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J Peds Readmissions
Pediatric heart failure can be life-threatening and lead to frequent readmissions. The article discusses the complex factors that contribute to high readmission rates for children with heart failure, including lack of care coordination and continuity. It recommends 10 strategies to improve communication during care transitions and reduce readmissions, such as creating common metrics to track outcomes, recognizing this as a complex adaptive challenge, and engaging clinicians in leadership and redesigning care processes. The goal is to improve outcomes and reduce costs through more coordinated, patient-centered care for this vulnerable population.
Resuc paper review
This document summarizes a study that assessed current practices in teaching life support competencies in healthcare. The study conducted surveys to: 1) Identify life support courses provided in UK hospitals and required by professional bodies, 2) Describe curriculum content and teaching methods of popular in-hospital courses, 3) Examine fidelity of implementation of courses in England. The study found that most NHS hospitals provide adult life support courses, with the Resuscitation Council UK Advanced Life Support course most common. Many hospitals also provide in-house courses. Recognition and management of pre-arrest deterioration are now widely taught. While life support training is provided in all medical schools, approaches vary and pre-arrest management courses are less common. Only a
Aptima_Human Factors Analysis of Duke University Hospital Pediatric Blood & M...
Aptima_Human Factors Analysis of Duke University Hospital Pediatric Blood & M...Wayne State University School of Medicine
This document provides a summary of a human factors analysis conducted of the Pediatric Blood & Marrow Transplantation Unit (PBMTU) at Duke University Hospital. The analysis was conducted over several months in late 2006 and early 2007 by a multi-disciplinary team from Aptima, Inc. The team conducted over 50 interviews and observations to identify stress points and potential failures within the PBMTU system. The analysis utilized several human factors techniques including interviews, observations, modeling, and assessment of the clinical microsystem framework. The report details the assessments and provides recommendations in each area of the framework to improve safety, quality of care, staff retention and the unit's ability to serve more patients.baker_salas_barach_battles_and_king_2007
This section discusses team training research and makes recommendations for improving team training in medical contexts. It summarizes that while some team training programs for healthcare professionals have shown promise, such as Anesthesia Crisis Resource Management (ACRM) training and MedTeams training, the evidence supporting their effectiveness in enhancing patient safety is still limited. It recommends developing a theoretical model of medical team performance, continuing to learn from the broader science of team performance and training, identifying core competencies for effective medical teamwork through consensus, and leveraging proven instructional strategies from team training research. The overall aim is to provide a strategy for further investigating how team training can help the medical community improve patient safety.
Sec36FinalReport
The document summarizes a study conducted by the Florida Patient Safety Network on establishing a Patient Safety Authority in Florida. Key points:
- The study was mandated by the Florida legislature in response to Senate Bill 2-D from 2003 to evaluate creating a statewide Patient Safety Authority.
- The Authority would be responsible for activities and functions to improve patient safety and quality of care in health facilities and among practitioners.
- The study examined options for the Authority to directly perform safety functions, or contract with or partner with university patient safety centers.
- The Network coordinated its efforts with various stakeholders and academic medical centers across the state to conduct a comprehensive review and provide recommendations.
Designingpsundergraduatemedicalcurriculum(1)
The Telluride Interdisciplinary Roundtable met in 2005 and 2006 to design a comprehensive patient safety curriculum for medical students. The group developed 11 specific curricular elements and identified challenges to implementation. A patient safety curriculum was successfully developed over two years. Future meetings focused on evaluating pilots of the curriculum in medical schools and developing new ideas. Continued collaboration between professions will help create a standardized longitudinal patient safety curriculum.
Lilford. Barach.Research_Methods_Reporting (2)
- Management interventions can be divided into targeted service interventions with narrow effects and generic service interventions that have diffuse effects like policy interventions.
- For targeted service interventions, measuring changes in clinical processes is often more cost-effective than measuring patient outcomes in evaluations.
