A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory.

BACKGROUND: Specific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer. METHODS: This comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology. RESULTS: Data from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians. CONCLUSIONS: Overall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process. TRIAL REGISTRATION: NCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.

Serious reportable events within the inpatient mental health care: Impact on physicians and nurses / Episodios graves notificables en atención hospitalaria de salud mental: repercusiones en médicos y enfermeras

Objectives. To investigate the prevalence of physicians and nurses involved in an adverse event within mental health. Materials and methods. A quantitative, cross-sectional study was performed. Six Flemish psychiatric hospitals (Belgium) participated in this exploratory cross-sectional study. All psychiatrists and nurses working in these hospitals were invited to complete an online questionnaire in March 2013. Results. 28 psychiatrists and 252 nurses completed the survey. 205 (73%) of the 280 respondents were personally involved at least once in an adverse event within their entire career. Respondents reported that the adverse event with the greatest impact was related to suicide in almost 64% of the cases. About one in eight respondents considered quitting their job because of it. Almost 18% declared that due to the impact of the event, they believed that the quality of the administered care was affected for longer than one month. Respondents stated that they received much support of colleagues (95%), the chief nurse (86%) and the partner (71%). Colleagues seemed to be most supportive in the recovery process. Conclusions. Physicians and nurses working in inpatient mental health care may be at high risk to being confronted with an adverse event at some point in their career. The influence on health professionals involved in an adverse event on their work is particularly important in the first 4-24h. Professionals at those moments had higher likelihood to be involved in another adverse event. Institutions should seriously consider giving support almost at that time (AU)

Objetivos. Investigar la prevalencia de médicos y enfermeras implicados en un episodio adverso en salud mental. Materiales y métodos. Se llevó a cabo un estudio cuantitativo y transversal. Seis hospitales psiquiátricos de Flandes (Bélgica) participaron en este estudio transversal de exploración. Se solicitó a todos los psiquiatras y enfermeras que trabajan en estos hospitales que completaran un cuestionario en línea en marzo de 2013. Resultados. Veintiocho psiquiatras y 252 enfermeras respondieron la encuesta. Doscientos cinco (73%) de los 280 encuestados participaron personalmente, al menos una vez, en un episodio adverso en toda su carrera. Los encuestados informaron de que el episodio adverso con mayores repercusiones estuvo relacionado con el suicidio en casi el 64% de los casos. Aproximadamente, uno de cada 8 encuestados consideró dejar el trabajo a causa de ello. Casi el 18% declaró que, debido a las repercusiones del episodio, creían que la calidad de la atención administrada se vio afectada durante más de un mes. Los encuestados declararon que recibieron mucho apoyo por parte de sus colegas (95%), la enfermera jefe (86%) y la pareja (71%). Al parecer, los compañeros fueron los más comprensivos en el proceso de recuperación. Conclusiones. Los médicos y enfermeras que trabajan en atención hospitalaria de salud mental pueden correr un gran riesgo de enfrentarse a un episodio adverso en algún momento de su carrera. La influencia de los profesionales sanitarios implicados en un episodio adverso en su trabajo es especialmente importante en las primeras 4-24h. Los profesionales en esos momentos tenían mayor probabilidad de verse implicados en otro episodio adverso. Las instituciones deberían considerar seriamente el hecho de prestar apoyo casi en el mismo momento (AU)

Personal, situational and organizational aspects that influence the impact of patient safety incidents: A qualitative study / Aspectos personales, situacionales y organizacionales que influyen en la repercusión de incidentes adversos durante una intervención sanitaria: un estudio cualitativo

Objectives. When a patient safety incident (PSI) occurs, not only the patient, but also the involved health professional can suffer. This study focused on this so-called ‘second victim’ of a patient safety incident and aimed to examine: (1) experienced symptoms in the aftermath of a patient safety incident; (2) applied coping strategies; (3) the received versus needed support and (4) the aspects that influenced whether one becomes a second victim. Materials and methods. Thirty-one in-depth interviews were performed with physicians, nurses and midwives who have been involved in a patient safety incident. Results. The symptoms were categorized under personal and professional impact. Both problem focused and emotion focused coping strategies were used in the aftermath of a PSI. Problem focused strategies such as performing a root cause analysis and the opportunity to learn from what happened were the most appreciated, but negative emotional responses such as repression and flight were common. Support from colleagues and supervisors who were involved in the same event, peer supporters or professional experts were the most needed. A few individuals described emotional support from the healthcare institution as unwanted. Rendered support was largely dependent on the organizational culture, a stigma remained among healthcare professionals to openly discuss patient safety incidents. Three aspects influenced the extent to which a healthcare professional became a second victim: personal, situational and organizational aspects. Conclusion. These findings indicated that a multifactorial approach including individual and emotional support to second victims is crucial (AU)

