improving safety and quality of care essay

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Improving quality of care and patient safety as a priority.

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Usman Iqbal, Shabbir Syed-Abdul, Yu-Chuan (Jack) Li, Improving quality of care and patient safety as a priority, International Journal for Quality in Health Care , Volume 27, Issue 5, October 2015, Page 335, https://doi.org/10.1093/intqhc/mzv066

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International Journal for Quality in Health Care ( IJQHC ) presents interesting studies in this issue mainly focusing on improving quality of care and patient safety.

Jeffrey and his colleagues [ 1 ] shed light on current approach to patient safety that current approach to patient safety, labeled Safety-I, is predicated on a ‘find and fix’ model. This helps to identifies that how things going wrong, after the event, and aims to stamp them out, in order to ensure that the number of errors is as low as possible. The Healthcare systems are much more complex; therefore, they suggested that we need to switch the focus to Safety-II: a concerted effort to enable things to go right more often. Patient safety usually requires more than prevention, elimination and compliance. So, the key is to appreciate that healthcare is resilient to a large extent, and everyday performance succeeds much more often than it fails. This new paradigm would help clinicians in facilitating work flexibility and actively increase the capacity of clinicians to deliver more care more effectively as they constantly adjust what they do to match the conditions.

Quality and patient safety is always an important concern around the world and in 2005, The World Health Organization (WHO) presented a global initiative called ‘Clean care is safer care’ to improve hand hygiene compliance among healthcare workers. One of the studies presented in this issue of journal focuses on improving hand hygiene in ICUs from hospitals of Buenos Aires, Argentina [ 2 ]. This study is a randomized cluster stepped wedge trial based upon multimodal intervention characterized by being evidence based, low-cost and suggested by qualitative research: (a) leadership commitment, (b) surveillance of materials needed to comply with hand hygiene and alcohol consumption, (c) utilization of reminders, (d) a storyboard of the project and (e) feedback (hand hygiene compliance rate). This study supports that a multimodal intervention was effective to improve compliance with hand hygiene in ICUs.

Another interesting study presented about performance measures whether improved more in accredited (The Joint Commission International or The Health Quality Service) hospitals than in non-accredited hospital at Danish hospitals [ 3 ]. Since accreditation is an external review process to assess how well an organization performs relative to established standards, but they found that participating in accreditation was not associated with larger improvement in performance measures for acute stroke, heart failure or ulcer. This could be also because they evaluated the development of process performance measures over a relatively short time span and does not show whether improvements due to accreditation are possible in the long term.

Since patients are increasingly being involved in evaluations of healthcare quality. The study from China included in this issue developed and validate Patient-Reported Outcomes Scale for Hypertension [ 4 ]. The instrument provides a means for comprehensive assessment of the impact of hypertension and for quantification of benefits of hypertension interventions from the patients' perspective. Kim et al., from Korea examined the impact of a government-directed regional cardiovascular center (RCVC) project on the length of stay and medical costs due to acute myocardial infarction [ 5 ]. They observed a reduction in length of stay and direct medical costs reported in limited number of regionalized hospitals after implementation of RCVC project by the Korean government to reduce the societal burden of acute myocardial infarction patients.

Hollnagel E Braithwaite J Wears RL . Resilient Health Care: Turning Patient Safety on its Head . London : Ashgate , 2015 .

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Rodriguez V Giuffre C Villa S et al.  A multimodal intervention to improve hand hygiene in ICUs in Buenos Aires, Argentina: a stepped wedge trial . Int J Qual Health Care 2015 ; 27 : 405 – 11 .

Bie Bogh S Falstie-Jensen AM Bartels P et al.  Accreditation and improvement in process quality of care: a nationwide study . Int J Qual Health Care 2015 ; 27 : 336 – 43 .

Zhi L Qiaojun L Yanbo Z . Development and validation of patient-reported outcomes scale for hypertension . Int J Qual Health Care 2015 ; 27 : 369 – 76 .

Kim A Yoon S-J Kim YA et al.  The burden of acute myocardial infarction after a regional cardiovascular center project in Korea . Int J Qual Health Care 2015 ; 27 : 349 – 55 .

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Improving Patient Safety and Quality of Medical Care Expository Essay

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Introduction

Use of technology, evidence-based medicine, health literacy.

Patient safety is an important aspect of risk management in health care. Improvement of patient safety entails assessment of possible ways that could harm patients, prevention and management of medical risks, and analysis of incidents that harm patients (Leape et al, 2007). In addition, it involves reporting such incidents to management and consequently putting measures in place to ensure that they do not recur.

Improving patient safety is one of the methods used to improve the quality of medical care given to patients. In provision of medical care, patient safety is the most important aspect to consider. For example, during medication, surgery and other medical procedures, health care givers should ensure that the safety of the patient is guaranteed. Medical errors, poor quality medical care, inadequate patient monitoring, and uncoordinated patient care services compromise patient safety (Leape et al, 2007).

How to improve patient safety and quality of care

Several measures can be put in place to ensure patient safety during treatment and hence improve the quality of medical care. These measures include use of technology, use of evidence-based medicine, and improving health literacy for both patients and health care professionals. Improving patient safety and quality of patient care helps in management of risk involved in the health care sector because it minimizes harm and injuries to patients.

A study by RAND Health revealed that if health information technology (HIT) was adopted by the healthcare system of the United States, more than $81 billion would be saved every year (Wong, 2012). Adoption of HIT would help to minimize dangerous healthcare incidents that compromise patient safety and lower the quality of healthcare.

In addition, it would minimize the length of stay of patients in hospitals. Examples of technology advancements that can be used include Electronic Health Record (HER), Computerized Provider Order Entry (CPOE), complete safety medication system, and active RFID platform (Wong, 2012).

EHR is useful in reduction of errors related to drug prescription, laboratory tests, and several medical procedures. In many hospitals, medical errors are caused by failure to embrace technology. Illegible handwritten reports are a common cause of medical errors in areas such as drug prescription, medical tests, and treatment procedures (Wong, 2012).

Electronic patient records contribute highly in improving the safety of patients and quality of medical care because they facilitate efficient storage of patient information. Use of technology helps to improve patient safety by reducing diagnosis errors and improving patient monitoring (Wong, 2012).

Evidence-based medicine is an effective method of improving patient safety and quality of patient care. It combines research findings and results of a patient’s examination by a doctor. The doctor uses the results of research studies to make accurate diagnosis and prescription to minimize chances of harming patients (Leape et al, 2007).

In addition, this medical approach inculcates therapy, rehabilitation, and prevention measures that guarantee the safety of patients. It is effective because it offers healthcare practitioners a chance to use improved treatment methods and guidelines. In addition, it reduces cases of incorrect diagnosis and other medical errors such as overuse of certain medications used during surgeries and minor operations (Leape et al, 2007).