- Clinical processes are not usually suitable primary endpoints for evaluations of policy and generic service interventions because their effects are too diffuse.
- Multiple clinical processes are consolidated into a small number of patient outcomes, which are the default primary endpoints for policy and generic service intervention evaluations.
- When a policy or generic service intervention is inexpensive and plausible effects on patient outcomes are difficult to detect, effects can still be studied at earlier process levels in Donabedian's causal chain model
BMJ Qual Saf-2012-Yao-i29-38
This document describes a 9-step framework for evaluating the expected cost-effectiveness of a service intervention at the design stage. It applies this framework to evaluate an intervention to improve clinical handovers between hospital and community care.
The key steps are: 1) Identifying endpoints and grouping them, 2) Estimating baseline risks, 3) Eliciting expected effectiveness from experts, 4) Assigning utility values to endpoint groups, 5) Costing the intervention, 6) Estimating healthcare costs of adverse events, 7) Calculating health benefits, 8) Determining cost-effectiveness, and 9) Conducting sensitivity analysis.
When applied to a handover improvement intervention, literature suggested adverse events follow 19%
Recommended
J Peds Readmissions
Pediatric heart failure can be life-threatening and lead to frequent readmissions. The article discusses the complex factors that contribute to high readmission rates for children with heart failure, including lack of care coordination and continuity. It recommends 10 strategies to improve communication during care transitions and reduce readmissions, such as creating common metrics to track outcomes, recognizing this as a complex adaptive challenge, and engaging clinicians in leadership and redesigning care processes. The goal is to improve outcomes and reduce costs through more coordinated, patient-centered care for this vulnerable population.
Resuc paper review
This document summarizes a study that assessed current practices in teaching life support competencies in healthcare. The study conducted surveys to: 1) Identify life support courses provided in UK hospitals and required by professional bodies, 2) Describe curriculum content and teaching methods of popular in-hospital courses, 3) Examine fidelity of implementation of courses in England. The study found that most NHS hospitals provide adult life support courses, with the Resuscitation Council UK Advanced Life Support course most common. Many hospitals also provide in-house courses. Recognition and management of pre-arrest deterioration are now widely taught. While life support training is provided in all medical schools, approaches vary and pre-arrest management courses are less common. Only a
Aptima_Human Factors Analysis of Duke University Hospital Pediatric Blood & M...
Aptima_Human Factors Analysis of Duke University Hospital Pediatric Blood & M...Wayne State University School of Medicine
This document provides a summary of a human factors analysis conducted of the Pediatric Blood & Marrow Transplantation Unit (PBMTU) at Duke University Hospital. The analysis was conducted over several months in late 2006 and early 2007 by a multi-disciplinary team from Aptima, Inc. The team conducted over 50 interviews and observations to identify stress points and potential failures within the PBMTU system. The analysis utilized several human factors techniques including interviews, observations, modeling, and assessment of the clinical microsystem framework. The report details the assessments and provides recommendations in each area of the framework to improve safety, quality of care, staff retention and the unit's ability to serve more patients.baker_salas_barach_battles_and_king_2007
This section discusses team training research and makes recommendations for improving team training in medical contexts. It summarizes that while some team training programs for healthcare professionals have shown promise, such as Anesthesia Crisis Resource Management (ACRM) training and MedTeams training, the evidence supporting their effectiveness in enhancing patient safety is still limited. It recommends developing a theoretical model of medical team performance, continuing to learn from the broader science of team performance and training, identifying core competencies for effective medical teamwork through consensus, and leveraging proven instructional strategies from team training research. The overall aim is to provide a strategy for further investigating how team training can help the medical community improve patient safety.
Sec36FinalReport
The document summarizes a study conducted by the Florida Patient Safety Network on establishing a Patient Safety Authority in Florida. Key points:
- The study was mandated by the Florida legislature in response to Senate Bill 2-D from 2003 to evaluate creating a statewide Patient Safety Authority.
