Virtual reality evidence on the impact of physicians' open versus defensive communication on patients.

Using virtual reality (VR) in an experimental setting, we analyse how communicating more openly about a medical incident influences patients' feelings and behavioural intentions. Using VR headsets, participants were immersed in an actual hospital room where they were told by a physician that a medical incident had occurred. In a given scenario, half of the participants were confronted by a physician who communicated openly about the medical incident, while the other half were confronted with the exact same scenario except that the physician employed a very defensive communication strategy. The employed technology allowed us to keep everything else in the environment constant. Participants exposed to open disclosure were significantly more likely to take further steps (such as contacting a lawyer to discuss options and filing a complaint against the hospital) and express more feelings of blame against the physician. At the same time, these participants rated the physician's communication skills and general impression more highly than those who were confronted with a defensive physician. Nevertheless, communicating openly about the medical incident does not affect trust in the physician and his competence, perceived incident severity and likelihood of changing physician and filing suit.

Does patient behaviour drive physicians to practice defensive medicine? Evidence from a video experiment.

OBJECTIVE: By manipulating patients' critical attitude in a video experiment, we examined whether physicians are more intended to perform defensive acts because of a higher perceived liability risk in Belgium. METHODS: We assigned 85 practicing gynaecologists/obstetricians and orthopaedists randomly to four hypothetical video consultations, in which the patients show either a critical attitude (i.e., getting ahead of the facts, showing distrust) or a non-critical attitude (i.e., displaying more neutral questions and expressions). We asked the physicians about the care they would administer in the presented cases and the expected likelihood that the patient would sue the physician in case of a medical incident. RESULTS: By manipulating patients' verbal critical attitude (which indicates patients' intention to take further steps), while keeping constant physician's communication, patients' clinical situation, preferences, and non-verbal behaviour in the videos, we were able to discover differential treatment styles driven by physicians' perceived liability risk among patients with a different critical attitude. We found that physicians perform 17 percentage points more defensive acts (e.g., surgeries and diagnostic tests that are not medically necessary) when experiencing a high liability risk. CONCLUSIONS: Our results show that patients' critical attitude drives physicians' perceived liability risk and consequent defensive behaviour among obstetricians/gynaecologists and orthopaedists.

Effectiveness of Telerehabilitation Interventions for Self-management of Tinnitus: Systematic Review.

BACKGROUND: Tinnitus is a highly prevalent symptom affecting 10%-20% of the adult population. Most patients with tinnitus have chronic tinnitus, which can directly or indirectly disrupt their daily life and negatively affect the health-related quality of life. Therefore, patients with tinnitus are frequently in need of costly and time-consuming treatments. As an answer, telerehabilitation interventions are on a rise to promote self-management in patients with tinnitus and reduce their dependency on in-person care. OBJECTIVE: This systematic review aimed to provide an overview of the research concerning the effectiveness of telerehabilitation interventions for self-management of tinnitus. METHODS: This systematic review adheres to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were eligible for inclusion if study participants were adult patients with complaints of primary subjective tinnitus and the study intervention comprised any possible telerehabilitation form for the self-management of tinnitus complaints. A search for eligible studies was conducted on PubMed, ScienceDirect, Scopus, Web of Science, and Cochrane Library. The Cochrane Risk of Bias 2 tool was used to the assess risk of bias. RESULTS: In total, 29 articles were found eligible, and of these, 5 (17%) studied multiple telerehabilitation forms. Internet-based cognitive behavioral treatment with guidance by a psychologist or audiologist was examined in 17 studies (n=1767), internet-based cognitive behavioral treatment without guidance was examined in 4 studies (n=940), self-help manuals were examined in 1 study (n=72), technological self-help devices were examined in 2 studies (n=82), smartphone apps were examined in 8 studies (n=284), and other internet-based interventions were examined in 2 studies (n=130). These rehabilitation categories were proven to be effective in decreasing tinnitus severity and relieving tinnitus distress as measured by tinnitus questionnaires such as Tinnitus Functional Index, Tinnitus Handicap Inventory, or Tinnitus Reactions Questionnaire. However, dropout rates were often high (range 4%-71.4%). All studies reported between some concerns and high concerns of risk of bias, resulting in low to moderate certainty levels. CONCLUSIONS: Overall, there is low to moderate quality evidence that telerehabilitation interventions effectively reduce tinnitus severity and distress. These interventions form a possible tool to improve the self-management capacities of the patient and the accessibility of tinnitus care as a replacement or an addition to in-person care. Nevertheless, barriers such as lack of time, engagement, motivation, and openness of the patient causing high dropout should be considered. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021285450; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285450.