Moreover, it eliminates the risk presented by outdated treatment methods and procedures. These practices improve the safety of patients and the quality of medical care given. The field of evidence-based medicine needs further research in order to develop new treatment methods and procedures as well as tests for diagnosis of diseases.

Heath literacy is an important factor in the process of improving patient safety and quality of health care. Low levels of health literacy in patients compromise their safety and the quality of care given. After a doctor prescribes drugs to a patient, it then becomes the responsibility of the patient to take the drugs as prescribed.

However, many patients fail to adhere to directions due to poor comprehension of medication directions (AHRQ, 2012). Poor communication between a patient and a doctor leads to severe medication errors that harm the patient. Low levels of health literacy among patients result in negative healthcare outcomes that lower the quality of healthcare and cause harm to patients.

Patients with low health literacy levels are at a higher risk level of making medication mistakes and are more likely to be hospitalized compared to patients with high health literacy levels. This lengthens their stay at hospital and may be a source of health complications. It is necessary to educate patients on proper interpretation of prescription directions in order to avoid errors that harm them and compromise their safety.

Another dimension of health literacy is education of healthcare providers. To improve patient safety, it is important to ensure that all healthcare professionals possess the required qualifications for their jobs (AHRQ, 2012).

Health care professionals in all sites that provide patient care services such as nursing homes, hospitals, and beneficiary homes should possess the required qualifications for their jobs. Frequent training programs should be offered to health care professionals to ensure that they keep up with recent discoveries and research in their respective medical field (AHRQ, 2012).

This is necessary in order to ensure that they stop using outdated treatment procedures and tests to treat patients. In addition, it is a way of ensuring that they adopt improved medical guidelines that are geared towards improving patient safety and raising the quality of health care provided to patients.

Errors made during medical procedures arise from the actions of unqualified health care professionals who possess inadequate knowledge that does not enable them to offer quality services to patients (AHRQ, 2012). On the other hand, unqualified professionals make errors in drug prescription due to ignorance. Stringent measures should be put in place to ensure that all health care professionals are qualified and fit to provide medical services to patients.

Patient safety and quality of patient care is an important area in risk management in health care. Improvement of patient safety entails assessment of possible ways that could harm patients, prevention, and management of medical risks and analysis of incidents that cause harm to patients.

In addition, it involves reporting of such incidents to management and putting measures in place to ensure that they do not recur. Medical errors, prescription and medication errors, poor monitoring of patients, quack health care professionals, and low levels of heath literacy compromise patient safety and quality of health care.

Methods that could be used to improve patient safety and quality of health care include use of technology in the health care sector, use of evidence-based medicine, and improving health literacy for both patients and health care professionals. To manage risk in health care sector, it is important to put stringent measures that guarantee improved patient safety and high quality of patient care.

Agency for Healthcare Research and Quality (AHRQ). (2012). Tips to Help Prevent Medical Errors . Web.

Leape, L., Berwick, D., and Bates, D. (2007). What Practices Will Most Improve Safety? Evidence-Based Medicine Meets Patient Safety . Web.

Wong, Michael. (2012). Tips on How to Improve Patient Safety With the Help of Technology . Web.

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IvyPanda. (2018, December 11). Improving Patient Safety and Quality of Medical Care. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/

"Improving Patient Safety and Quality of Medical Care." IvyPanda , 11 Dec. 2018, ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/.

IvyPanda . (2018) 'Improving Patient Safety and Quality of Medical Care'. 11 December.

IvyPanda . 2018. "Improving Patient Safety and Quality of Medical Care." December 11, 2018. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/.

1. IvyPanda . "Improving Patient Safety and Quality of Medical Care." December 11, 2018. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/.

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IvyPanda . "Improving Patient Safety and Quality of Medical Care." December 11, 2018. https://ivypanda.com/essays/improving-patient-safety-and-quality-of-medical-care/.

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Quality improvement into practice

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• Peer review
• Adam Backhouse , quality improvement programme lead 1 ,
• Fatai Ogunlayi , public health specialty registrar 2
• 1 North London Partners in Health and Care, Islington CCG, London N1 1TH, UK
• 2 Institute of Applied Health Research, Public Health, University of Birmingham, B15 2TT, UK
• Correspondence to: A Backhouse adam.backhouse{at}nhs.net

What you need to know

Thinking of quality improvement (QI) as a principle-based approach to change provides greater clarity about ( a ) the contribution QI offers to staff and patients, ( b ) how to differentiate it from other approaches, ( c ) the benefits of using QI together with other change approaches

QI is not a silver bullet for all changes required in healthcare: it has great potential to be used together with other change approaches, either concurrently (using audit to inform iterative tests of change) or consecutively (using QI to adapt published research to local context)

As QI becomes established, opportunities for these collaborations will grow, to the benefit of patients.

The benefits to front line clinicians of participating in quality improvement (QI) activity are promoted in many health systems. QI can represent a valuable opportunity for individuals to be involved in leading and delivering change, from improving individual patient care to transforming services across complex health and care systems. 1

However, it is not clear that this promotion of QI has created greater understanding of QI or widespread adoption. QI largely remains an activity undertaken by experts and early adopters, often in isolation from their peers. 2 There is a danger of a widening gap between this group and the majority of healthcare professionals.

This article will make it easier for those new to QI to understand what it is, where it fits with other approaches to improving care (such as audit or research), when best to use a QI approach, making it easier to understand the relevance and usefulness of QI in delivering better outcomes for patients.

How this article was made

AB and FO are both specialist quality improvement practitioners and have developed their expertise working in QI roles for a variety of UK healthcare organisations. The analysis presented here arose from AB and FO’s observations of the challenges faced when introducing QI, with healthcare providers often unable to distinguish between QI and other change approaches, making it difficult to understand what QI can do for them.

How is quality improvement defined?

There are many definitions of QI ( box 1 ). The BMJ ’s Quality Improvement series uses the Academy of Medical Royal Colleges definition. 6 Rather than viewing QI as a single method or set of tools, it can be more helpful to think of QI as based on a set of principles common to many of these definitions: a systematic continuous approach that aims to solve problems in healthcare, improve service provision, and ultimately provide better outcomes for patients.

Definitions of quality improvement

Improvement in patient outcomes, system performance, and professional development that results from a combined, multidisciplinary approach in how change is delivered. 3

The delivery of healthcare with improved outcomes and lower cost through continuous redesigning of work processes and systems. 4

Using a systematic change method and strategies to improve patient experience and outcome. 5

To make a difference to patients by improving safety, effectiveness, and experience of care by using understanding of our complex healthcare environment, applying a systematic approach, and designing, testing, and implementing changes using real time measurement for improvement. 6

In this article we discuss QI as an approach to improving healthcare that follows the principles outlined in box 2 ; this may be a useful reference to consider how particular methods or tools could be used as part of a QI approach.

