Floundering or Flourishing? Early Insights from the Inception of Integrated Care Systems in England.

Background: In 2022, England embarked on an ambitious and innovative re-organisation to produce an integrated health and care system with a greater focus on improving population health. This study aimed to understand how nascent ICSs are developing and to identify the key challenges and enablers to integration. Methods: Four ICSs participated in the study between November 2021 and May 2022. Semi-structured interviews with system leaders (n = 67) from health, social and voluntary care as well as representatives of local communities were held. A thematic framework approach supported by Leutz's five laws of integration framework was used to analyse the data. Results: The benefits of ICSs include enhancing the delivery of good quality care, improving population health and providing more person-centred care in the community. However, differences between health and social care such as accountability, organisational/professional cultures, risks of duplicating efforts, tensions over funding allocation, issues of data integration and struggles in engaging local communities threaten to hamper integration. Conclusions: Despite ICS's investing in the structural and relational components of integrated care, the unprecedented pressures on systems to reduce demand on primary and emergency care tackling elective backlogs may detract from a key goal of ICSs, improving population health and prevention.

Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports.

Patient safety incident reports are a key source of safety intelligence. This study aimed to explore whether information contained in such reports can elicit facilitators of safety, including responding, anticipating, monitoring, learning, and other mechanisms by which safety is maintained. The review further explored whether, if found, this information could be used to inform safety interventions. Anonymized incident reports submitted between August and October 2020 were obtained from two large teaching hospitals. The Systems Engineering Initiative for Patient Safety (SEIPS) tool and the resilience potentials (responding, anticipating, monitoring, and learning) frameworks guided thematic analysis. SEIPS was used to explore the components of people, tools, tasks, and environments, as well as the interactions between them, which contribute to safety. The resilience potentials provided insight into healthcare resilience at individual, team, and organizational levels. Sixty incident reports were analysed. These included descriptions of all the SEIPS framework components. People used tools such as electronic prescribing systems to perform tasks within different healthcare environments that facilitated safety. All four resilient capacities were identified, with mostly individuals and teams responding to events; however, monitoring, anticipation, and learning were described for individuals, teams, and organizations. Incident reports contain information about safety practices, much of which is not identified by traditional approaches such as root cause analysis. This information can be used to enhance safety enablers and encourage greater proactive anticipation and system-level learning.

Assessing progress in managing and improving quality in nascent integrated care systems in England.

OBJECTIVES: In 2022, England embarked on an ambitious reorganisation to produce an integrated health and care system, intended also to maximise population health. The newly created integrated care systems (ICSs) aim to improve quality of care, by achieving the best outcomes for individuals and populations through the provision of evidence-based services. An emerging approach for managing quality in organisations is the Quality Management System (QMS) framework. Using the framework, this study assessed how ICSs are managing and improving quality. METHODS: Four ICSs were purposively sampled, with the data collected between November 2021 and May 2022. Semi-structured interviews with system leaders (n=60) from health and social care, public health and local representatives were held. We also observed key ICS meetings and reviewed relevant documents. A thematic framework approach based on the QMS framework was used to analyse the data. RESULTS: The ICSs placed an emphasis on population health, reducing inequity and improving access. This represents a shift in focus from the traditional clinical approach to quality. There were tensions between quality assurance and improvement, with concerns that a narrow focus on assurance would impede ICSs from addressing broader quality issues, such as tackling inequalities and unwarranted variation in care and outcomes. Partnerships, a key enabler for integration, was seen as integral to achieving improvements in quality. Overall, the ICSs expressed concerns that any progress made in quality development and in improving population health would be tempered by unprecedented system pressures. CONCLUSION: It is unclear whether ICSs can achieve their ambition. As they move away from an assurance-dominated model of quality to one that emphasises openness, learning and improvement, they must simultaneously build the digital infrastructure, staff expertise and culture to support such a shift.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

BACKGROUND: Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management. OBJECTIVES: To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio. METHODS: Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored. RESULTS: Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support. CONCLUSION: The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

The Evolution of External Healthcare Regulation in England; From Performance Oversight to Supporting Improvement Comment on "The Special Measures for Quality and Challenged Provider Regimes in the English NHS: A Rapid Evaluation of a National Improvement Initiative for Failing Healthcare Organisations".