Objetivos. Cuando se produce un incidente adverso durante una intervención sanitaria, no solo puede sufrir el paciente, sino también el profesional sanitario implicado. Este estudio se centró en la conocida como ‘segunda víctima’ de un incidente adverso durante una intervención y su objetivo fue evaluar: 1) los síntomas experimentados a raíz de un incidente adverso durante una intervención sanitaria; 2) las estrategias de afrontamiento que se aplicaron; 3) el apoyo recibido frente al apoyo necesario, y 4) los aspectos que influyeron en que uno se convirtiera en una segunda víctima. Material y métodos. Se llevaron a cabo 31 entrevistas exhaustivas con médicos, enfermeras y comadronas que habían estado involucrados en un incidente adverso durante una intervención. Resultados. Los síntomas se clasificaron por repercusión personal y profesional. Se utilizaron estrategias de afrontamiento centradas en el problema y en la emoción después de un incidente adverso durante una intervención. Las estrategias centradas en el problema, como el análisis de la causa primordial y la oportunidad de aprender de lo sucedido, fueron las más apreciadas, pero las respuestas emocionales negativas, como represión y huida, eran frecuentes. Lo más necesitado era el apoyo de colegas y supervisores que participaron en la misma intervención, partidarios de los compañeros o expertos profesionales. Algunas personas describen el apoyo emocional de la institución sanitaria como no deseado. El apoyo prestado depende, en gran medida, de la cultura organizacional, aunque entre los profesionales sanitarios subsiste el estigma de hablar abiertamente de incidentes adversos durante una intervención. Tres aspectos influyeron en la medida en que un profesional sanitario se convirtió en una segunda víctima: aspectos personales, situacionales y organizacionales. Conclusión. Estos resultados indicaron que es fundamental un enfoque multifactorial que incluya apoyo individual y emocional a la segunda víctima (AU)

Serious reportable events within the inpatient mental health care: Impact on physicians and nurses.

OBJECTIVES: To investigate the prevalence of physicians and nurses involved in an adverse event within mental health. MATERIALS AND METHODS: A quantitative, cross-sectional study was performed. Six Flemish psychiatric hospitals (Belgium) participated in this exploratory cross-sectional study. All psychiatrists and nurses working in these hospitals were invited to complete an online questionnaire in March 2013. RESULTS: 28 psychiatrists and 252 nurses completed the survey. 205 (73%) of the 280 respondents were personally involved at least once in an adverse event within their entire career. Respondents reported that the adverse event with the greatest impact was related to suicide in almost 64% of the cases. About one in eight respondents considered quitting their job because of it. Almost 18% declared that due to the impact of the event, they believed that the quality of the administered care was affected for longer than one month. Respondents stated that they received much support of colleagues (95%), the chief nurse (86%) and the partner (71%). Colleagues seemed to be most supportive in the recovery process. CONCLUSIONS: Physicians and nurses working in inpatient mental health care may be at high risk to being confronted with an adverse event at some point in their career. The influence on health professionals involved in an adverse event on their work is particularly important in the first 4-24h. Professionals at those moments had higher likelihood to be involved in another adverse event. Institutions should seriously consider giving support almost at that time.

Development and validation of the FertiMed questionnaire assessing patients' experiences with hormonal fertility medication.