Principles of QI

Primary intent— To bring about measurable improvement to a specific aspect of healthcare delivery, often with evidence or theory of what might work but requiring local iterative testing to find the best solution. 7

Employing an iterative process of testing change ideas— Adopting a theory of change which emphasises a continuous process of planning and testing changes, studying and learning from comparing the results to a predicted outcome, and adapting hypotheses in response to results of previous tests. 8 9

Consistent use of an agreed methodology— Many different QI methodologies are available; commonly cited methodologies include the Model for Improvement, Lean, Six Sigma, and Experience-based Co-design. 4 Systematic review shows that the choice of tools or methodologies has little impact on the success of QI provided that the chosen methodology is followed consistently. 10 Though there is no formal agreement on what constitutes a QI tool, it would include activities such as process mapping that can be used within a range of QI methodological approaches. NHS Scotland’s Quality Improvement Hub has a glossary of commonly used tools in QI. 11

Empowerment of front line staff and service users— QI work should engage staff and patients by providing them with the opportunity and skills to contribute to improvement work. Recognition of this need often manifests in drives from senior leadership or management to build QI capability in healthcare organisations, but it also requires that frontline staff and service users feel able to make use of these skills and take ownership of improvement work. 12

Using data to drive improvement— To drive decision making by measuring the impact of tests of change over time and understanding variation in processes and outcomes. Measurement for improvement typically prioritises this narrative approach over concerns around exactness and completeness of data. 13 14

Scale-up and spread, with adaptation to context— As interventions tested using a QI approach are scaled up and the degree of belief in their efficacy increases, it is desirable that they spread outward and be adopted by others. Key to successful diffusion of improvement is the adaption of interventions to new environments, patient and staff groups, available resources, and even personal preferences of healthcare providers in surrounding areas, again using an iterative testing approach. 15 16

What other approaches to improving healthcare are there?

Taking considered action to change healthcare for the better is not new, but QI as a distinct approach to improving healthcare is a relatively recent development. There are many well established approaches to evaluating and making changes to healthcare services in use, and QI will only be adopted more widely if it offers a new perspective or an advantage over other approaches in certain situations.

A non-systematic literature scan identified the following other approaches for making change in healthcare: research, clinical audit, service evaluation, and clinical transformation. We also identified innovation as an important catalyst for change, but we did not consider it an approach to evaluating and changing healthcare services so much as a catch-all term for describing the development and introduction of new ideas into the system. A summary of the different approaches and their definition is shown in box 3 . Many have elements in common with QI, but there are important difference in both intent and application. To be useful to clinicians and managers, QI must find a role within healthcare that complements research, audit, service evaluation, and clinical transformation while retaining the core principles that differentiate it from these approaches.

Alternatives to QI

Research— The attempt to derive generalisable new knowledge by addressing clearly defined questions with systematic and rigorous methods. 17

Clinical audit— A way to find out if healthcare is being provided in line with standards and to let care providers and patients know where their service is doing well, and where there could be improvements. 18

Service evaluation— A process of investigating the effectiveness or efficiency of a service with the purpose of generating information for local decision making about the service. 19

Clinical transformation— An umbrella term for more radical approaches to change; a deliberate, planned process to make dramatic and irreversible changes to how care is delivered. 20

Innovation— To develop and deliver new or improved health policies, systems, products and technologies, and services and delivery methods that improve people’s health. Health innovation responds to unmet needs by employing new ways of thinking and working. 21

Why do we need to make this distinction for QI to succeed?

Improvement in healthcare is 20% technical and 80% human. 22 Essential to that 80% is clear communication, clarity of approach, and a common language. Without this shared understanding of QI as a distinct approach to change, QI work risks straying from the core principles outlined above, making it less likely to succeed. If practitioners cannot communicate clearly with their colleagues about the key principles and differences of a QI approach, there will be mismatched expectations about what QI is and how it is used, lowering the chance that QI work will be effective in improving outcomes for patients. 23

There is also a risk that the language of QI is adopted to describe change efforts regardless of their fidelity to a QI approach, either due to a lack of understanding of QI or a lack of intention to carry it out consistently. 9 Poor fidelity to the core principles of QI reduces its effectiveness and makes its desired outcome less likely, leading to wasted effort by participants and decreasing its credibility. 2 8 24 This in turn further widens the gap between advocates of QI and those inclined to scepticism, and may lead to missed opportunities to use QI more widely, consequently leading to variation in the quality of patient care.

Without articulating the differences between QI and other approaches, there is a risk of not being able to identify where a QI approach can best add value. Conversely, we might be tempted to see QI as a “silver bullet” for every healthcare challenge when a different approach may be more effective. In reality it is not clear that QI will be fit for purpose in tackling all of the wicked problems of healthcare delivery and we must be able to identify the right tool for the job in each situation. 25 Finally, while different approaches will be better suited to different types of challenge, not having a clear understanding of how approaches differ and complement each other may mean missed opportunities for multi-pronged approaches to improving care.

What is the relationship between QI and other approaches such as audit?

Academic journals, healthcare providers, and “arms-length bodies” have made various attempts to distinguish between the different approaches to improving healthcare. 19 26 27 28 However, most comparisons do not include QI or compare QI to only one or two of the other approaches. 7 29 30 31 To make it easier for people to use QI approaches effectively and appropriately, we summarise the similarities, differences, and crossover between QI and other approaches to tackling healthcare challenges ( fig 1 ).

How quality improvement interacts with other approaches to improving healthcare

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QI and research

Research aims to generate new generalisable knowledge, while QI typically involves a combination of generating new knowledge or implementing existing knowledge within a specific setting. 32 Unlike research, including pragmatic research designed to test effectiveness of interventions in real life, QI does not aim to provide generalisable knowledge. In common with QI, research requires a consistent methodology. This method is typically used, however, to prove or disprove a fixed hypothesis rather than the adaptive hypotheses developed through the iterative testing of ideas typical of QI. Both research and QI are interested in the environment where work is conducted, though with different intentions: research aims to eliminate or at least reduce the impact of many variables to create generalisable knowledge, whereas QI seeks to understand what works best in a given context. The rigour of data collection and analysis required for research is much higher; in QI a criterion of “good enough” is often applied.