The Special Measures and Challenged Provider (SMCP) Regime introduced for struggling healthcare organisations in England represents a subtle shift to the scope of external regulation from performance oversight to include supporting internal service improvement. External regulation alone has a had a mixed impact on the quality of care and Vindrola-Padros and colleagues' study highlights that externally driven improvement initiatives may also struggle to succeed in turning around performance. Principally, this is due to a failure in acknowledgment that poor performance results from a myriad of external and internal factors which coalesce to impede organisational performance. A struggling organisation may be indicative of wider issues in the local health and care system. Whole systems approaches to improvement with collaboration across providers and the effective use of data may support struggling organisations but their role maybe tempered with the increased centralisation of the delivery of improvement regimes such as SMCP.

Approaches to improving patient safety in integrated care: a scoping review.

OBJECTIVES: This scoping review aimed to establish the approaches employed to improving patient safety in integrated care for community-dwelling adults with long-term conditions. DESIGN: Scoping review. SETTING: All care settings. SEARCH STRATEGY: Systematic searches of seven academic and grey literature databases for studies published between 2000 and 2021. At the full-text review stage both the first and second reviewer (SW) independently assessed full texts against the eligibility criteria and any discrepancies were discussed. RESULTS: Overall, 24 studies were included in the review. Two key priorities for safety across care boundaries for adults with long-term conditions were falls and medication safety. Approaches for these priorities were implemented at different levels of an integrated care system. At the micro-level, approaches involved care primarily in the home setting provided by multi-disciplinary teams. At the meso-level, the focus was on planning and designing approaches at the managerial/organisational level to deliver multi-disciplinary care. At the macro-level, system-wide approaches included integrated care records, training and education and the development of care pathways involving multiple organisations. Across the included studies, evaluation of these approaches was undertaken using a wide range of process and outcome measures to capture patient harm and contributory factors associated with falls and medication safety. CONCLUSIONS: For integrated care initiatives to fulfil their promise of improving care for adults with long-term conditions, approaches to improve patient safety need to be instituted across the system, at all levels to support the structural and relational aspects of integrated care as well as specific risk-related safety improvements.

Understanding the factors influencing implementation of a new national patient safety policy in England: Lessons from 'learning from deaths'.

OBJECTIVE: A new patient safety policy, 'Learning from Deaths' (LfD), was implemented in 2017 in National Health Service (NHS) organisations in England. This study examined how contextual factors influenced the implementation of LfD policy and the ability of the programme to achieve its goals. METHODS: Semi-structured interviews were undertaken with key policymakers involved in the development of the policy, along with interviews with managers and senior clinicians in five NHS organisations responsible for implementing the policy at the local level. We also undertook non-participant observation of relevant meetings and documentary reviews of key organisation procedures and policies pertaining to LfD. RESULTS: The study findings suggest several factors that hinder or support patient safety policy implementation at a local level. These include: (a) an organisation's capacity and capability to support data collation, analysis and synthesis, (b) the dissemination of the resulting information, (c) the learning culture and hence perceptions of the purpose of LfD within an organisation, and (d) the extent of engagement in cross-organisational approaches to learning. CONCLUSIONS: Extra and intra-organisational contextual factors influence all stages of the policy implementation process from preparation and tracking to implementation support and review affecting its chances of success or failure. Successful adoption of a national patient safety policy within health care organisations can be informed by taking into consideration those factors.

Scoping review exploring the impact of digital systems on processes and outcomes in the care management of acute kidney injury and progress towards establishing learning healthcare systems.