Evaluation of the implementation of Value-Based Healthcare with a weekly digital follow-up of lung cancer patients in clinical practice.

OBJECTIVE: The aim of this study was to evaluate the implementation of Value-Based Healthcare principles for lung cancer patients in a large Belgian hospital. This hospital implemented a digital platform for the collection of patient-reported outcomes and the standardisation of care pathways. Also, a follow-up by the multidisciplinary care team was put in place. METHODS: Evaluation was done by employing a mixed method approach with data analysis of all included patients (n = 201), a pilot study (n = 30) and semi-structured interviews with the care team (n = 5). RESULTS: Overall, 95% of all lung cancer patients of two thoracic oncologists agreed to participate in the digital follow-up during the period January 2018 to September 2020 (201 participating patients). The response rates of those patients were high: 92% of the weekly questionnaires and 90% of the 6-weekly ICHOM questionnaires were responded. Based on the pilot study, we conclude that questions are clear and the platform is user-friendly for 90% of patients in the pilot. The interviews revealed that the weekly follow-up has a positive impact on the patient-provider communication and makes it easier to discuss psychological and palliative care needs. CONCLUSION: This study shows a successful implementation of Value Based Healthcare with weekly digital follow-up. Clinical trial registration is as follows: www. CLINICALTRIALS: gov, NCT04712149.

Cost-effectiveness of a smartphone Application for Tinnitus Treatment (the CATT trial): a study protocol of a randomised controlled trial.

BACKGROUND: Tinnitus is a highly prevalent symptom, affecting 10-15% of the adult population. Tinnitus influenced by alterations in somatosensory afference from the neck or jaw is referred to as somatic tinnitus (ST). ST is known to respond positively to physiotherapy treatment; however, it is challenging to motivate patients to systematically perform home exercises correctly, and the necessary tinnitus counselling is often lacking. The aim of this study is twofold, namely to investigate both the effectiveness and cost-effectiveness of a blended physiotherapy program for ST, including a smartphone application designed to increase exercise therapy compliance and provide tinnitus counselling. METHODS: This study is designed as a single-blind two-arm 1:1 randomised controlled trial (RCT). Adult patients diagnosed with ST, without psychiatric comorbidities and with experience in using a smartphone, will be recruited at the Ear Nose Throat (ENT) department of the Antwerp University Hospital (UZA). Patients will be randomised into two groups. The experimental group will receive the blended physiotherapy program comprising six in-clinic physiotherapy sessions over a period of 12 weeks (1x/2 weeks) and an exercise and counselling program provided by the smartphone application. The control group will receive the standard care program comprising twelve weekly in-clinic physiotherapy sessions. Each physiotherapy session has a duration of 30 min. The primary outcome measure is the change in Tinnitus Functional Index (TFI) score. Additionally, a cost-effectiveness analysis will be performed from a societal perspective considering both direct and indirect costs. There will be follow-up assessments at one and 3 months after the final treatment session. DISCUSSION: Our study is the first to combine both tinnitus counselling and neck/jaw treatment provided by a digital application in a blended physiotherapy program. This, in order to empower ST patients to improve and better manage their own health and, possibly, reduce economic costs by alleviating the tinnitus burden that ST patients experience. The strengths of the planned RCT are the high-quality methodological design, the large sample size and the expertise of the involved multidisciplinary research team. TRIAL REGISTRATION: Clinicaltrials.gov NCT05245318 . Registered on 26 January 2022.

Examining the acceptance of an integrated Electronic Health Records system: Insights from a repeated cross-sectional design.