Relationship with QI

Though the goal of clinical research is to develop new knowledge that will lead to changes in practice, much has been written on the lag time between publication of research evidence and system-wide adoption, leading to delays in patients benefitting from new treatments or interventions. 33 QI offers a way to iteratively test the conditions required to adapt published research findings to the local context of individual healthcare providers, generating new knowledge in the process. Areas with little existing knowledge requiring further research may be identified during improvement activities, which in turn can form research questions for further study. QI and research also intersect in the field of improvement science, the academic study of QI methods which seeks to ensure QI is carried out as effectively as possible. 34

Scenario: QI for translational research

Newly published research shows that a particular physiotherapy intervention is more clinically effective when delivered in short, twice-daily bursts rather than longer, less frequent sessions. A team of hospital physiotherapists wish to implement the change but are unclear how they will manage the shift in workload and how they should introduce this potentially disruptive change to staff and to patients.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this article?

Adopting a QI approach, the team realise that, although the change they want to make is already determined, the way in which it is introduced and adapted to their wards is for them to decide. They take time to explain the benefits of the change to colleagues and their current patients, and ask patients how they would best like to receive their extra physiotherapy sessions.

The change is planned and tested for two weeks with one physiotherapist working with a small number of patients. Data are collected each day, including reasons why sessions were missed or refused. The team review the data each day and make iterative changes to the physiotherapist’s schedule, and to the times of day the sessions are offered to patients. Once an improvement is seen, this new way of working is scaled up to all of the patients on the ward.

The findings of the work are fed into a service evaluation of physiotherapy provision across the hospital, which uses the findings of the QI work to make recommendations about how physiotherapy provision should be structured in the future. People feel more positive about the change because they know colleagues who have already made it work in practice.

QI and clinical audit

Clinical audit is closely related to QI: it is often used with the intention of iteratively improving the standard of healthcare, albeit in relation to a pre-determined standard of best practice. 35 When used iteratively, interspersed with improvement action, the clinical audit cycle adheres to many of the principles of QI. However, in practice clinical audit is often used by healthcare organisations as an assurance function, making it less likely to be carried out with a focus on empowering staff and service users to make changes to practice. 36 Furthermore, academic reviews of audit programmes have shown audit to be an ineffective approach to improving quality due to a focus on data collection and analysis without a well developed approach to the action section of the audit cycle. 37 Clinical audits, such as the National Clinical Audit Programme in the UK (NCAPOP), often focus on the management of specific clinical conditions. QI can focus on any part of service delivery and can take a more cross-cutting view which may identify issues and solutions that benefit multiple patient groups and pathways. 30

Audit is often the first step in a QI process and is used to identify improvement opportunities, particularly where compliance with known standards for high quality patient care needs to be improved. Audit can be used to establish a baseline and to analyse the impact of tests of change against the baseline. Also, once an improvement project is under way, audit may form part of rapid cycle evaluation, during the iterative testing phase, to understand the impact of the idea being tested. Regular clinical audit may be a useful assurance tool to help track whether improvements have been sustained over time.

Scenario: Audit and QI

A foundation year 2 (FY2) doctor is asked to complete an audit of a pre-surgical pathway by looking retrospectively through patient documentation. She concludes that adherence to best practice is mixed and recommends: “Remind the team of the importance of being thorough in this respect and re-audit in 6 months.” The results are presented at an audit meeting, but a re-audit a year later by a new FY2 doctor shows similar results.

Before continuing reading think about your own practice— How would you approach this situation, and how would you use the QI principles described in this paper?

Contrast the above with a team-led, rapid cycle audit in which everyone contributes to collecting and reviewing data from the previous week, discussed at a regular team meeting. Though surgical patients are often transient, their experience of care and ideas for improvement are captured during discharge conversations. The team identify and test several iterative changes to care processes. They document and test these changes between audits, leading to sustainable change. Some of the surgeons involved work across multiple hospitals, and spread some of the improvements, with the audit tool, as they go.

QI and service evaluation

In practice, service evaluation is not subject to the same rigorous definition or governance as research or clinical audit, meaning that there are inconsistencies in the methodology for carrying it out. While the primary intent for QI is to make change that will drive improvement, the primary intent for evaluation is to assess the performance of current patient care. 38 Service evaluation may be carried out proactively to assess a service against its stated aims or to review the quality of patient care, or may be commissioned in response to serious patient harm or red flags about service performance. The purpose of service evaluation is to help local decision makers determine whether a service is fit for purpose and, if necessary, identify areas for improvement.

Service evaluation may be used to initiate QI activity by identifying opportunities for change that would benefit from a QI approach. It may also evaluate the impact of changes made using QI, either during the work or after completion to assess sustainability of improvements made. Though likely planned as separate activities, service evaluation and QI may overlap and inform each other as they both develop. Service evaluation may also make a judgment about a service’s readiness for change and identify any barriers to, or prerequisites for, carrying out QI.

QI and clinical transformation

Clinical transformation involves radical, dramatic, and irreversible change—the sort of change that cannot be achieved through continuous improvement alone. As with service evaluation, there is no consensus on what clinical transformation entails, and it may be best thought of as an umbrella term for the large scale reform or redesign of clinical services and the non-clinical services that support them. 20 39 While it is possible to carry out transformation activity that uses elements of QI approach, such as effective engagement of the staff and patients involved, QI which rests on iterative test of change cannot have a transformational approach—that is, one-off, irreversible change.

There is opportunity to use QI to identify and test ideas before full scale clinical transformation is implemented. This has the benefit of engaging staff and patients in the clinical transformation process and increasing the degree of belief that clinical transformation will be effective or beneficial. Transformation activity, once completed, could be followed up with QI activity to drive continuous improvement of the new process or allow adaption of new ways of working. As interventions made using QI are scaled up and spread, the line between QI and transformation may seem to blur. The shift from QI to transformation occurs when the intention of the work shifts away from continuous testing and adaptation into the wholesale implementation of an agreed solution.

Scenario: QI and clinical transformation

An NHS trust’s human resources (HR) team is struggling to manage its junior doctor placements, rotas, and on-call duties, which is causing tension and has led to concern about medical cover and patient safety out of hours. A neighbouring trust has launched a smartphone app that supports clinicians and HR colleagues to manage these processes with the great success.

This problem feels ripe for a transformation approach—to launch the app across the trust, confident that it will solve the trust’s problems.

Before continuing reading think about your own organisation— What do you think will happen, and how would you use the QI principles described in this article for this situation?

Outcome without QI

Unfortunately, the HR team haven’t taken the time to understand the underlying problems with their current system, which revolve around poor communication and clarity from the HR team, based on not knowing who to contact and being unable to answer questions. HR assume that because the app has been a success elsewhere, it will work here as well.

People get excited about the new app and the benefits it will bring, but no consideration is given to the processes and relationships that need to be in place to make it work. The app is launched with a high profile campaign and adoption is high, but the same issues continue. The HR team are confused as to why things didn’t work.