OBJECTIVES: Digital systems have long been used to improve the quality and safety of care when managing acute kidney injury (AKI). The availability of digitised clinical data can also turn organisations and their networks into learning healthcare systems (LHSs) if used across all levels of health and care. This review explores the impact of digital systems i.e. on patients with AKI care, to gauge progress towards establishing LHSs and to identify existing gaps in the research. METHODS: Embase, PubMed, MEDLINE, Cochrane, Scopus and Web of Science databases were searched. Studies of real-time or near real-time digital AKI management systems which reported process and outcome measures were included. RESULTS: Thematic analysis of 43 studies showed that most interventions used real-time serum creatinine levels to trigger responses to enable risk prediction, early recognition of AKI or harm prevention by individual clinicians (micro level) or specialist teams (meso level). Interventions at system (macro level) were rare. There was limited evidence of change in outcomes. DISCUSSION: While the benefits of real-time digital clinical data at micro level for AKI management have been evident for some time, their application at meso and macro levels is emergent therefore limiting progress towards establishing LHSs. Lack of progress is due to digital maturity, system design, human factors and policy levers. CONCLUSION: Future approaches need to harness the potential of interoperability, data analytical advances and include multiple stakeholder perspectives to develop effective digital LHSs in order to gain benefits across the system.

A narrative account of the key drivers in the development of the Learning from Deaths policy.

OBJECTIVE: In recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development. METHODS: A qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon's Multiple Streams Approach was used to frame the policymaking process. RESULTS: The publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a 'policy window.' Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as 'policy entrepreneurs,' recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them. CONCLUSIONS: The development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement.

Measuring safety in older adult care homes: a scoping review of the international literature.

BACKGROUND: Safety is a key concern in older adult care homes. However, it is a less developed concept in older adult care homes than in healthcare settings. As part of study of the collection and application of safety data in the care home sector in England, a scoping review of the international literature was conducted. OBJECTIVES: The aim of the review was to identify measures that could be used as indicators of safety for quality monitoring and improvement in older adult residential or nursing care homes. SOURCES OF EVIDENCE: Systematic searches for journal articles published in English language from 1 January 1970, without restriction to the study location or country, were conducted in Web of Science, Scopus and PubMed on 28 July 2019. ELIGIBILITY CRITERIA: Inclusion criteria were: peer-reviewed journal articles; qualitative or quantitative studies of older adult nursing and/or residential care homes; and related to any aspect of safety in care homes, including the safety of healthcare provision in the care home. A total of 45 articles were included after review of the title/abstract or full text against the inclusion criteria. CHARTING METHODS: Key information was extracted and charted. These findings were then mapped to the Safety Measurement and Monitoring Framework in healthcare (SMMF), adapted by the research team to reflect the care home context, to determine the coverage of different aspects of safety, as well as potential gaps. RESULTS AND CONCLUSIONS: Systematic searches for journal articles published in English language from 1 January 1970, without restriction to the study location or country, were conducted in Web of Science, Scopus and PubMed on 28 July 2019. Inclusion criteria were: peer-reviewed journal articles; qualitative or quantitative studies of older adult nursing and/or residential care homes; and related to any aspect of safety in care homes, including the safety of healthcare provision in the care home.A total of 45 articles were included after review of the title/abstract or full text against the inclusion criteria. Key information was extracted and charted. These findings were then mapped to the Safety Measurement and Monitoring Framework in healthcare (SMMF), adapted by the research team to reflect the care home context, to determine the coverage of different aspects of safety, as well as potential gaps.The findings indicate that there are a range of available safety measures used for quality monitoring and improvement in older adult care homes. These cover all five domains of safety in the SMMF. However, there are potential gaps. These include user experience, psychological harm related to the care home environment, abusive or neglectful care practice and the processes for integrated learning. Some of these gaps may relate to challenges and feasibility of measurement in the care home context.

Type of Track and Trigger system and incidence of in-hospital cardiac arrest: an observational registry-based study.