- The Authority would be responsible for activities and functions to improve patient safety and quality of care in health facilities and among practitioners.
- The study examined options for the Authority to directly perform safety functions, or contract with or partner with university patient safety centers.
- The Network coordinated its efforts with various stakeholders and academic medical centers across the state to conduct a comprehensive review and provide recommendations.
Designingpsundergraduatemedicalcurriculum(1)
The Telluride Interdisciplinary Roundtable met in 2005 and 2006 to design a comprehensive patient safety curriculum for medical students. The group developed 11 specific curricular elements and identified challenges to implementation. A patient safety curriculum was successfully developed over two years. Future meetings focused on evaluating pilots of the curriculum in medical schools and developing new ideas. Continued collaboration between professions will help create a standardized longitudinal patient safety curriculum.
Lilford. Barach.Research_Methods_Reporting (2)
- Management interventions can be divided into targeted service interventions with narrow effects and generic service interventions that have diffuse effects like policy interventions.
- For targeted service interventions, measuring changes in clinical processes is often more cost-effective than measuring patient outcomes in evaluations.
- Clinical processes are not usually suitable primary endpoints for evaluations of policy and generic service interventions because their effects are too diffuse.
- Multiple clinical processes are consolidated into a small number of patient outcomes, which are the default primary endpoints for policy and generic service intervention evaluations.
- When a policy or generic service intervention is inexpensive and plausible effects on patient outcomes are difficult to detect, effects can still be studied at earlier process levels in Donabedian's causal chain model
BMJ Qual Saf-2012-Yao-i29-38
This document describes a 9-step framework for evaluating the expected cost-effectiveness of a service intervention at the design stage. It applies this framework to evaluate an intervention to improve clinical handovers between hospital and community care.
The key steps are: 1) Identifying endpoints and grouping them, 2) Estimating baseline risks, 3) Eliciting expected effectiveness from experts, 4) Assigning utility values to endpoint groups, 5) Costing the intervention, 6) Estimating healthcare costs of adverse events, 7) Calculating health benefits, 8) Determining cost-effectiveness, and 9) Conducting sensitivity analysis.
When applied to a handover improvement intervention, literature suggested adverse events follow 19%
handover publication Medical Care
Three key themes emerged from the analysis of organizational culture aspects that impact hospital discharge: 1) A fragmented interface between hospitals and primary care with an inward focus on hospital care and lack of awareness of community needs; 2) Undervaluing of administrative discharge tasks compared to clinical work; and 3) A lack of reflection on discharge processes and opportunities for improvement. Nine categories further described barriers such as insufficient communication, task burdens, and negative attitudes. The study suggests organizational culture, including how hospital providers value discharge handovers and community outreach, is critical to effective transitions of care.
handoversrannals
The document summarizes a systematic review of 36 randomized controlled trials that tested interventions to improve handovers of patients from hospitals to primary care. The majority (69.4%) of studies found statistically significant effects favoring the intervention, and most (94.4%) interventions were multicomponent. Effective interventions included medication reconciliation, electronic tools to facilitate discharge summaries, discharge planning involving both hospital and primary care providers, electronic discharge notifications, and Web-based access to discharge information for primary care physicians. The review found interventions often reduced hospital use, improved continuity of care, and enhanced patient status after discharge. However, the heterogeneity of interventions and outcomes made firm conclusions difficult to draw.
BMC implementation paper (1)
This document summarizes a research study that used the Intervention Mapping framework to develop a guiding framework for improving patient discharge from hospitals to primary care. The study conducted interviews and focus groups with patients, families, and providers to identify barriers to effective discharge. Key issues included lack of communication between hospital and primary care providers, incomplete discharge information, and lack of patient understanding. The study then defined desired outcomes, specific performance objectives, and change objectives needed to address the identified barriers. Finally, the study selected evidence-based methods and strategies to achieve the change objectives, such as discharge templates, medication reconciliation, and teach-back techniques. The resulting framework provides guidance for interventions to improve patient handovers between hospital and primary care.