Outcome with QI

Although the app has worked elsewhere, rolling it out without adapting it to local context is a risk – one which application of QI principles can mitigate.

HR pilot the app in a volunteer specialty after spending time speaking to clinicians to better understand their needs. They carry out several tests of change, ironing out issues with the process as they go, using issues logged and clinician feedback as a source of data. When they are confident the app works for them, they expand out to a directorate, a division, and finally the transformational step of an organisation-wide rollout can be taken.

Education into practice

Next time when faced with what looks like a quality improvement (QI) opportunity, consider asking:

How do you know that QI is the best approach to this situation? What else might be appropriate?

Have you considered how to ensure you implement QI according to the principles described above?

Is there opportunity to use other approaches in tandem with QI for a more effective result?

How patients were involved in the creation of this article

This article was conceived and developed in response to conversations with clinicians and patients working together on co-produced quality improvement and research projects in a large UK hospital. The first iteration of the article was reviewed by an expert patient, and, in response to their feedback, we have sought to make clearer the link between understanding the issues raised and better patient care.

Contributors: This work was initially conceived by AB. AB and FO were responsible for the research and drafting of the article. AB is the guarantor of the article.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: This article is part of a series commissioned by The BMJ based on ideas generated by a joint editorial group with members from the Health Foundation and The BMJ , including a patient/carer. The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees and The BMJ ’s quality improvement editor post are funded by the Health Foundation.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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Safety and Quality Improvement

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Second year student nurse, Saima

Practice learning experience scenario in a general hospital setting – Ward A

• First year student nurse, Emma
• Third year student nurse, Darren

This scenario focuses on the learning that Saima undertook while on a shift during her third week of a ten-week practice learning experience on Ward A which is a surgical ward.

Saima is starting to feel a little more confident on the ward after being there for nearly three weeks

Her key objectives during this placement are: to develop her knowledge and skills around person-centred patient assessment, medicines optimisation and administration and safeguarding in the acute hospital setting. Her previous practice learning environments included a care home, a medical ward and a health centre.

Saima also wants to develop patient management skills. She’s currently being supervised to manage the care of two patients during her shift, and her practice assessor has set her an objective of leading the care of four patients in a bay by the end of this placement.

Saima is joined on this shift by:

• Emma: a first-year student nurse
• Darren: a third-year student nurse (who will be co-ordinating the bay and will be Saima’s practice supervisor under the supervision of Grace)
• Colin: a Health Care Assistant (HCA), also allocated to support the care of people in the bay
• Grace: the RN who is the practice supervisor to Darren, Emma and Saima

Saima also has a named practice assessor who is different to her practice supervisor and she is working in another bay on this shift.

Planning for her shift

Saima is familiar with the patients as she was supporting their care the day before. Under the supervision of Grace, Darren asked what her learning objectives were for this practice experience so that he could appropriately delegate the care of the patients. As Saima had cared for Annie and Elouise the day before and to ensure continuity of care the same patient allocation was agreed.

Saima's patients

• Female aged 93 and normally lives in a residential care home; her son and daughter-in-law live locally.
• Admitted with pyrexia, coughing, trouble swallowing, and shortness of breath, confusion, loss of appetite, weight loss, rapid heartbeat, and bluish skin around her mouth and finger tips, and sputum that is pink. She has an initial diagnosis of aspiration pneumonia.
• Various tests and investigations have been requested and carried out including blood tests, sputum culture, urine sample and a chest x-ray.
• Intravenous (IV) fluids, IV antibiotics, oxygen therapy and steroids have been prescribed and have been administered over the last 24 hours.
• Annie is mildly confused.
• There were no medical beds available on admission and she may be moved later in the day.
• Female aged 19 years.
• Elouise has a two-year-old daughter (Riley) who she’s very concerned about as the last few months have been disruptive. Elouise lives with Riley in bed and breakfast (B&B) accommodation awaiting local authority housing. She moved to the B&B from a woman’s refuge having recently left an abusive relationship. Riley is currently being looked after by a trusted friend as Elouise is currently estranged from her family.
• She had an appendectomy performed two days ago where an abscess was found, now she has an elevated temperature of 38ºC and her wound is looking inflamed. IV antibiotics have been prescribed and administered over the last 48 hours.

Learning objectives and priorities for Saima

Saima identified her learning objectives with Darren and Grace and gave an outline plan of care that would meet both Annie and Elouise’s needs. She struggled to provide a detailed level of understanding of their admissions, the physical, mental and social aspects of their health and care in terms of their current pathophysiology. Grace recommended to Darren that Saima should consider these areas during her shift and feedback later in the day. Saima was keen to learn more about medicines optimisation and administration. Darren suggested that post-operative medicines including analgesia, IV fluids and antibiotics should be the area she focuses on and their impact on Elouise following surgery.

After receiving a handover from the night staff, Saima outlined her priorities and planned to start by introducing herself to Annie and Elouise. She wanted to make sure she understood what their needs were, their plan of care, that they were comfortable and to familiarise herself with their physiological observations and medication charts, and ensure she was aware of when these were next due.

Saima recognised the need to actively listen to and find out what was important to them. She acknowledged that although they have different needs, they both required sensitivity in her approach. She planned to assess Elouise first as she was still recovering from surgery. Saima established that Annie would require more time and assistance in her care.

Moving and handing, patient safety and safeguarding are part of Saima’s learning objectives for this experience. Darren recommended that she reads the relevant local policies and then discusses how these apply to Annie and Elouise. Saima and Colin were working together as Annie’s moving and handling assessment indicated that two people are needed for moving her from the bed to a chair. Saima was also able to delegate some aspects of Annie and Elouise’s care to Colin, for example, administering and documentation of oral fluids.

Putting the proficiencies into practice

The Standards of proficiency for registered nurses state the knowledge, skills and behaviours that every nurse must have by the end of their programme and to join the register.

The standards are set out in seven sections called 'platforms'.

In addition, there are two annexes to the platforms that list the communication and relationship management skills nurses must have, and the nursing procedures they must be able to do when they join our register.

Through some examples see how Saima was able to demonstrate certain learning outcomes of these proficiencies through this practice experience.

What Saima did

Saima re-introduced herself to Annie and Elouise and made sure she was familiar with their needs and agreed care plans.

She recognised that Annie required a considerable amount of assistance. Annie had referrals to the speech and language therapist and to the hospital social worker and Saima needed to follow these up and find out more about the next steps. Saima took guidance and support from Darren acting as co-ordinator and Grace overseeing his supervision regarding how to do this.