BACKGROUND: Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such patients. This study examines the association between the type of Track & Trigger System (TTS) (National Early Warning Score (NEWS) versus non-NEWS) and the mode of TTS (paper TTS versus electronic TTS) and incidence of in-hospital ward-based cardiac arrests (IHCA) attended by a resuscitation team. METHODS: TTS type and mode was retrospectively collected at hospital level from 106 NHS acute hospitals in England between 2009 to 2015 via an organisational survey. Poisson regression and logistic regression models, adjusted for case-mix, temporal trends and seasonality were used to determine the association between TTS and hospital-level ward-based IHCA and survival rates. RESULTS: The NEWS was introduced in England in 2012 and by 2015, three-fifths of hospitals had adopted it. One fifth of hospitals had instituted an electronic TTS by 2015. Between 2009 and 2015 the incidence of IHCA fell. Introduction or use of NEWS in a hospital was associated with a reduction of 9.4% in the rate of ward-based IHCA compared to non-NEWS systems (incidence rate ratio 0.906, p < 0.001). The use of an electronic TTS was also associated with a reduction of 9.8% in the rate of IHCA compared with paper-based TTS (incidence rate ratio 0.902, p = 0.009). There was no change in hospital survival. CONCLUSIONS: The introduction of standardised TTS and electronic TTS have the potential to reduce ward-based IHCA. This is likely to be via a range of mechanisms from early intervention to institution of treatment limits. The lack of association with survival may reflect the complexity of response to triggering of the afferent arm of the rapid response system.

Observational study to determine the utility of hospital administrative data to support case finding of English patients at higher risk of severe healthcare-related harm.

OBJECTIVES: To identify ways of using routine hospital data to improve the efficiency of retrospective reviews of case records for identifying avoidable severe harm DESIGN: Development and testing of thresholds and criteria for two indirect indicators of healthcare-related harm (long length of stay (LOS) and emergency readmission) to determine the yield of specified harms coded in Hospital Episode Statistics (HES). SETTING: Acute National Health Service hospitals in England. PARTICIPANTS: HES for acute myocardial infarction (AMI), bowel cancer surgery and hip replacement admissions from 2014 to 2015. INTERVENTIONS: Case-mix-adjusted linear regression models were used to determine expected LOS. Different thresholds were examined to determine the association with harm. Screening criteria for readmission included time to readmission, length of readmission and diagnoses in initial admission and readmission. The association with harm was examined for each criterion. RESULTS: The proportions of AMI cases with a harm code increased from 14% among all cases to 47% if a threshold of three times the expected LOS was used. For hip replacement the respective increase was from 10% to 51%. However as the number of patients at these higher thresholds was small, the overall proportion of harm identified is relatively small (15%, 19%, 9% and 8% among AMI, urgent bowel surgery, elective bowel surgery and hip replacement cohorts, respectively). Selection of the time to readmission had an effect on the yield of harms but this varied with condition. At least 50% of surgical patients had a harm code if readmitted within 7 days compared with 21% of patients with AMI. CONCLUSIONS: Our approach would select a substantial number of patients for case record review. Many of these cases would contain no evidence of healthcare-related harm. In practice, Trusts may choose how many reviews it is feasible to do in advance and then select random samples of cases that satisfy the screening criteria.

Quality metrics for the evaluation of Rapid Response Systems: Proceedings from the third international consensus conference on Rapid Response Systems.

BACKGROUND: Clinically significant deterioration of patients admitted to general wards is a recognized complication of hospital care. Rapid Response Systems (RRS) aim to reduce the number of avoidable adverse events. The authors aimed to develop a core quality metric for the evaluation of RRS. METHODS: We conducted an international consensus process. Participants included patients, carers, clinicians, research scientists, and members of the International Society for Rapid Response Systems with representatives from Europe, Australia, Africa, Asia and the US. Scoping reviews of the literature identified potential metrics. We used a modified Delphi methodology to arrive at a list of candidate indicators that were reviewed for feasibility and applicability across a broad range of healthcare systems including low and middle-income countries. The writing group refined recommendations and further characterized measurement tools. RESULTS: Consensus emerged that core outcomes for reporting for quality improvement should include ten metrics related to structure, process and outcome for RRS with outcomes following the domains of the quadruple aim. The conference recommended that hospitals should collect data on cardiac arrests and their potential predictability, timeliness of escalation, critical care interventions and presence of written treatment goals for patients remaining on general wards. Unit level reporting should include the presence of patient activated rapid response and metrics of organizational culture. We suggest two exploratory cost metrics to underpin urgently needed research in this area. CONCLUSION: A consensus process was used to develop ten metrics for better understanding the course and care of deteriorating ward patients. Others are proposed for further development.

Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review.

BACKGROUND: The proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods. METHODS: A retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care. RESULTS: We found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital's report system. CONCLUSIONS: Avoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.