BACKGROUND AND PURPOSE: Hospital staff's acceptance of an integrated Electronic Health Records system (EHR) is a critical success factor to exploit the benefits EHRs can offer. This study employs a repeated cross-sectional design to differentiate between the enablers and barriers of EHR acceptance prior to EHR implementation and those that arise over time by testing a theoretical model specifically tailored to the EHR context. METHODS: A repeated cross-sectional design, consisting of one measurement of staff's acceptance before and two after EHR implementation, was employed in a Belgian hospital. To test the theoretical model, partial least squares structural equation modelling (PLS-SEM) was used. Furthermore, partial least squares multigroup analyses (PLS-MGA) and permutation tests were applied to examine whether the relations in the model vary significantly over time. RESULTS: The formulated model explains up to 80 % of the variance in hospital staff's attitude towards the EHR. The extent to which the EHR leads to administrative simplification outperforms the core technology acceptance variables. Furthermore, support was found for the significant role of implementation factors (i.e. communication quality and training) and prior IT experiences in explaining EHR acceptance. Finally, the results show significant evolutions in path coefficients over time. An important trade-off between effort expectancy and performance expectancy was revealed, meaning effort expectancy is the most important determinant of hospital staff's attitude towards the EHR, but once the EHR has been implemented performance expectancy becomes more important. CONCLUSIONS: The results of testing the hypothesized model reveal the importance of taking into account hospital staff's perception of the extent to which the EHR generates administrative simplification, a combination of implementation factors, and attitude towards technology in general when assessing the acceptance of an EHR. Moreover, the results highlight the importance of conducting repeated cross-sectional or longitudinal technology acceptance research as relations between core variables vary significantly over time, which implies hospital management and healthcare technology providers should adjust their policy throughout the various implementation stages.

The resolution process and the timing of settlement of medical malpractice claims.

We draw on uniquely detailed micro-level data from a Belgian professional medical liability insurer to examine how different procedural and legal events that take place during the unfolding of a medical malpractice claim influence the timing of its settlement. Utilizing the competing risks regression framework, we find that settlement hazard is all else equal statistically significantly positively associated with the completion of those procedural and legal events that most effectively reveal factual information about the underlying medical malpractice case. Consistent with theory, settlement hazard is either unassociated or even negatively associated with the completion of other procedural and legal events. Our analysis, therefore, provides policy insights into which aspects of the resolution process could be emphasized, and which de-emphasized, in order to reduce the often excessive duration of medical malpractice claims and its adverse effects on the healthcare system.

Investigating medical malpractice victim compensation: micro-level evidence from a professional liability insurer's files.

We examine micro-level data on medical incidents recorded by a major Belgian professional liability insurer to identify the predictors of medical malpractice victim compensation. The data allow us to track each instance of suspect medical malpractice from the moment of insurer's knowledge about the incident to file closure. We are, therefore, able to investigate the determinants of both the incidence and amount of indemnity payment while addressing the associated sample selection concerns. Conditional on some indemnity having been paid, provider specialty risk predicts the indemnity payment amount, but only via the effect of sustained injury type. We find little evidence of vertical or horizontal inequities in indemnity payment. Our results highlight previously overlooked features of the incident resolution process as quantitatively important predictors of victim compensation.

A Factorial Survey on Safety Behavior Providing Opportunities to Improve Safety.

OBJECTIVES: To realize safe, high-quality treatment, employees should behave according to patient safety standards. Periodic measurement of safety behavior could provide management-relevant information to adjust the implementation of interventions and maximize improvement. Therefore, we constructed a factorial survey measuring safety awareness and intentions for behavior. METHODS: Cross-sectional results of the factorial survey were compared with results from the Hospital Survey on Patient Safety Culture, distributed in MAASTRO radiotherapy in 2010 to 2011. Respondents were presented 20 scenarios about incidents, randomly varying on work pressure, person causing incident, whether patient level was reached, severity of harm, notification by patient, and management support. After each scenario, questions were asked about safety awareness and behavior. χ and multilevel regression analyses were used. RESULTS: Response rates were 64% (n = 54) for the culture survey and 62% (n = 52) for the factorial survey on intentions. The culture survey reflected positive opinions regarding nonpunitive response and incident reporting, in accordance with high scores (factorial survey) on safety awareness (9.0; scale, 1-10) and reporting intentions (8.7). Whether an incident reached the patient level predicted safety awareness and intentions for safety behavior (ß = -1.3/-3.08) most strongly. Severity of harm showed minimal additional effects (ß = -0.24/-0.42). CONCLUSIONS: The factorial survey presented practical information on safety awareness and intentions for behavior. Therefore, it created additional opportunities for improving safety interventions. Because behavior is expected to change before values, one could hypothesize that factorial surveys would be more sensitive to change than culture surveys. Longitudinal research should further study the surveys' sensitivity to measure changes.