Seeing that Annie was becoming more distressed and confused, Saima considered the potential reasons for this, drawing on her knowledge and experiences. She provided support and time for Annie by speaking calmly, using simple language and spent time asking open questions and actively listened to her concerns and needs.

Saima knew that she normally lives in a residential care home, and noted that her overall nursing care needs seemed significant. Saima wanted to know if Annie had been confused for some time or if this was linked to her aspiration pneumonia diagnosis. Saima spoke to the nurse at the care home and it became clear that Annie had progressively become more disorientated and confused in recent days. Saima decided to speak to her practice supervisor about this.

During the multidisciplinary round and review Saima felt she now knew Annie and Elouise and the care that they required well enough to participate. She had not felt confident to do this before.

Saima discussed Elouise with Darren, including the relevant anatomy and physiology that led to her condition. This supported Darren’s confidence that Saima understood the surgery that Elouise had received. Darren and Saima discussed what an abscess is, and the best practice evidence to support wound care and healing. Saima was able to explain and reassure Elouise about the wound abscess when she became distressed that the dressing was soiled with exudate and what the plan of care would be.

Annie required regular IV medication and Saima ensured that she was aware of when these were next due and observed the preparation and administration of these medicines. Both Annie and Elouise had IV fluids administered and Saima made sure that this was clearly documented on their respective fluid balance charts.

Saima took some time with her supervisor to discuss the shift and her reflections on her own learning objectives in relation to the care delivered to both Annie and Elouise.

What this demonstrated

Saima demonstrated the need to base all decisions about person centred care and interventions on people’s needs and preferences. Through her focused communication Saima was able to manage and maintain appropriate therapeutic relationships with both Annie and Elouise. Saima demonstrated the ability to keep clear and accurate documentation. She drew on her knowledge and experiences to contribute effectively to the multidisciplinary team discussions.

Saima noticed that Elouise was feeling unwell and Saima assessed and checked her vital signs, which showed she had an elevated temperature of 38ºC. Saima spoke to her supervisor and the doctor who both reviewed her wound. Saima was asked to take a wound swab, something she had not done before but was able to do so using an aseptic technique with Grace’s guidance and supervision.

Saima noted that both Annie and Elouise were receiving antibiotics. She spent some time reading the hospital’s antimicrobial guidance and reflected on the use of antibiotics for acute medical conditions for Annie and as part of the post-surgical plan of care for Elouise. She discussed with Darren the role of the registered nurse in antimicrobial stewardship and had a conversation with the ward pharmacist about the review date for these medicines.

Saima observed correct infection control measures that applied to both patients including appropriate use of personal protective equipment (PPE), asepsis and correct waste disposal.

Saima recognised the need to protect health through principles of infection prevention for patients and staff.

This included her responsibility to wear the appropriate PPE to create a barrier between herself and any infectious agents. She was also aware of the underlying principles of managing healthcare waste and understood the wider consideration of antibiotic resistance in relation to public health.

Saima used a range of approaches to re-assess the care of both Annie and Elouise, including their history, mental, cognitive and physical health needs assessment, measuring vital signs and recognising the need for timely and planned interventions and care.

While listening to Elouise, who said that she was scared of her former partner and was worried about her daughter, Saima noticed burn marks on her forearms.

When talking with Elouise and helping her wash, Saima noted further burn marks elsewhere on her skin and sensitively asked what the marks were and how she got them. Elouise was reluctant to respond to Saima and changed the subject.

Saima decided to discuss her concerns with her Darren who also had a conversation with Elouise. They both felt the safeguarding team needed to be made aware and discussed this with Elouise who agreed but was visibly scared. Time was given to Elouise to express her fears. Darren then supported Saima and contacted the safeguarding team for advice and the next steps.

Saima was commended by her supervisor on how she was able to look beyond her patients’ initial reason for admission and start to put together the information gathered to provide person-centred care.

Saima had limited knowledge about safeguarding issues but knew who to speak to and escalate her concerns to. She recognised that Elouise has wider care needs including safeguarding and had multiple social issues to consider. These care needs were planned respectfully, taking any ethical considerations into account when supporting Elouise to voice what her health, social and wellbeing needs, and preferences were.

Throughout her shift, Saima demonstrated many elements of the proficiencies within this platform and particularly the ability to use knowledge and skills to evaluate the care of people and apply her knowledge of anxiety, confusion, discomfort and pain.

Saima also discussed with Darren the diagnostic tests that had been requested and actions taken around the use of steroids and the selection of IV antibiotics that can be prescribed for people with aspiration pneumonia. Saima provided a good level of understanding of the affect steroids would have on Annie’s breathing/condition and was able to present possible reasons for her current confusion.

Furthermore, she was able to emphasise the need to continue to monitor Annie’s cognitive and mental state to be able to evaluate whether the prescribed medication was being effective or whether further investigations and treatment were needed.

Saima showed some understanding of aspiration pneumonia pathophysiology and a clear understanding of applying a person-centred approach to nursing care.

She also demonstrated the ability to process information for evidence-based care. Saima also wanted to understand the reaction of the body’s systems when such aspiration happens, to enable her to provide better support and person-centred care.

Saima lead the care of Annie and Elouise throughout the day, including undertaking regular physiological observations and administering medication at the appropriate times.

With the support of Darren and Grace, Saima felt empowered to prioritise and deliver the care they both needed. She worked within her limitations by asking for support and advice to ensure their safety at all times. She also confidently delegated some aspects of patient care to Colin.

With the support of Darren and Grace Saima coordinated their care throughout the shift. She showed an understanding of the importance of team working and collaborative and inclusive decision making.

Saima was required to undertake a series of routine risk assessments, such as skin integrity assessments, nutrition, hydration, moving and handling.

Once completed Saima discussed the outcome of those assessments and planned interventions. In particular, Saima noted that Annie was at risk of developing pressure ulcers. Saima followed the local policies aimed at preventing the development of pressure ulcers, explained to Annie what needed to happen and arranged for the appropriate pressure relieving mattress to be delivered without delay.

In addition, Saima escalated her concerns around Elouise’s social situation promptly acting on what she’d observed and what was disclosed to her.

Saima demonstrated an understanding of managing and reporting emerging risks. She recognised Annie’s risk of developing pressure ulcers, and the need to avoid this from happening and that a safeguarding concern surrounding Elouise’s and her daughter’s safety needed wider agency collaboration. Saima knew how to plan, escalate and respond to different concerns in a timely way.

Saima correctly used available patient data and had the confidence to communicate the reasoning behind her actions and decisions and was able to identify the potential next steps.

Neither Annie nor Elouise were ready for discharge. Saima was aware of this, however, she did identify the importance of early preparation and planning for discharge.

Saima built a good rapport, actively listened to both and made sure that they felt comfortable with her and trusted her. She engaged with other members of the multidisciplinary team and gained important information about both patients.