Universal screening at age 1-2 years as an adjunct to cascade testing for familial hypercholesterolaemia in the UK: A cost-utility analysis.

BACKGROUND AND AIMS: Familial hypercholesterolaemia (FH) is widely underdiagnosed. Cascade testing (CT) of relatives has been shown to be feasible, acceptable and cost-effective in the UK, but requires a supply of index cases. Feasibility of universal screening (US) at age 1-2 years was recently demonstrated. We examined whether this would be a cost-effective adjunct to CT in the UK, given the current and plausible future undiagnosed FH prevalence. METHODS: Seven cholesterol and/or mutation-based US ±â€¯reverse cascade testing (RCT) alternatives were compared with no US in an incremental analysis with a healthcare perspective. A decision model was used to estimate costs and outcomes for cohorts exposed to the US component of each strategy. RCT case ascertainment was modelled using recent UK CT data, and probabilistic Markov models estimated lifetime costs and health outcomes for the cohorts screened under each alternative. 1000 Monte Carlo simulations were run for each model, and average outcomes reported. Further uncertainty was explored deterministically. Threshold analysis investigated the association between undiagnosed FH prevalence and cost-effectiveness. RESULTS: A strategy involving cholesterol screening followed by diagnostic genetic testing and RCT was the most cost-effective modelled (incremental cost-effectiveness ratio (ICER) versus no US £12,480/quality adjusted life year (QALY); probability of cost-effectiveness 96·8% at £20,000/QALY threshold). Cost-effectiveness was robust to both deterministic sensitivity analyses and threshold analyses that modelled ongoing case ascertainment at theoretical maximum levels. CONCLUSIONS: These findings support implementation of universal cholesterol screening followed by diagnostic genetic testing and RCT for FH, under a UK conventional willingness-to-pay threshold.

Effectiveness of ways to improve detection and rescue of deteriorating patients.

A number of interventions has been introduced to improve recognition of and response to deterioration, but evidence for improved outcomes is mixed. Future evaluations need better articulation of intervention components and outcomes, longer run-in times and consideration of the interplay between concurrent interventions.

Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis.

OBJECTIVES: To determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust's hospital-wide standardised mortality ratio assessed using the two commonly used methods--the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI). DESIGN: Retrospective case record review of deaths. SETTING: 34 English acute hospital trusts (10 in 2009 and 24 in 2012/13) randomly selected from across the spectrum of HSMR. MAIN OUTCOME MEASURES: Avoidable death, defined as those with at least a 50% probability of avoidability in view of trained medical reviewers. Association of avoidable death proportion with the HSMR and the SHMI assessed using regression coefficients, to estimate the increase in avoidable death proportion for a one standard deviation increase in standardised mortality ratio. PARTICIPANTS: 100 randomly selected hospital deaths from each trust. RESULTS: The proportion of avoidable deaths was 3.6% (95% confidence interval 3.0% to 4.3%). It was lower in 2012/13 (3.0%, 2.4% to 3.7%) than in 2009 (5.2%, 3.8% to 6.6%). This difference is subject to several factors, including reviewers' greater awareness in 2012/13 of orders not to resuscitate, patients being perceived as sicker on admission, minor differences in review form questions, and cultural changes that might have discouraged reviewers from criticising other clinicians. There was a small but statistically non-significant association between HSMR and the proportion of avoidable deaths (regression coefficient 0.3, 95% confidence interval -0.2 to 0.7). The regression coefficient was similar for both time periods (0.1 and 0.3). This implies that a difference in HSMR of between 105 and 115 would be associated with an increase of only 0.3% (95% confidence interval -0.2% to 0.7%) in the proportion of avoidable deaths. A similar weak non-significant association was observed for SHMI (regression coefficient 0.3, 95% confidence interval -0.3 to 1.0). CONCLUSIONS: The small proportion of deaths judged to be avoidable means that any metric based on mortality is unlikely to reflect the quality of a hospital. The lack of association between the proportion of avoidable deaths and hospital-wide SMRs partly reflects methodological shortcomings in both metrics. Instead, reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist.