Physician engagement in organisational patient safety through the implementation of a Medical Safety Huddle initiative: a qualitative study.

BACKGROUND: Efforts to increase physician engagement in quality and safety are most often approached from an organisational or administrative perspective. Given hospital-based physicians' strong professional identification, physician-led strategies may offer a novel strategic approach to enhancing physician engagement. It remains unclear what role medical leadership can play in leading programmes to enhance physician engagement. In this study, we explore physicians' experience of participating in a Medical Safety Huddle initiative and how participation influences engagement with organisational quality and safety efforts. METHODS: We conducted a qualitative study of the Medical Safety Huddle initiative implemented across six sites. The initiative consisted of short, physician focused and led, weekly meetings aimed at reviewing, anticipating and addressing patient safety issues. We conducted 29 semistructured interviews with leaders and participants. We applied an interpretive thematic analysis to the data using self-determination theory as an analytic lens. RESULTS: The results of the thematic analysis are organised in two themes, (1) relatedness and meaningfulness, and (2) progress and autonomy, representing two forms of intrinsic motivation for engagement that we found were leveraged through participation in the initiative. First, participation enabled a sense of community and a 'safe space' in which professionally relevant safety issues are discussed. Second, participation in the initiative created a growing sense of ability to have input in one's work environment. However, limited collaboration with other professional groups around patient safety and the ability to consistently address reported concerns highlights the need for leadership and organisational support for physician engagement. CONCLUSION: The Medical Safety Huddle initiative supports physician engagement in quality and safety through intrinsic motivation. However, the huddles' implementation must align with the organisation's multipronged patient safety agenda to support multidisciplinary collaborative quality and safety efforts and leaders must ensure mechanisms to consistently address reported safety concerns for sustained physician engagement.

Protocol for a stepped wedge cluster randomized quality improvement project to evaluate the impact of medical safety huddles on patient safety.

Introduction: Physician engagement is crucial for furthering patient safety and quality improvement within healthcare organizations. Medical Safety Huddles, which are physician-specific huddles, is a novel way to engage physicians with patient safety and may reduce adverse events experienced by patients. We plan to conduct a multi-center quality improvement (QI) initiative to implement and evaluate Medical Safety Huddles. The primary objective is to determine the impact of the huddles on adverse events experienced by patients. Secondary objectives include assessing the impact of the huddles on patient safety culture and physician engagement, and a process evaluation to assess the fidelity of implementation. Methods: This stepped wedge cluster randomized study will be conducted at four academic inpatient hospitals over 19 months. Each site will adapt Medical Safety Huddles to its own practice context to best engage physicians. We will review randomly selected patient charts for adverse events. Generalized linear mixed effects regression will be used to estimate the overall intervention effect on adverse events. Process measures such as physician attendance rates and number of safety issues raised per huddle will be tracked to monitor implementation adherence. Conclusion: Medical Safety Huddles may help healthcare organizations and medical leaders to better engage physicians with patient safety. The project results will assess the fidelity of implementation and determine the impact of Medical Safety Huddles on patient safety.

Medication Use by Alternate Level of Care Patients: A Descriptive Analysis.

BACKGROUND: The population of patients designated as alternate level of care (ALC) consists predominantly of frail older adults who are medically stable and awaiting discharge from hospital. They have complex medication regimens, often including potentially inappropriate medications (PIMs). There has been increasing emphasis on managing the burden that ALC patients place on the health care system, but little is known about their health care needs. OBJECTIVE: To characterize the medication regimens, including use of PIMs, of ALC patients at the study institution. METHODS: A cross-sectional chart audit of ALC patients was conducted between May and July 2017. For all patients in the sample, each medication was categorized by therapeutic class, and PIMs were categorized according to the Beers criteria, the STOPP/START criteria, and an established list of high-alert medications. RESULTS: A total of 82 patients met the audit criteria, for whom the mean number of chronic conditions was 6.4 (standard deviation [SD] 3.3) and the mean number of prescribed medications was 12.8 (SD 6.9). Twenty-four (29%) of the patients were receiving at least 1 drug from 7 different drug classes. All but one of the patients had PIMs in their regimen; the frequency of PIMs was highest according to the Beers criteria (mean 3.9 [SD 2.6] medications per patient). CONCLUSIONS: At the study institution, ALC patients had on average more than 6 chronic conditions managed with at least 12 medications, of which one-quarter were PIMs. These data will be used to inform next steps in making recommendations to simplify, reduce, or discontinue medications for which there is an unclear indication, lack of effectiveness, or evidence of potential harm.

CONTEXTE: La population de patients désignés comme « niveaux de soins alternatifs ¼ (NSA) se compose majoritairement d'aînés faibles, médicalement stables et en attente de leur congé hospitalier. Ils suivent des traitements médicamenteux complexes qui comprennent souvent des médicaments potentiellement contre-indiqués (MPCI). L'accent a été progressivement mis sur la gestion du fardeau que les patients NSA font peser sur le système de soins de santé, mais on connait peu de choses sur leurs besoins en matière de soins de santé. OBJECTIF: Décrire les traitements médicamenteux, y compris l'utilisation des MPCI, des patients NSA dans l'institution où s'est déroulée l'étude. MÉTHODES: Une vérification transversale des dossiers de patients NSA a été menée entre mai et juillet 2017. Chaque médicament pris par les patients de l'échantillon a été classé selon sa catégorie thérapeutique, et les MPCI ont été catégorisés selon les critères de Beers, les critères STOPP/START ainsi qu'une liste établie de médicaments dont le niveau d'alerte est élevé. RÉSULTATS: Au total, 82 patients remplissaient les critères de l'audit, car le nombre moyen de maladies chroniques était de 6,4 (écart type [ET] 3,3) et le nombre moyen de médicaments prescrits se montait à 12,8 (ET 6,9). Vingt-quatre (29 %) patients recevaient au moins un médicament de sept classes médicamenteuses différentes. Tous les patients sauf un avaient des MPCI dans leur programme. La fréquence des MPCI était plus élevée selon les critères de Beers (moyenne de MPCI par patient de 3,9 [ET 2,6]). CONCLUSIONS: Sur le lieu de l'étude, les patients NSA avaient en moyenne plus de six maladies chroniques gérées à l'aide d'au moins 12 médicaments, dont un quart était des MPCI. Ces données seront utilisées pour informer les cliniciens sur les étapes suivantes et formuler des recommandations afin de simplifier, de réduire ou d'arrêter les médicaments pour lesquels l'indication n'est pas claire, dont l'efficacité est insuffisante ou sur lesquels il existe des données probantes faisant état de dangers potentiels.

Chaos and correspondence in classical and quantum Hamiltonian ratchets: a Heisenberg approach.

Previous work [Gong and Brumer, Phys. Rev. Lett. 97, 240602 (2006)] motivates this study as to how asymmetry-driven quantum ratchet effects can persist despite a corresponding fully chaotic classical phase space. A simple perspective of ratchet dynamics, based on the Heisenberg picture, is introduced. We show that ratchet effects are in principle of common origin in classical and quantum mechanics, although full chaos suppresses these effects in the former but not necessarily the latter. The relationship between ratchet effects and coherent dynamical control is noted.