Successful use of "Choice Architecture" and "Nudge Theory" in a quality improvement initiative of analgesia administration after Caesarean section.

BACKGROUND: Regular, routine, multimodal analgesia provides better pain relief following Caesarean section than reliance on "as required" opiate dosing. This quality improvement report describes the effective use of an education programme coupled with a highlighted, preprinted medication chart, employing "Nudge Theory" principles to achieve significant improvements in the administration of analgesic medications to patients after Caesarean section operations. PROBLEM: An acute pain service audit identified a serious deficiency with delivery of regular postoperative analgesic medications to patients following Caesarean section operations. METHODS: An audit of pain medication delivery to patients following Caesarean section demonstrated that postoperative analgesia was not being administered in line with local prescribing guidelines. Two interventions were planned: Education sessions for anaesthetic recovery and ward staff. Introduction of a new preprinted and highlighted medication chart. A postintervention audit was then conducted. RESULTS: There were statistically significant improvements in all medications administered to patients following the two interventions. For analgesic medications, the rate of administration of drugs in compliance with guidelines rose from 39.6% to 89.9% (P < 0.001 using 2-sample z test). Each subgroup of medications also showed statistically significant improvements in administration compliance. CONCLUSION: A combined approach, including application of "Nudge Theory" to the administration of analgesic medication after Caesarean section, considerably improved delivery of medications prescribed for postoperative analgesia.

Clinical engagement: a new concept or common sense all round?

Clinical engagement has supplemented clinical governance in healthcare to strengthen the contribution of medical professionals to the assessment of clinical outcomes for patients. Assessments of clinical engagement have, until now, been qualitative; this case study introduces the concept of quantitative assessment of clinical engagement by measuring the number of patients managed according to specialist society guidelines. Such an assessment engages all staff (medical, nursing, allied health and pharmacy) involved in patients receiving treatment according to such guidelines and provides an assessment of individual and organisational compliance with those guidelines. Clinical engagement is then quantified as the percentage of patients that have been documented to receive specialist society- or college-approved guideline-compliant treatment, relative to the total number who could receive such treatment, in any healthcare organisation.

Revalidation is not to be feared and can be achieved by continuous objective assessment.

Revalidation is defined by the International Association of Medical Regulatory Authorities as "the process by which doctors have to regularly show that they are up to date, and fit to practice medicine". In December 2012, the General Medical Council in the United Kingdom introduced revalidation processes that involve medical practitioners collecting a portfolio of evidence for assessment and appraisal by a "responsible officer". The responsible officer is usually the medical director of the hospital or group of primary care providers and reports directly to the General Medical Council on the fitness of the doctor to practice in their current role. The time taken to collect and analyse the portfolio and sources available are all contentious issues, along with the cost of the revalidation process. We propose that effective revalidation processes based on performance measurement would be cost-effective and, if correctly applied, could lead to significant cost savings in Australian health care. The driving force for an effective and efficient revalidation process should be the professional and ethical responsibility that each doctor has to their patients and to the society which has granted them the right to practice.

Monitoring the rate of re-exploration for excessive bleeding after cardiac surgery in adults.

BACKGROUND: The monitoring of adverse events in clinical care can be an important part of quality assurance. There is little evidence on the monitoring of re-exploration after cardiac surgery. OBJECTIVE: To apply statistical monitoring techniques to the rate of re-exploration for excessive bleeding in adult patients undergoing cardiac surgery procedures using cardiopulmonary bypass at Geelong Hospital, Victoria, Australia, between 1997 and 2003. METHODS: Shewhart charts, moving average plots and cumulative sum (CUSUM) charts were used to demonstrate changes in the rate of re-exploration over time. RESULTS: A CUSUM chart was used retrospectively at a time of perceived deteriorating clinical outcomes in patients of the cardiac surgery service. At this time, an intervention aimed at reducing the re-exploration rate was performed, and subsequent CUSUM charts indicated an improvement in this rate. The CUSUM chart has become an important part of the quality feedback of clinical care outcomes within the Anaesthesia & Pain Management unit of Geelong Hospital. CONCLUSION: Statistical monitoring techniques for quality assurance can identify important changes in clinical performance, and their adoption by clinicians is recommended.

Voluntary incident reporting by anaesthetic trainees in an Australian hospital.

OBJECTIVE: To assess the reporting of critical incidents by anaesthetic trainees using personal digital assistants. The project also identified the reporting of 'near miss' incidents by anaesthetic trainees. DESIGN: Comparison of electronic incident reporting with retrospective case note review of cases in which no incident was reported. SETTING: A 400-bed university teaching hospital in Victoria. PARTICIPANTS: Fourteen accredited Australian and New Zealand College of Anaesthetists (ANZCA) registrars and their training supervisors. INTERVENTIONS: Registrars and supervisors underwent initial training for 1 hour and were provided with ongoing support. The cases and incidents reported to the database using the portable digital assistants were analysed. MAIN OUTCOME MEASURES: These were the total number of anaesthetics reported to the database; the number of incidents reported to the database; the outcome severity of incidents reported; and the number of incidents detected in the case note review that were not reported to the database. RESULTS: An incident was reported for 156 (3.5%) of 4441 anaesthetic procedures reported to the database. Of these incidents, 72 (46.2%) were 'near misses'. One incident was identified in a review of 208 case notes, which had no incidents reported electronically, and was not reported to the database electronically. This gives a reporting rate of 99.52% [95% confidence interval (CI) 96.9-100%]. CONCLUSIONS: ANZCA trainees in routine anaesthetic practice can reliably use mobile computing technology to report critical incidents and 'near miss' incident data.

New technology to enable personal monitoring and incident reporting can transform professional culture: the potential to favourably impact the future of health care.

There have been recent exposures of poor health care performance in many countries with western health care systems. The poor performance has either related to poor or criminal practices routinely going undetected or to organizational indifference or hostility to staff raising concerns about perceived poor standards of care. The demonstration that routine performance data monitoring would have detected and prevented many of the deaths attributed to poor surgical standards in the Bristol Royal Infirmary paediatric cardiac surgery scandal and criminal behaviour in the Harold Shipman scandal has highlighted the need for routine data collection to demonstrate to both health care administrators and patients that minimum standards of clinical practice are being achieved. The recent proposal that surgical report cards represent an important minimum ethical standard for health care consent will force the medical profession to engage in the debate surrounding routine data collection for performance monitoring and other purposes. This article considers the cultural background to data collection in the medical profession and the cost implications of failing to improve data collection in the areas of performance monitoring and incident reporting. A potential solution developed by the Geelong hospital group and in use in Australia is proposed as a novel, technologically appropriate and working example of practical data collection. This model is endorsed by the professional specialties and supported by modern regulatory theory. The individual, local and system wide benefits of such personal professional data collection are outlined and the necessary prerequisites are detailed.

Using portable digital technology for clinical care and critical incidents: a new model.

The number of patients suffering adverse incidents during treatment in hospitals is not declining. The cost of this poor safety record in Australia is 1 billion dollars to 4.7 billion dollars each year. Quality and safety initiatives focus on promoting adverse event reporting. Major problems include poor reporting of adverse events and lack of clinician involvement. We propose a model for clinician-led reporting based on secure transmission of encrypted data from a programmed personal digital assistant (PDA) to a secure database, leading to automated analysis of clinician-performance data. The programmed PDA also facilitates the reporting of critical incidents. All critical incidents are automatically fed back by email to the organisational quality managers.