STUDY QUESTION: Can a valid and reliable questionnaire be developed to assess patients' experiences with all of the characteristics of hormonal fertility medication valued by them? SUMMARY ANSWER: The FertiMed questionnaire is a valid and reliable tool that assesses patients' experiences with all medication characteristics valued by them and that can be used for all hormonal fertility medications, irrespective of their route of administration. WHAT IS KNOWN ALREADY: Hormonal fertility medications cause emotional strain and differ in their dosage regime and route of administration, although they often have comparable effectiveness. Medication experiences of former patients would be informative for medication choices. A recent literature review showed that there is no trustworthy tool to compare patients' experiences of medications with differing routes of administration, regarding all medication characteristics which patients value. STUDY DESIGN, SIZE, DURATION: The items of the new FertiMed questionnaire were generated by literature review and 23 patient interviews. In 2013, 411 IVF-patients were asked to retrospectively complete the FertiMed questionnaire to assess 1 out of the 8 different medications used for ovarian stimulation, induction of pituitary quiescence, ovulation triggering or luteal support. PARTICIPANTS/MATERIALS, SETTING, METHODS: In total, 276 patients (on average 35 per medication) from 2 university fertility clinics (Belgium, the Netherlands) completed the FertiMed questionnaire (67% response rate). The FertiMed questionnaire questioned whether items were valued by patients and whether these items were experienced while using the assessed medication. Hence, the final outcome 'Experiences with Valued Aspects Scores' (EVAS) combined importance and experience ratings. The content and face validity, reliability, feasibility and discriminative potential of the FertiMed questionnaire were tested and changes were made accordingly. MAIN RESULTS AND THE ROLE OF CHANCE: Patient interviews defined 51 items relevant to seven medication characteristics previously proved to be important to patients. Item analysis deleted 10 items. The combined results from the reliability and content validity analysis identified 10 characteristics instead of 7. The final FertiMed questionnaire was valid (Adapted Goodness of Fit Index = 0.95) and all but one characteristic ('ease of use: disturbance') could be assessed reliably (Cronbach's α > 0.60). The EVAS per characteristic differed between the medications inducing pituitary quiescence (P = 0.001). LIMITATIONS, REASON FOR CAUTION: As all eight medications prescribed in the recruiting clinics were questioned, sample sizes per medication were rather small for presenting EVAS per medication and for testing the discriminative potential of the FertiMed questionnaire. WIDER IMPLICATION OF THE FINDINGS: The FertiMed questionnaire can be used for all hormonal fertility medications to assess in a valid and reliable way whether patients experience what they value regarding 10 medication characteristics (e.g. side effects and ease of use). Future randomized controlled trials (RCT) comparing medications could include the FertiMed questionnaire as a Patient Reported Experience Measure (PREM). Insights from these RCTs could be used to develop evidence-based decision aids aiming to facilitate shared physician-patient medication choices. STUDY FUNDING/COMPETING INTERESTS: Funding was received from the University of Leuven and Amsterdam University Medical Centre. E.A.F.D. holds a postdoctoral fellowship of the Research Foundation of Flanders. T.D. was appointed Vice-President and Head Global Medical Affairs Fertility at Merck (Darmstadt, Germany) on 1 October 2015. The reported project was initiated and finished before this date. The other authors had no conflicts of interest to declare.

Personal, situational and organizational aspects that influence the impact of patient safety incidents: A qualitative study.

OBJECTIVES: When a patient safety incident (PSI) occurs, not only the patient, but also the involved health professional can suffer. This study focused on this so-called "second victim" of a patient safety incident and aimed to examine: (1) experienced symptoms in the aftermath of a patient safety incident; (2) applied coping strategies; (3) the received versus needed support and (4) the aspects that influenced whether one becomes a second victim. MATERIALS AND METHODS: Thirty-one in-depth interviews were performed with physicians, nurses and midwives who have been involved in a patient safety incident. RESULTS: The symptoms were categorized under personal and professional impact. Both problem focused and emotion focused coping strategies were used in the aftermath of a PSI. Problem focused strategies such as performing a root cause analysis and the opportunity to learn from what happened were the most appreciated, but negative emotional responses such as repression and flight were common. Support from colleagues and supervisors who were involved in the same event, peer supporters or professional experts were the most needed. A few individuals described emotional support from the healthcare institution as unwanted. Rendered support was largely dependent on the organizational culture, a stigma remained among healthcare professionals to openly discuss patient safety incidents. Three aspects influenced the extent to which a healthcare professional became a second victim: personal, situational and organizational aspects. CONCLUSION: These findings indicated that a multifactorial approach including individual and emotional support to second victims is crucial.

Quality indicators for all dimensions of infertility care quality: consensus between professionals and patients.