Saima spent time prioritising the care required and was able to safely delegate tasks to Colin the HCA.

Saima co-ordinated the person-centred care provided for each. She demonstrated an understanding of mental, cognitive, behavioural, social and physical care needs.

Both patients had different complex needs. Saima showed that she had an understanding of their individual needs and also knew when and how to escalate her concerns.

Saima showed that she had an understanding of the principles and processes involved in facilitating safe discharges. She contacted the wider agency teams that needed to be involved with their support and care and gained essential information relevant to planning their discharge.

Test your understanding

Questions to prompt reflection and discussion

In order for Saima to achieve her objectives in relation to medicines optimisation and understanding of the law around safeguarding identify two proficiencies that Saima still needs to learn and apply and what learning opportunities would you consider might be available for her in your practice area to achieve this?

Examples could be:

Platform Four

4.15 demonstrate knowledge of pharmacology and the ability to recognise the effects of medicines, allergies, drug sensitivities, side effects, contraindications, incompatibilities, adverse reactions, prescribing errors and the impact of polypharmacy and over the counter medication usage.

Learning opportunities /objectives to meet the requirements of this proficiency:

• Medication rounds: Saima should be involved in the administration of medicines for the patients in her care with the objective of leading on the safe administration of medicine for these patients.
• Ward Pharmacist: Saima could spend time with the ward pharmacist with the objective of understanding their role, specifically with reference to how medication reviews are carried out.

In addition, Saima could work towards the following related Annexe A & B skills and procedures:

• Annexe A: 1. Underpinning communication skills for assessing, planning, providing and managing best practice, evidence-based nursing care.
• Annexe B: 11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation.

3.8 understand and apply the relevant laws about mental capacity for the country in which you are practising when making decisions in relation to people who do not have capacity.

Saima will meet other people like Annie who may temporarily or permanently lack mental capacity to make decisions for themselves. She should observe and then participate in how to involve people generally and the decision-making process for someone who lacks capacity for a particular situation or care decision.

In addition, Saima could work towards the following related Annexe B skills and procedures:

• Annexe B: 1.1.2 Cognitive health status and wellbeing.

Revalidation

If you are a registered nurse you may wish to use this scenario and your reading as part of your continuing professional development (CPD) for your revalidation.

• Last updated: 06/12/2022

Looking Ahead: New Opportunities for Improving Sepsis Care and Outcomes

While our work and commitment to addressing sepsis span the entire year, Sepsis Awareness Month is when CDC and its partners put a figurative exclamation point on our sepsis activities and honor the patients and families impacted by this medical emergency and public health threat. For this Sepsis Awareness Month, CDC is highlighting what we have learned thus far about hospital sepsis programs and the opportunities for us to work together to improve processes and patient outcomes through these programs.

In August 2023, CDC released the Hospital Sepsis Program Core Elements (Sepsis Core Elements) to provide a framework for hospitals to improve sepsis outcomes. The Sepsis Core Elements aid in the fast recognition of sepsis, facilitate the implementation of evidence-based management of sepsis and support the recovery of patients after sepsis.

Additionally, CDC included several questions in the National Healthcare Safety Network (NHSN) 2023 Annual Survey [PDF – 34 pages] to understand the current state of sepsis programs. That information will help us understand how the Sepsis Core Elements are working in U.S. hospitals, and where we should focus our efforts to drive better sepsis care.

The NHSN Annual Survey data* show that the number of U.S. hospitals with sepsis programs and resources to support them has modestly increased. Compared to 2022, 78% of hospitals reported having sepsis committees (up from 73%) in 2023 ; 59% of hospitals reported providing dedicated time for sepsis program leaders (up from 55%) ; and 66% of hospitals reported their sepsis committees involved Antibiotic Stewardship Programs (up from 55%).

The NHSN data also highlighted opportunities to improve hospital sepsis programs, including providing more support for patients recovering from sepsis and enhancing sepsis awareness for some groups of healthcare workers, such as certified nursing assistants and patient care technicians. These essential healthcare workers have a lot of face-to-face time with patients and can help in hospitals’ efforts to make sure the signs and symptoms of sepsis are identified as early as possible. Finally, most hospitals have tools and standardized approaches for diagnosing and treating sepsis, but not all track how helpful or acceptable these tools are for their staff, so they may be underused.

While the data represent facility practices over a relatively short period, it’s encouraging to see the progress being reported. CDC is dedicated to working with facilities to keep the momentum moving forward.

In fiscal year 2024, CDC received funds from Congress designated specifically for sepsis activities. Subsequently, CDC has invested in expanded sepsis data collection through NHSN, including implementation of the Sepsis Core Elements. This will further our ability to assess and improve processes in place to care for patients with sepsis and measure progress in improving patient outcomes. This year, CDC is also expanding its suite of materials to reach communities and schools with information about sepsis in children .

Sepsis care is complex; improving how we detect and care for patients with sepsis requires all of us to work together to raise awareness, understand where opportunities for improvement exist, and engage with patients who have been affected by sepsis, like Katy Grainger , the families who have lost their loved ones, Erin Flatley ,   Clover Harrold , Rory Staunton , and others; together, we can stop sepsis from impacting more families.  We are honored to continue to work alongside our many passionate and dedicated partners.

Learn more about the Hospital Sepsis Program Core Elements and CDC’s national educational effort, Get Ahead of Sepsis .

  *The NHSN Annual Survey data include input from 5,254 U.S. acute care hospitals from January to June 2024 representing 2023 practices.

Mike Bell, MD Division Director, Division of Healthcare Quality Promotion

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The Role of Technology in Modern In-Home Senior Care

As the population ages, the demand for quality in-home senior care continues to rise. Fortunately, technological advancements are transforming the way we care for our elderly loved ones, making it easier, safer, and more efficient. From telehealth services to wearable health monitors and smart home devices, technology is revolutionizing in-home senior care, offering numerous benefits that enhance safety, communication, and health monitoring.

Technological Advancements in Senior Care

One of the most significant advancements in senior care is the rise of telehealth services. Telehealth allows seniors to access healthcare professionals without the need to travel, which can be especially beneficial for those with mobility issues. Virtual doctor visits and remote consultations ensure that seniors receive timely medical attention, reducing the risk of complications from delayed care. This convenience not only saves time but also minimizes the stress and physical strain associated with frequent trips to the doctor.