Flyer
This document is a business reply card from Jones & Bartlett Learning requesting a review copy of the book "Case Studies in Patient Safety: Foundations for Core Competencies". It provides instructions for qualified instructors to request a complimentary review copy for course adoption consideration by filling out their contact and course details on the pre-paid reply card or online. The book contains 24 first-person accounts of preventable health care errors told from the patient's perspective to illustrate lessons learned and strategies for preventing future errors.
Part 1 Chapter 1
- 15-year-old Lewis Blackman underwent elective surgery for pectus excavatum (sunken chest) at an academic medical center.
- In the days following surgery, Lewis experienced worsening abdominal pain but nurses dismissed it as constipation and insisted he walk more.
- His condition deteriorated over several hours but nurses were busy preparing for an inspection and did not take his worsening vital signs seriously.
- It was not until Lewis said "It's going black" that a cardiac code was called, but he could not be resuscitated and died 31 hours after reporting the abdominal pain.
Improvement Science, Reliability and Resilience- Engaging Leaders, Clinicians...
Improvement Science, Reliability and Resilience- Engaging Leaders, Clinicians...Wayne State University School of Medicine
This document discusses improving quality and safety in healthcare systems through an improvement science approach. It provides three key building blocks for developing a "high reliability organization":
1) Establishing a culture devoted to quality with trust, constructive error management, and zero tolerance for unsafe practices.
2) Implementing clear responsibility and accountability through defined care pathways, outcome measurement, and bottom-up process improvement.
3) Optimizing and standardizing processes through evidence-based standard operating procedures and scrutiny of variations.
Measurement of outcomes is also discussed as crucial for continuous improvement towards being "better than the rest." Engaging all levels is emphasized as fundamental to achieving reliable performance.Barach talk.MAB.Final
This document discusses the potential role of national health insurance in creating a safe, affordable, and high-quality healthcare system in the Bahamas. It begins by outlining the government's vision of transforming healthcare to be the safest and most effective in the region. It then discusses some of the current challenges in the Bahamian healthcare system, including a lack of coordination, increasing costs, and workforce issues. The document also reviews international healthcare system rankings and compares mortality rates between public and private patients in Bahamian hospitals. Overall, the document examines how a national health insurance system could help address issues in the current healthcare system and better serve the needs of Bahamians.
Barach.Human factors HMA talk Sept 4
Yes, we're ready to go on bypass.
Perfusionist: Yes, I'm ready for bypass.
Surgeon: Okay, let's go on bypass.
Hospital B
Surgeon: Heparin please.
Anaesthetist: Heparin going in now. *administers heparin*
Perfusionist: Heparin level is therapeutic, I'm ready for bypass.
Surgeon: Okay, let's go on bypass.
Learning: Explicit verbal confirmation of key steps improves safety.
Catchpole K, 2011, in press
Human Factors in Healthcare
l Design of equipment, tasks, jobs, and environments
l Understanding human
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handover publication Medical Care
Three key themes emerged from the analysis of organizational culture aspects that impact hospital discharge: 1) A fragmented interface between hospitals and primary care with an inward focus on hospital care and lack of awareness of community needs; 2) Undervaluing of administrative discharge tasks compared to clinical work; and 3) A lack of reflection on discharge processes and opportunities for improvement. Nine categories further described barriers such as insufficient communication, task burdens, and negative attitudes. The study suggests organizational culture, including how hospital providers value discharge handovers and community outreach, is critical to effective transitions of care.
handoversrannals
The document summarizes a systematic review of 36 randomized controlled trials that tested interventions to improve handovers of patients from hospitals to primary care. The majority (69.4%) of studies found statistically significant effects favoring the intervention, and most (94.4%) interventions were multicomponent. Effective interventions included medication reconciliation, electronic tools to facilitate discharge summaries, discharge planning involving both hospital and primary care providers, electronic discharge notifications, and Web-based access to discharge information for primary care physicians. The review found interventions often reduced hospital use, improved continuity of care, and enhanced patient status after discharge. However, the heterogeneity of interventions and outcomes made firm conclusions difficult to draw.
