Senior staff perspectives of a quality indicator program in public sector residential aged care services: a qualitative cross-sectional study in Victoria, Australia.

OBJECTIVE: The aims of the present study were to describe the views of senior clinical and executive staff employed in public sector residential aged care services (RACS) about the benefits and limitations of using quality indicators (QIs) for improving care, and to identify any barriers or enablers to implementing the QI program. METHODS: A cross-sectional qualitative study using semistructured interviews and direct observation of key informants involved in the QI program was performed across 20 public sector RACS in Victoria, Australia. Participants included senior clinical, executive and front-line staff at the RACS. The main outcome measures were perceived benefits and the enablers or barriers to the implementation of a QI program. RESULTS: Most senior clinical and executive staff respondents reported substantive benefits to using the QIs and the QI program. A limited number of staff believed that the QI program failed to improve the quality of care and that the resource requirements outweighed the benefits of the program, resulting in disaffected staff. CONCLUSIONS: The QIs and QI program acted as a foundation for improving standards of care when used at the front line or point of care. Senior executive engagement in the QI program was vital to successful implementation.

Reorganizing a hospital ward as an accountable care unit.

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

Use of Quality Indicators in Nursing Homes in Victoria, Australia: A Cross-Sectional Descriptive Survey.

OBJECTIVE: This study aimed to characterize the use of mandated quality indicators (QIs) in public sector nursing homes by describing their adherence to established principles of measurement and whether nursing homes respond to QI data to improve care. METHOD: Data were collected from a descriptive cross-sectional quantitative study using a confidential survey questionnaire distributed electronically to senior staff in all public sector nursing homes in Victoria, Australia. RESULTS: Staff from 113 of 196 facilities completed the survey (58%). Adherence to principles of measurement was suboptimal, with variation in applying QI definitions and infrequent random audits of data (n = 54, 48%). QI data triggered reviews of individual residents (62%-79%), staff practice (44%-65%), and systems of care (45%-55%). Most facilities (58%-75%) reported that beneficial changes in care occurred as a result of using QIs. DISCUSSION: QI performance data are positively received and used to improve care. Standardization of data collection, analysis, and reporting should strengthen the program's utility.

Interns' perceptions of performance feedback.

CONTEXT: Internship, the first year after medical school, is an important time for identity formation and role development. Effective performance feedback is essential for identifying strengths and weaknesses, guiding self-regulation to improve clinical performance and developing accurate self-assessment. However, developing feedback systems is notoriously difficult. A better understanding of interns' perspectives is important to increase engagement with feedback systems and to improve their effectiveness. METHODS: This study explores the interns' role clarity and confidence in evaluating their own performance; their views of the existing health care organisation's formal performance appraisal system based on national intern assessment tools and guidelines and whether the self-directed audit of clinical tasks is a feasible feedback tool. Qualitative data were collected through a cross-sectional survey using semi-structured interviews with interns in their last week of employment from a single large regional public health care organisation in Australia. Interviewee-verified data were analysed thematically using a 'framework' approach. RESULTS: Twenty-one of 28 interns were included in the final analyses. We found that interns conceptualise good performance in terms of efficient completion of daily tasks and are unable to confidently judge their own performance. The current health care organisation performance appraisal system based on national intern assessment tools and guidelines does not meet their expectations and could be improved through greater involvement of the medical staff who work alongside interns on a daily basis, particularly registrars and regular, scheduled opportunities for formative and informal feedback with a focus on personalised, constructive feedback. The introduction of specific task assessments or audit, such as a formal appraisal of patient discharge documentation, is also valued. CONCLUSIONS: Performance appraisal formats need improving to better align with interns' expectations, to meet interns' learning goals and to improve practices in the health care organisation.

Recognizing junior doctors' potential contribution to patient safety and health care quality improvement.

PURPOSE: The purpose of this paper is to re-frame perceptions surrounding junior doctors' capacity to contribute to patient safety and quality improvement. DESIGN/METHODOLOGY/APPROACH: A targeted literature review was conducted followed by individual telephone interviews and a half-day forum involving junior doctor representatives and selected leaders in the sector. FINDINGS: Junior doctors' entry into health care is an ideal time to cultivate practitioners' interest and expertise in improving the health system for better patient care. Junior doctors are more likely to bring or embrace new ideas, and recognize the importance of transparency and integration of technology into healthcare systems. Engaging with junior doctors in collaborative processes, rather than focusing on their more senior colleagues, may create a more effective culture. ORIGINALITY/VALUE: The attributes of junior doctors (as they are in the absence of specific quality improvement or leadership training) that are currently underutilized in patient safety and quality improvement are explored, along with the factors limiting and facilitating the utilization of these attributes.

Functional safety of health information technology.

In an effort to improve patient safety and reduce adverse events, there has been a rapid growth in the utilisation of health information technology (HIT). However, little work has examined the safety of the HIT systems themselves, the methods used in their development or the potential errors they may introduce into existing systems. This article introduces the conventional safety-related systems development standard IEC 61508 to the medical domain. It is proposed that the techniques used in conventional safety-related systems development should be utilised by regulation bodies, healthcare organisations and HIT developers to provide an assurance of safety for HIT systems. In adopting the IEC 61508 methodology for HIT development and integration, inherent problems in the new systems can be identified and corrected during their development. Also, IEC 61508 should be used to develop a healthcare-specific standard to allow stakeholders to provide an assurance of a system's safety.

Human reliability assessment of a critical nursing task in a radiotherapy treatment process.

Radiotherapy treatment, like many other fields of medicine, has changed significantly in the last decade with the introduction of more advanced technology and automation. This change has often resulted in aspects of the system which cannot be automated due to technological feasibility and local implementation constraints. This has resulted in a requirement for significant human interaction. This combination of human operations and automation has introduced new error pathways. Traditionally, recommendations to improve the safety of such systems are typically made after the analysis of an adverse event or a significant series of incidents. In contrast, adopting a proactive approach to safety would enable prior identification of potential errors and the specification of appropriate defences against them, thus avoiding costs associated with adverse outcomes. In this paper, a modified version of the proactive Human Reliability Assessment (HRA) method Human Error Assessment and Reduction Technique (HEART) was used to analyse a critical nursing task within a modern radiotherapy system. The modified technique used a participative team approach to complete the assessment in contrast to the normal approach, which uses a single expert assessor. The HEART technique quantifies the likelihood of unreliability of a task and ranks the conditions which most affect the successful completion of that task. HEART has been proposed as a potentially useful HRA tool for applications in healthcare, but such applications have not previously been formally documented. As a result of the modified HEART analysis reported in this paper, remedial measures were identified which were both cost effective and easy to implement.