Trust incident highlighted patient safety concerns. Questionnaires reinforced the need for improvement, with concerns such as a lack of referral traceability and delays in the referral delivery due to workload. The aims of the project were to improve patient safety and junior doctor efficiency in the referral process. Through appreciative enquiry and the PDSA (Plan-Do-Study-Act) model, an electronic referral system was developed, piloted within two specialties and later expanded to others with improvements made along the way based on user feedback. The system includes novel features including specialties 'acknowledging' a referral to allow referral progress to be tracked. The system stores all referrals, creating a fully auditable inpatient referral pathway. Qualitative data indicated improvement to patient safety and user experience (n=31). Timings for referrals were measured over a 6-month period; referrals became faster with the electronic system, with average time from decision to refer to referral submission improving from 2.1 hours to 1.9 hours, with a noted statistically significant improvement in timings on a statistical process control chart. An unexpected benefit was that patients were also reviewed faster by specialties. Measuring these changes presented a significant challenge due to the complexity of the referral process, and this was a big limitation. Overall, the re-design of a paper-based referral system into an electronic system has been proven to be more efficient and felt to be safer for patients. This is a sustainable change which is being rolled out Trust-wide. We hope that the reporting of this project will help others considering reviewing their inpatient referral pathways.

'From scared to prepared': targeted structured induction training during the transition from medical school to foundation doctor.

The risks to patients at August handover time are well known, yet there is no national consensus on the best way to deliver induction programmes for Foundation Year One (F1). The aim of this study was to design, deliver and assess a targeted structured induction programme for new F1 doctors. The induction training programme was designed using educational models of topic analysis informed by results of a survey of F1s and medical students, and the F1 curriculum. Data regarding serious untoward incidents and self-reported preparedness were collected between 2008 and 2010, and rates were compared between those receiving optional (2008) and compulsory (2009 and 2010) training. By delivering targeted education and spending time with the outgoing F1 doctors, 97 % of our new doctors felt adequately prepared for practice. The incidence of self-reported mistakes made by F1s in the first 4 months of their practice fell by 45 % and serious untoward incidents also decreased. Targeted structured induction training addresses final-year medical students' concerns about their preparedness for practice as junior doctors, and improves patient safety. This study supports the General Medical Council recommendation that targeted structured induction training should be mandatory for all new doctors.