BMC implementation paper (1)
This document summarizes a research study that used the Intervention Mapping framework to develop a guiding framework for improving patient discharge from hospitals to primary care. The study conducted interviews and focus groups with patients, families, and providers to identify barriers to effective discharge. Key issues included lack of communication between hospital and primary care providers, incomplete discharge information, and lack of patient understanding. The study then defined desired outcomes, specific performance objectives, and change objectives needed to address the identified barriers. Finally, the study selected evidence-based methods and strategies to achieve the change objectives, such as discharge templates, medication reconciliation, and teach-back techniques. The resulting framework provides guidance for interventions to improve patient handovers between hospital and primary care.
Flyer
This document is a business reply card from Jones & Bartlett Learning requesting a review copy of the book "Case Studies in Patient Safety: Foundations for Core Competencies". It provides instructions for qualified instructors to request a complimentary review copy for course adoption consideration by filling out their contact and course details on the pre-paid reply card or online. The book contains 24 first-person accounts of preventable health care errors told from the patient's perspective to illustrate lessons learned and strategies for preventing future errors.
Part 1 Chapter 1
- 15-year-old Lewis Blackman underwent elective surgery for pectus excavatum (sunken chest) at an academic medical center.
- In the days following surgery, Lewis experienced worsening abdominal pain but nurses dismissed it as constipation and insisted he walk more.
- His condition deteriorated over several hours but nurses were busy preparing for an inspection and did not take his worsening vital signs seriously.
- It was not until Lewis said "It's going black" that a cardiac code was called, but he could not be resuscitated and died 31 hours after reporting the abdominal pain.
Improvement Science, Reliability and Resilience- Engaging Leaders, Clinicians...
Improvement Science, Reliability and Resilience- Engaging Leaders, Clinicians...Wayne State University School of Medicine
This document discusses improving quality and safety in healthcare systems through an improvement science approach. It provides three key building blocks for developing a "high reliability organization":
1) Establishing a culture devoted to quality with trust, constructive error management, and zero tolerance for unsafe practices.
2) Implementing clear responsibility and accountability through defined care pathways, outcome measurement, and bottom-up process improvement.
3) Optimizing and standardizing processes through evidence-based standard operating procedures and scrutiny of variations.
Measurement of outcomes is also discussed as crucial for continuous improvement towards being "better than the rest." Engaging all levels is emphasized as fundamental to achieving reliable performance.Barach talk.MAB.Final
This document discusses the potential role of national health insurance in creating a safe, affordable, and high-quality healthcare system in the Bahamas. It begins by outlining the government's vision of transforming healthcare to be the safest and most effective in the region. It then discusses some of the current challenges in the Bahamian healthcare system, including a lack of coordination, increasing costs, and workforce issues. The document also reviews international healthcare system rankings and compares mortality rates between public and private patients in Bahamian hospitals. Overall, the document examines how a national health insurance system could help address issues in the current healthcare system and better serve the needs of Bahamians.
Barach.Human factors HMA talk Sept 4
Yes, we're ready to go on bypass.
Perfusionist: Yes, I'm ready for bypass.
Surgeon: Okay, let's go on bypass.
Hospital B
Surgeon: Heparin please.
Anaesthetist: Heparin going in now. *administers heparin*
Perfusionist: Heparin level is therapeutic, I'm ready for bypass.
Surgeon: Okay, let's go on bypass.
Learning: Explicit verbal confirmation of key steps improves safety.
Catchpole K, 2011, in press
Human Factors in Healthcare
l Design of equipment, tasks, jobs, and environments
l Understanding human
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Improvement Science, Reliability and Resilience- Engaging Leaders, Clinicians...
Improvement Science, Reliability and Resilience- Engaging Leaders, Clinicians...