The effects of a lean transition on process times, patients and employees.

Purpose Treatment delays must be avoided, especially in oncology, to assure sustainable high-quality health care and increase the odds of survival. The purpose of this paper is to hypothesize that waiting times would decrease and patients and employees would benefit, when specific lean interventions are incorporated in an organizational improvement approach. Design/methodology/approach In 2013, 15 lean interventions were initiated to improve flow in a single radiotherapy institute. Process/waiting times, patient satisfaction, safety, employee satisfaction, and absenteeism were evaluated using a mixed methods methodology (2010-2014). Data from databases, surveys, and interviews were analyzed by time series analysis, χ2, multi-level regression, and t-tests. Findings Median waiting/process times improved from 20.2 days in 2012 to 16.3 days in 2014 ( p<0.001). The percentage of palliative patients for which waiting times had exceeded Dutch national norms (ten days) improved from 35 (six months in 2012: pre-intervention) to 16 percent (six months in 2013-2014: post-intervention; p<0.01), and the percentage exceeding national objectives (seven days) from 22 to 17 percent ( p=0.44). For curative patients, exceeding of norms (28 days) improved from 17 (2012) to 8 percent (2013-2014: p=0.05), and for the objectives (21 days) from 18 to 10 percent ( p<0.01). Reported safety incidents decreased 47 percent from 2009 to 2014, whereas safety culture, awareness, and intention to solve problems improved. Employee satisfaction improved slightly, and absenteeism decreased from 4.6 (2010) to 2.7 percent (2014; p<0.001). Originality/value Combining specific lean interventions with an organizational improvement approach improved waiting times, patient safety, employee satisfaction, and absenteeism on the short term. Continuing evaluation of effects should study the improvements sustainability.

Advantages and disadvantages of the Belgian not-only-fault system for medical incidents.

In 2010, the Belgian compensation system for medical incidents was reformed, in order to overcome some important deficiencies of court procedures. This resulted in a not-only-fault compensation system, following the establishment of the Fund for Medical Accidents (FMA). This paper seeks to clarify the main advantages and disadvantages of this reform. After all, the legislator paid little attention to the impact on physicians, who also seem to be insufficiently informed. However, currently the FMA experiences a significant delay in processing compensation requests. The true effects of the not-only-fault system for patients and physicians as well as for health care quality therefore still remain unclear today.

The determinants of defensive medicine practices in Belgium.

In 2010 the Belgian government introduced a low cost administrative procedure for compensating medical injuries to overcome the major shortcomings of the existing tort system. This paper examines, for the first time, to what extent this reform had an impact on physician specialists' defensive practices and what are the relevant determinants affecting physicians' clinical decision making. Based on a survey of 508 physicians, we find evidence of a relatively modest increase in defensive practices among physicians in various specialties. In general, 14% of the respondents, who were aware of the reform, reported to have increased their overall defensive behaviour, while respectively 18 and 13% altered their assurance and avoidance behaviour. Commonly used physician characteristics, such as claims experience and gender, have a similar impact on defensive medicine as documented in existing literature. Furthermore, the determinant physician's access to an incident reporting system is found to have a significant impact on most of the defensive medicine measures. Health care institutions may therefore play an important role in controlling and reducing physicians' defensive practices.

Has Lean improved organizational decision making?