STUDY QUESTION: What is the relative importance of the six dimensions of quality of care according to different stakeholders and can a quality indicator set address all six quality dimensions and incorporate the views from professionals working in different disciplines and from patients? SUMMARY ANSWER: Safety, effectiveness and patient centeredness were the most important quality dimensions. All six quality dimensions can be assessed with a set of 24 quality indicators, which is face valid and acceptable according to both professionals from different disciplines and patients. WHAT IS KNOWN ALREADY: To our knowledge, no study has weighted the relative importance of all quality dimensions to infertility care. Additionally, there are very few infertility care-specific quality indicators and no quality indicator set covers all six quality dimensions and incorporated the views of professionals and patients. STUDY DESIGN, SIZE AND DURATION: A three-round iterative Delphi survey including patients and professionals from four different fields, conducted in two European countries over the course of 2011 and 2012. PARTICIPANTS/MATERIALS, SETTINGS AND METHODS: Dutch and Belgian gynaecologists, embryologists, counsellors, nurses/midwifes and patients took part (n = 43 in round 1 and finally 30 in round 3). Respondents ranked the six quality dimensions twice for importance and their agreement was evaluated. Furthermore, in round 1, respondents gave suggestions, which were subsequently uniformly formulated as quality indicators. In rounds 2 and 3, respondents rated the quality indicators for preparedness to measure and for importance (relation to quality and prioritization for benchmarking). Providing feedback allowed selecting indicators based on consensus between stakeholder groups. Measurable indicators, important to all stakeholder groups, were selected for each quality dimension. MAIN RESULTS: All stakeholder groups and most individuals agreed that safety, effectiveness and patient centeredness were the most important quality dimensions. A total of 498 suggestions led to the development of 298 indicators. Professionals were sufficiently prepared to measure 204 of these indicators. Based on importance, 52 (7-15 per dimension; round 2) and finally 24 (4 per dimension; round 3) quality indicators were selected. LIMITATIONS, REASONS FOR CAUTION: The final quality indicator set does not cover the entire care process, but rather takes a 'sample' of each quality dimension. Although the quality indicators are face valid and acceptable, their psychometric characteristics need to be tested by further research. WIDER IMPLICATIONS OF THE FINDINGS: Quality management should focus on safety, effectiveness and patient centeredness of care. Clinics can use the quality indicator set to assess all quality dimensions of their care.

The ENDOCARE questionnaire guides European endometriosis clinics to improve the patient-centeredness of their care.

STUDY QUESTION: How patient-centered are two included specialized endometriosis clinics relative to each other and how can they improve the patient-centeredness of their care? SUMMARY ANSWER: The validated ENDOCARE questionnaire (ECQ) reliably concluded that the adjusted overall patient-centeredness did not differ between the clinics, that each clinic was significantly more patient-centered for 2 out of 10 dimensions of patient-centered endometriosis care and that clinics 1 and 2 had to improve 8 and 13 specific care aspects, respectively. WHAT IS KNOWN ALREADY: Patient-centered endometriosis care is essential to high-quality care and is defined by 10 dimensions. The ECQ was developed, validated and proved to be reliable in a European setting of self-reported endometriosis patients but had not yet been used at a clinic level for quality management. STUDY DESIGN, SIZE, DURATION: A cross-sectional survey was disseminated in 2011 to all 514 women diagnosed with endometriosis during a laparoscopy indicated for pain and/or infertility during a retrospective 2-year period (2009-2010) in two university clinics from two different European countries. PARTICIPANTS/MATERIALS, SETTING, METHODS: In total 337 patients completed the ECQ (216 and 121 per clinic). Respondents had a mean age of 34.3 years. Three in four reported a surgical diagnosis of moderate or severe endometriosis and the majority reported surgical treatment by a multidisciplinary team. The ECQ assessed the 10 dimensions of patient-centeredness, more specifically whether the health-care performance, as perceived by patients, measured up to what is important to patients in general. MAIN RESULTS: The ECQ was completed by 337 respondents (response rate = 65.6%). Reliability and validity of the ECQ for use on clinic level were confirmed. Clinics did not differ in overall mean importance scores; importance rankings of the ECQ dimensions were almost identical. The overall patient-centeredness scores (PCS), adjusted for education level, did not discriminate between the clinics. However, the adjusted PCS for the dimensions 'clinic staff' and 'technical skills' were significantly better in clinic 1, whereas the dimensions 'physical comfort' and 'access to care' were significantly better in clinic 2. There were 8 (clinic 1) and 13 (clinic 2) targets identified for joint and cross-clinic improvement. LIMITATIONS, REASONS FOR CAUTION: Response rates were relatively high. Recall bias was the most important limitation and research in more clinics is needed to define the statistical discriminative value of the ECQ. WIDER IMPLICATIONS OF THE FINDINGS: European endometriosis clinics can use the validated ECQ for reliable assessment of their 'patient-centeredness', for comparison with others and for setting specific targets to improve the patient-centeredness of their endometriosis care, to plan interventions, and to evaluate their effectiveness. STUDY FUNDING/COMPETING INTEREST: This work was funded by KU Leuven and European Network of Endometriosis (ENE), supported by the European Commission (Public Health Executive Agency). No competing interests are declared.

Patients from across Europe have similar views on patient-centred care: an international multilingual qualitative study in infertility care.

BACKGROUND: International patient centredness concepts were suggested but never conceptualized from the patients' perspective. Previously, a literature review and a monolingual qualitative study defined 'patient-centred infertility care' (PCIC). The present study aimed to test whether patients from across Europe value the same aspects of infertility care. METHODS: An international multilingual focus group (FG) study with 48 European patients from fertility clinics in Austria, Spain, the UK and Belgium, with deductive content analysis. RESULTS: All specific care aspects important to participants from all countries could be allocated to the 10 dimensions of PCIC, each discussed in every FG, including: 'information provision', 'attitude of and relationship with staff', 'competence of clinic and staff', 'communication', 'patient involvement and privacy', 'emotional support', 'coordination and integration', 'continuity and transition', 'physical comfort' and 'accessibility'. Most specific care aspects (65%) were discussed in two or more countries and only a few new codes (11%) needed to be added to the previously published coding tree. Rankings from across Europe clearly showed that 'information provision' is a top priority. CONCLUSIONS: The PCIC-model is the first patient-centred care (PCC) model based on the patients' perspective to be validated in an international setting. Although health-care organization and performance differ, the similarities between countries in the infertile patients' perspective were striking, as were the similarities with PCC models from other clinical conditions. A non-condition specific international PCC model and a European instrument for the patient centredness of infertility care could be developed. European professionals can learn from each other on how to provide PCC.

The ENDOCARE questionnaire (ECQ): a valid and reliable instrument to measure the patient-centeredness of endometriosis care in Europe.

BACKGROUND: Endometriosis is prevalent and women need high-quality care, which should be patient-centered. This study aimed to develop a valid and reliable patient-centeredness questionnaire, based on a defined concept of patient-centered endometriosis care (PCEC). METHODS: A literature review, focus groups (FGs) with patients and an expert panel defined PCEC with 10 dimensions. The ENDOCARE questionnaire (ECQ) was developed. FGs resulted in 43 specific statements covering the 10 dimensions of PCEC, for which the ECQ measured 'importance' and 'performance'. Medical and demographic questions and an open question were added. The Dutch ECQ questionnaire was piloted and reciprocally translated into English and Italian. Patients with endometriosis from Belgium, The Netherlands, Italy and the UK were invited to complete the ECQ online. Item analysis, inter-item analysis and confirmatory and exploratory factor analyses (EFA) and reliability analysis were performed. The theory-driven dimensions were adapted. RESULTS: The ECQ was completed by 541 patients. Based on item analysis, five statements were deleted. Factor analysis was performed on 322 questionnaires (only from respondents with a partner). Insights from the data-driven EFA suggested adaptations of the theory-driven dimensions. The reliability statistics of 9/10 adapted theory-driven dimensions were satisfactory and the root mean square error of approximation was good. CONCLUSIONS: This study resulted in a valid and reliable instrument to measure PCEC. For data presentation, the adapted theory-driven dimensions of PCEC are preferred over the data-driven factors. The ECQ may serve to benchmark patient-centeredness, conduct cross-cultural European research and set targets for improvement.

Impact of care pathways for in-hospital management of COPD exacerbation: a systematic review.

BACKGROUND: In-hospital management of COPD exacerbation is suboptimal, and outcomes are poor. Care pathways are a possible strategy for optimizing care processes and outcomes. OBJECTIVES: The aim of the literature review was to explore characteristics of existing care pathways for in-hospital management of COPD exacerbations and to address their impact on performance of care processes, clinical outcomes, and team functioning. METHODS: A literature search was conducted for articles published between 1990 and 2010 in the electronic databases of Medline, CINAHL, EMBASE, and Cochrane Library. Main inclusion criteria were (I) patients hospitalized for a COPD exacerbation; (II) implementation and evaluation of a care pathway; (III) report of original research, including experimental and quasi experimental designs, variance analysis, and interviews of professionals and patients about their perception on pathway effectiveness. RESULTS: Four studies with a quasi experimental design were included. Three studies used a pre-post test design; the fourth study was a non randomized controlled trial comparing an experimental group where patients were treated according to a care pathway with a control group where usual care was provided. The four studied care pathways were multidisciplinary structured care plans, outlining time-specific clinical interventions and responsibilities by discipline. Statistic analyses were rarely performed, and the trials used very divergent indicators to evaluate the impact of the care pathways. The studies described positive effects on blood sampling, daily weight measurement, arterial blood gas measurement, referral to rehabilitation, feelings of anxiety, length of stay, readmission, and in-hospital mortality. CONCLUSIONS: Research on COPD care pathways is very limited. The studies described few positive effects of the care pathways on diagnostic processes and on clinical outcomes. Though due to limited statistical analysis and weak design of the studies, the internal validity of results is limited. Therefore, based on these studies the impact of care pathways on COPD exacerbation is inconclusive. These findings indicate the need for properly designed research like a cluster randomized controlled trial to evaluate the impact of COPD care pathways on performance of care processes, clinical outcomes, and teamwork.

Testicular biopsy before ART: the patients' perspective on the quality of care.

BACKGROUND: So far, research on the patients' perspective on fertility care has mainly focused on women. Our primary aim was to explore what is important to men with respect to care related to testicular sperm extraction (TESE) and to identify strengths and weaknesses of that care. METHODS: This was a mixed-method study including phenomenology on interviews with 17 'interview participants' (a purposive sample with diversification for the TESE result) who received a TESE treatment at a tertiary university clinic. Strengths and weaknesses of our TESE-related quality of care were identified. Additionally, a telephone questionnaire was answered by 15 'rating participants' not willing to be interviewed and the questionnaire was analyzed quantitatively. RESULTS: Interview participants wanted more than effective treatment and attached importance to the attitude of fertility clinic staff, information, time flow, personalized care, 'all that is necessary', coaching, a homely atmosphere, continuity, privacy and separate accommodation. The satisfaction of rating participants (independent of the TESE result) was problematic for 'overall experience', 'physician at the day clinic' and 'gynecologist at discussion of the result'. The attitude of fertility clinic staff and information were the most obvious strengths of our TESE-related care. Weaknesses were lack of practical information on post-surgical recovery and waiting times in the waiting room. CONCLUSIONS: TESE patients focus not only on clinical effectiveness but also on patient-centeredness of care, and this has led to organizational changes and a new patient information brochure in our center. Qualitative research is useful to examine, understand and improve the patient-centeredness of care.

Patients' experiences and preferences with co-managed care in a cataract pathway.

BACKGROUND/AIMS: Co-managed care in cataract pathways allows ophthalmologists more time to treat other patients. However, little is known on how patients experience pathways that greatly reduce the amount of time spent with ophthalmologists. PURPOSE: To determine experiences and preferences of cataract patients with co-managed postoperative care. METHODS: In a nested-case control study, 194 patients who received their first-day review and final review by an ophthalmologist and 289 patients who received a telephone first-day review by a nurse and a final review by an optometrist were included. The Consumer Quality Index Cataract Questionnaire was used to measure patients' experiences with the quality of care after uncomplicated first-eye cataract surgery. RESULTS: Patients in the co-managed care pathway reported similarly good experiences with the quality of care as patients who received their reviews by an ophthalmologist. Patients who were reviewed by a nurse reported to prefer the same first-day review method significantly more often than those who were reviewed by an ophthalmologist. Most patients preferred the final review by an ophthalmologist. CONCLUSION: Overall, patients with cataract highly rated co-managed care pathways without any postoperative contact with ophthalmologists. Nevertheless, patients still preferred ophthalmologists for their final review to optometrists. Any added patients' benefits should be clearly determined before substituting activities from ophthalmologists to other care professionals.

Establishing the relationship between nurse staffing and hospital mortality using a clustered discrete-time logistic model.

Studies based on aggregated hospital outcome data have established that there is a relationship between nurse staffing and adverse events. However, this result could not be confirmed in Belgium where 96 per cent of the variability of nurse staffing levels over nursing units (belonging to different hospitals) is explained by within-hospital variability. To better appreciate the possible impact of nurse staffing levels on adverse events, we propose a multilevel approach reflecting the complex nature of the data. In particular we suggest a clustered discrete-time logistic model that captures the risks associated with a given unit in the patient's trajectory through the hospital. The model also allows for nurse staffing levels to affect the current and subsequent nursing unit (carry-over effect). In the model 'time' is represented by the sequential number of the nursing unit that the patient is passing through. The model incorporates hospital and nursing unit random effects to express that patients treated in the same hospital and taken care of by nurses of the same unit share a common environment. In this study we used Belgian national administrative databases for the year 2003 to assess the relationship between nurse staffing levels and nurse education variables with in-hospital mortality. The analysis was restricted to elective cardiac surgery patients. Lower nursing unit staffing levels in the general nursing units were associated with high in-hospital mortality in units past the traditional cardiac surgery nursing units.

The patients' perspective on fertility care: a systematic review.

BACKGROUND: Patient-centered reproductive medicine (PCRM) is important for quality of care, and this is increasingly being recognized. However, its scientific basis is unclear. The main research questions addressed in this review are: 'How has the patients' perspective on fertility care been examined (method and quality)?' and 'What is the perspective of patients in developed countries on fertility care?'. METHODS: A systematic search of electronic databases was conducted and inclusion criteria with respect to eligibility and quality were applied. The methodology of the studies was critically appraised; the findings of the studies were synthesized and organized according to: patients' value clarification and assessment of service quality and dimensions of patient-centeredness. Additionally data on patient preferences and determinants of patients' perspective on care were collected. RESULTS: In 51 selected studies, patients' perspective on fertility care was examined with (few or many item) questionnaires and/or qualitative interviews. Significant methodological problems were observed. Fertility patients attached importance to seven out of eight dimensions of patient-centeredness (Picker institute) and two new dimensions 'fertility clinic staff' and 'skills' were developed. Overall, fertility patients want to be treated like human beings with a need for: medical skills, respect, coordination, accessibility, information, comfort, support, partner involvement and a good attitude of and relationship with fertility clinic staff. Patients' preferences between procedures and demographic, medical and psychological determinants of their perspective were defined. CONCLUSIONS: Fertility patients have 'human needs' besides their need for medical care. Evidence on PCRM is available but significant methodological limitations call for the development and validation of a European questionnaire.

Assessing future health workforce needs

The choice of a strategy to assess the future health workforce (HW) is value-based and depends on what health outcomes and service objectives policy-makers have set.Various models, approaches and toolkits have been proposed and tried over the years by international agencies, as well as by individual countries.Workforce situation analysis for determining future staff requirements typically builds upon variables such as expected population growth, technological and social change, skills mix, individual performance and health policy.There is little benefit in educating adequate numbers of doctors or nurses, and then seeing them migrate to other countries because the labour market cannot integrate them, or because working conditions are not attractive enough.Assessing future HW needs is not only about projecting the numbers. Policy-makers need also to address the issues of recruiting, educating, distributing, retaining, motivating and managing the HW, which implies improving the knowledge about the expectations and behaviours of health workers.Addressing needs implies more than producing more workers; scaling up can be achieved by improving competences, changing skills mix, and by augmenting productivity.It is important to see HW planning as a process that engages the main stakeholders in assessing needs for change and in devising strategies to achieve those changes.The better the information base and the technical capacity to use it, the better the diagnosis and the selection of interventions will be.Monitoring is essential to adjust interventions to a changing environment.Sufficient and predictable funding must be available to invest in workforce development. The benefits will soon be apparent in terms of better access to services, more efficient utilization of resources and higher satisfaction of citizens

Effects of clinical pathways in the joint replacement: a meta-analysis.

BACKGROUND: A meta-analysis was performed to evaluate the use of clinical pathways for hip and knee joint replacements when compared with standard medical care. The impact of clinical pathways was evaluated assessing the major outcomes of in-hospital hip and knee joint replacement processes: postoperative complications, number of patients discharged at home, length of in-hospital stay and direct costs. METHODS: Medline, Cinahl, Embase and the Cochrane Central Register of Controlled Trials were searched. The search was performed from 1975 to 2007. Each study was assessed independently by two reviewers. The assessment of methodological quality of the included studies was based on the Jadad methodological approach and on the New Castle Ottawa Scale. Data analysis abided by the guidelines set out by The Cochrane Collaboration regarding statistical methods. Meta-analyses were performed using RevMan software, version 4.2. RESULTS: Twenty-two studies met the study inclusion criteria and were included in the meta-analysis for a total sample of 6,316 patients. The aggregate overall results showed significantly fewer patients suffering postoperative complications in the clinical pathways group when compared with the standard care group. A shorter length of stay in the clinical pathway group was also observed and lower costs during hospital stay were associated with the use of the clinical pathways. No significant differences were found in the rates of discharge to home. CONCLUSION: The results of this meta-analysis show that clinical pathways can significantly improve the quality of care even if it is not possible to conclude that the implementation of clinical pathways is a cost-effective process, because none of the included studies analysed the cost of the development and implementation of the pathways. Based on the results we assume that pathways have impact on the organisation of care if the care process is structured in a standardised way, teams critically analyse the actual organisation of the process and the multidisciplinary team is highly involved in the re-organisation. Further studies should focus on the evaluation of pathways as complex interventions to help to understand which mechanisms within the clinical pathways can really improve the quality of care. With the need for knee and hip joint replacement on the rise, the use of clinical pathways might contribute to better quality of care and cost-effectiveness.

Functional evaluation of conventional 'Celsite' venous ports versus 'Vortex' ports with a tangential outlet: a prospective randomised pilot study.

GOAL OF WORK: Totally implantable venous access ports are widely accepted in cancer patient treatment, but withdrawal occlusion (WO) can hamper the use of the device. A newly designed Vortex VX port, with a tangential outlet, should allow better clearance of the chamber, thereby reducing occlusion of the device. The present study compared the Vortex port to the classically shaped Celsite port with regards to functional complications. MATERIALS AND METHODS: Two hundred cancer patients were included in a prospective, randomised controlled trial and randomly assigned to the implantation of a Vortex or a Celsite port. Insertion details such as used vein, catheter tip position and infusion or aspiration abilities were recorded. Data were collected concerning ease of access, and functional evaluation was performed each time the port was accessed, regarding the ability to infuse fluids with a syringe and to withdraw blood by measuring the filling time of a Vacutainer blood tube. MAIN RESULTS: Ninety-nine patients received a Celsite port, and 101 had a Vortex port. Demographic variables and insertion details were comparable in both groups. All functional complications, including WO, total occlusion, sluggish inflow and sluggish withdrawal, were higher in the Celsite group (16.12%) than in the Vortex group (11.36%). This difference was not statistically significant. CONCLUSIONS: This study revealed that functional problems occurred less frequently in Vortex compared to Celsite ports. Differences were small and not significant, which indicates that functional problems may be related to other factors.

[Frequency of oral hygiene nursing in cancer patients in Belgian hospitals. Frequency of nursing interventions and indicators]. / Häufigkeit von Mundpflege bei Krebspatienten in belgischen Krankenhäusern. Häufigkeiten pflegerischer Interventionen und Indikatoren.

This article describes the frequency of mouth care for cancer patients in Belgian hospitals. It also analyses the indicators used for this specific type of compensatory nursing care. The study was designed as a secondary data analysis of the 1990 Belgian Nursing Minimum Data set. The randomised sample included 35,347 oncology patients. Frequency of mouth care was 10.3%. The most important indicators were ventilation (70.58%), nasogastric tube (55.01%), endotracheal tube (43.17%), isolation of the patient (40.57%), malignant neoplasmas of lip, cavity and pharynx (40.21%), age younger than 8 years (37.06%) and disorientation of the patient (31.49%). Frequency of mouth care increased with a higher qualification of staff and higher staffing ratios.

Updating the Belgian Nursing Minimum Data Set: framework and methodology.

The Belgium Nursing Minimum Data Set (BNMDS) started nationally in 1988. It has to be updated to reflect the current evolution of health care. This document describes the framework and methodology for this updating project. The main preoccupation of the research project is to update the existing instrument while avoiding an overload of additional items. A wide range and in-depth analysis of the existing data sets (BNMDS and related data sets) is prerequisite with a view to the development of relevant and effective nursing care indicators. New items and their registration are only acceptable when existing data are insufficient for the required indicators. Indicators relate to clinical nursing care as well as the management of nursing care, e.g. nursing care, nurse staffing, variability of nursing care in view of hospitalization types. While the current indicators make the nursing care process visible only, the updated BNMDS and its indicators should pilot the appropriateness of hospital admissions and their modus, e.g. in-patient versus one-day, and length of stay, the quality of nursing care and the adequacy of nurse staffing. The project focuses on six care programs or clinical pathways: care of the elderly, intensive care, chronic care, pediatrics, cardiology and oncology. A first work package includes the development of new indicators and updating of existing ones, based on secondary data analysis of the existing BNMDS and related data sets. The second work package involves the establishment of workgroups for each care program. The workgroups will review, evaluate and fine-tune the proposals of the researchers. Finally, in work package three, the updated BNMDS will be tested in the hospital setting.