Purpose - Sustainable improvement is likely to be hampered by ambiguous objectives and uncertain cause-effect relations in care processes (the organization's decision-making context). Lean management can improve implementation results because it decreases ambiguity and uncertainties. But does it succeed? Many quality improvement (QI) initiatives are appropriate improvement strategies in organizational contexts characterized by low ambiguity and uncertainty. However, most care settings do not fit this context. The purpose of this paper is to investigate whether a Lean-inspired change program changed the organization's decision-making context, making it more amenable for QI initiatives. Design/methodology/approach - In 2014, 12 professionals from a Dutch radiotherapy institute were interviewed regarding their perceptions of a Lean program in their organization and the perceived ambiguous objectives and uncertain cause-effect relations in their clinical processes. A survey (25 questions), addressing the same concepts, was conducted among the interviewees in 2011 and 2014. The structured interviews were analyzed using a deductive approach. Quantitative data were analyzed using appropriate statistics. Findings - Interviewees experienced improved shared visions and the number of uncertain cause-effect relations decreased. Overall, more positive (99) than negative Lean effects (18) were expressed. The surveys revealed enhanced process predictability and standardization, and improved shared visions. Practical implications - Lean implementation has shown to lead to greater transparency and increased shared visions. Originality/value - Lean management decreased ambiguous objectives and reduced uncertainties in clinical process cause-effect relations. Therefore, decision making benefitted from Lean increasing QI's sustainability.

Safer radiation therapy treatment resulting from an equipment transition: A mixed-methods study.

PURPOSE: To realize individualized safe radiation therapy, reliable treatment equipment is essential in combination with a system-level improvement approach. We hypothesized that implementation of a system that integrated all required treatment equipment would result in improved safety and stability of the irradiation treatment process. METHODS AND MATERIALS: Seven accelerators, portal imaging, and the treatment planning software were replaced by an integrated system that included 6 accelerators. The number of reported safety incidents and root causes were recorded between 2010 and 2014. Time series analysis was performed, and quantitative results were explored by structured interviews. Additionally, downtime was recorded. RESULTS: From January 2010 to July 2014, 5085 incidents were reported. Reports related to the accelerators decreased from 33% (2010) to 20% (2013-2014) of total reports, whereas the number of delivered fractions per accelerator increased by 20% (2010: 643 per month; 2013: 795 per month). Reports related to portal imaging decreased from 16.5 reports per month (2010) to 3.1 (2013-2014). Of these portal imaging reports, 316 had at least 1 technical cause in 2010, which decreased to 13 in 2013-2014. Interviewees attributed the decreased reporting to the equipment transition, not to decreased safety awareness. Downtime decreased by 46%, from 5.4% in 2010 to 2.9% in 2013. CONCLUSIONS: The number of reported accelerator- and portal imaging-related incidents decreased significantly, whereas safety awareness remained stable. In addition, accelerator downtime decreased, possibly resulting in less rescheduling of patients and fewer disruptions of work processes. Therefore, we conclude that the risk for serious safety incidents and patient harm decreased after implementation of the new integrated system.

Cost-Effectiveness of Reduced Waiting Time for Head and Neck Cancer Patients due to a Lean Process Redesign.

BACKGROUND: Compared with new technologies, the redesign of care processes is generally considered less attractive to improve patient outcomes. Nevertheless, it might result in better patient outcomes, without further increasing costs. Because early initiation of treatment is of vital importance for patients with head and neck cancer (HNC), these care processes were redesigned. OBJECTIVES: This study aimed to assess patient outcomes and cost-effectiveness of this redesign. METHODS: An economic (Markov) model was constructed to evaluate the biopsy process of suspicious lesion under local instead of general anesthesia, and combining computed tomography and positron emission tomography for diagnostics and radiotherapy planning. Patients treated for HNC were included in the model stratified by disease location (larynx, oropharynx, hypopharynx, and oral cavity) and stage (I-II and III-IV). Probabilistic sensitivity analyses were performed. RESULTS: Waiting time before treatment start reduced from 5 to 22 days for the included patient groups, resulting in 0.13 to 0.66 additional quality-adjusted life-years. The new workflow was cost-effective for all the included patient groups, using a ceiling ratio of €80,000 or €20,000. For patients treated for tumors located at the larynx and oral cavity, the new workflow resulted in additional quality-adjusted life-years, and costs decreased compared with the regular workflow. The health care payer benefited €14.1 million and €91.5 million, respectively, when individual net monetary benefits were extrapolated to an organizational level and a national level. CONCLUSIONS: The redesigned care process reduced the waiting time for the treatment of patients with HNC and proved cost-effective. Because care improved, implementation on a wider scale should be considered.

Workshops as a useful tool to better understand care professionals' views of a lean change program.

PURPOSE: For change programs to succeed, it is vital to have a detailed understanding of employees' views regarding the program, especially when the proposed changes are potentially contested. Gaining insight into employee perceptions helps managers to decide how to proceed. The authors conducted two workshops in a radiotherapy institute to assess the benefits and drawbacks, as well as their underlying causes, of a proposed Lean change program. Managers' views on the workshops' usefulness were charted. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: Two workshops were organized in which employees predicted positive and negative effects of a Lean program. The workshops combined a structured brainstorm (KJ-technique) and an evaluation of the expected effects. Eight top managers judged the workshops' value on supporting decision making. FINDINGS: In total, 15 employees participated in the workshops. Participants from workshop 2 reported more expected effects (27 effects; 18 positive) than from workshop 1 (14 effects; six positive). However, when effects were categorized, similar results were shown. Three from eight managers scored the results relevant for decision making and four neutral. Seven managers recommended future use of the instrument. Increased employee involvement and bottom-up thinking combined with relatively low costs were appreciated most. PRACTICAL IMPLICATIONS: The workshop could serve as a simple instrument to improve decision making and enhance successful implementation of change programs, as it was expected to enhance employees' involvement and was relatively easy to conduct and cheap. ORIGINALITY/VALUE: The workshop increased insight into employee views, facilitating adaptive actions by healthcare organization managers.

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

OBJECTIVE: The objective of this review is to obtain a better understanding of the user-related barriers against, and facilitators for, the implementation of surgical safety checklists. METHODS: We searched MEDLINE for articles describing stakeholders' perspectives regarding, and experiences with, the implementation of surgical safety checklists. The quality of the papers was assessed by means of the Qualitative Assessment and Review Instrument. Thematic synthesis was used to integrate the emergent descriptive themes into overall analytical themes. RESULTS: The synthesis of 18 qualitative studies indicated that implementation requires change in the workflow of healthcare professionals as well as in their perception of the checklist and the perception of patient safety in general. The factors impeding or advancing the required change concentrated around the checklist, the implementation process and the local context. We found that the required safety checks disrupt operating theatre staffs' routines. Furthermore, conflicting priorities and different perspectives and motives of stakeholders complicate checklist implementation. When approaching the checklist as a simple technical intervention, the expectation of cooperation between surgeons, anaesthetists and nurses is often not addressed, reducing the checklist to a tick-off exercise. CONCLUSIONS: The complex reality in which the checklist needs to be implemented requires an approach that includes more than eliminating barriers and supporting facilitating factors. Implementation leaders must facilitate team learning to foster the mutual understanding of perspectives and motivations, and the realignment of routines. This paper provides a pragmatic overview of the user-related barriers and facilitators upon which theories, hypothesising potential change strategies and interactions, can be developed and tested empirically.

Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.

PURPOSE: The importance of a safety culture to maximize safety is no longer questioned. However, achieving sustainable culture improvements are less evident. Evidence is growing for a multifaceted approach, where multiple safety interventions are combined. Lean management is such an integral approach to improve safety, quality and efficiency and therefore, could be expected to improve the safety culture. This paper presents the effects of lean management activities on the patient safety culture in a radiotherapy institute. METHODS: Patient safety culture was evaluated over a three year period using triangulation of methodologies. Two surveys were distributed three times, workshops were performed twice, data from an incident reporting system (IRS) was monitored and results were explored using structured interviews with professionals. Averages, chi-square, logistical and multi-level regression were used for analysis. RESULTS: The workshops showed no changes in safety culture, whereas the surveys showed improvements on six out of twelve dimensions of safety climate. The intention to report incidents not reaching patient-level decreased in accordance with the decreasing number of reports in the IRS. However, the intention to take action in order to prevent future incidents improved (factorial survey presented ß: 1.19 with p: 0.01). CONCLUSIONS: Due to increased problem solving and improvements in equipment, the number of incidents decreased. Although the intention to report incidents not reaching patient-level decreased, employees experienced sustained safety awareness and an increased intention to structurally improve. The patient safety culture improved due to the lean activities combined with an organizational restructure, and actual patient safety outcomes might have improved as well.