Telehealth Services : 

Telehealth is a broad term encompassing various digital healthcare services provided remotely through telecommunications technology. It includes virtual doctor visits, remote patient monitoring, and teletherapy, among other services. Virtual doctor visits allow seniors to consult with healthcare providers from the comfort of their homes, using video conferencing tools. These consultations can cover routine check-ups, medication management, and follow-up appointments, making healthcare more accessible and less intimidating for seniors. Remote patient monitoring uses devices that collect and transmit health data (such as blood pressure, glucose levels, and weight) to healthcare providers, enabling continuous monitoring and timely interventions. Teletherapy, including mental health counseling and physical therapy, provides essential support for seniors' mental and physical well-being.

Wearable Health Monitors : 

Wearable health monitors are compact devices that seniors can wear to continuously track various health metrics. These devices, such as smartwatches and fitness trackers, come equipped with sensors that monitor vital signs like heart rate, blood pressure, and oxygen levels. Some advanced wearables also include fall detection sensors, which can automatically alert caregivers or emergency services if a fall is detected. These devices are designed to be user-friendly, often featuring large, easy-to-read displays and simple interfaces. For instance, a senior wearing a smartwatch can receive reminders to take medication, track their daily physical activity, and get notifications about irregular heart rates. This continuous health monitoring allows for early detection of potential health issues, enabling timely medical interventions that can prevent complications.

Smart Home Devices : 

Smart home technology encompasses a range of devices that automate and enhance various aspects of home living. Voice assistants like Amazon Alexa and Google Home can help seniors with daily tasks through voice commands. These devices can set reminders, control smart appliances, and even call for help during emergencies. Smart thermostats automatically adjust home temperatures to maintain comfort, while smart lighting systems can be programmed to turn on and off at specific times or in response to motion. These technologies not only make daily living more convenient but also significantly enhance safety. For example, smart home security systems equipped with cameras, motion detectors, and door/window sensors can alert caregivers to unusual activity, ensuring seniors are safe at home.

Medication Management Apps : 

Managing multiple medications can be challenging for seniors, leading to missed doses or medication errors. Medication management apps offer a solution by providing reminders for each dose, tracking medication adherence, and even offering information about potential side effects and drug interactions. These apps can be synced with other devices, such as smart pill dispensers, to automate the dispensing process, ensuring seniors take the right medication at the right time.

Robotic Assistants : 

Emerging technologies like robotic assistants are also making their way into in-home senior care. These robots can perform various tasks, from reminding seniors to take their medication to assisting with mobility and daily activities. Some advanced models can even monitor a senior’s vital signs and provide companionship, reducing feelings of loneliness and isolation.

The integration of these technologies in senior care represents a significant step forward, offering enhanced safety, improved communication, and better health monitoring. By leveraging these advancements, caregivers can provide more comprehensive and efficient care, ensuring that seniors maintain their independence and quality of life.

Benefits of Technology in Enhancing Senior Care

The integration of technology in senior care offers several benefits, particularly in terms of safety, communication, and health monitoring.

Safety and Emergency Response : 

One of the most significant benefits of technology in senior care is the enhancement of safety and emergency response. Wearable devices equipped with fall detection sensors can automatically alert caregivers or emergency services if a fall is detected. This immediate response can be life-saving, ensuring that help arrives promptly and reducing the risk of serious injury. Additionally, smart home security systems, including cameras and motion sensors, can monitor the home environment and alert caregivers to unusual activity, such as a door being left open or a stove being left on, further enhancing the safety of seniors living alone.

Improved Communication : 

Technology has revolutionized the way seniors communicate with their loved ones and caregivers. Video calling platforms, such as Skype, Zoom, and FaceTime, enable seniors to stay connected with family members, reducing feelings of isolation and loneliness. These platforms are especially beneficial for seniors with limited mobility or those living far from their families. Moreover, messaging apps and social media provide additional avenues for seniors to engage with others, participate in online communities, and maintain social interactions, which are crucial for mental and emotional health.

Health Monitoring and Management : 

Continuous health monitoring devices collect data on vital signs and physical activity, allowing for proactive healthcare management. Wearable health monitors, such as smartwatches, can track heart rate, blood pressure, and oxygen levels, providing real-time data that can be shared with healthcare providers. This continuous monitoring allows for the early detection of potential health issues, enabling timely medical interventions that can prevent complications. For instance, if a wearable device detects an irregular heartbeat, it can alert both the senior and their healthcare provider, prompting a medical consultation before the condition worsens.

Medication Management : 

Managing multiple medications can be challenging for seniors, leading to missed doses or medication errors. Technology provides solutions through medication management apps and smart pill dispensers. These tools can remind seniors to take their medication at the prescribed times, track their adherence, and provide information about potential side effects and drug interactions. Smart pill dispensers can automate the dispensing process, ensuring that seniors take the correct medication in the right dosage, further reducing the risk of medication-related issues.

Enhanced Quality of Life : 

Overall, the integration of technology in senior care significantly enhances the quality of life for seniors. By providing tools that improve safety, communication, and health monitoring, technology helps seniors maintain their independence and dignity while receiving the care they need. This independence is critical for seniors' mental and emotional well-being, as it allows them to continue living in their homes and communities, surrounded by familiar environments and loved ones.

Peace of Mind for Caregivers : 

The benefits of technology extend beyond seniors to their caregivers as well. Continuous health monitoring, emergency alerts, and real-time communication tools provide caregivers with peace of mind, knowing that they can monitor their loved ones' well-being even from a distance. This reassurance allows caregivers to balance their responsibilities more effectively, reducing stress and improving their overall quality of life.

Cost-Effective Care : 

Integrating technology into senior care can also be cost-effective. Telehealth services and remote monitoring can reduce the need for frequent in-person doctor visits and hospitalizations, lowering healthcare costs. Additionally, smart home devices and wearables can help prevent accidents and health issues, potentially reducing the long-term costs associated with medical emergencies and chronic conditions.

Real-World Applications and Success Stories

Real-world applications of these technologies highlight their effectiveness in improving senior care. For instance, a senior living alone with a wearable device that monitors heart rate and detects falls can live independently with confidence, knowing that help is just a button press away. Caregivers have reported that such devices reduce their stress levels, as they can monitor their loved ones remotely and receive alerts if any issues arise.

One caregiver shared how a smart home security system helped her feel at ease while she was at work. The system included cameras and motion sensors that allowed her to check on her mother throughout the day. This peace of mind enabled her to balance her work and caregiving responsibilities more effectively.

Challenges and Considerations

Despite the many benefits, there are challenges and considerations when integrating technology into senior care. Accessibility and affordability are significant concerns, as not all seniors can afford these advanced devices and services. Efforts must be made to make technology more accessible to all seniors, regardless of their financial situation.

Learning and adaptation can also be hurdles for seniors unfamiliar with new technology. Caregivers and family members play a vital role in helping seniors adapt to using these devices. Providing clear instructions, demonstrating usage, and offering ongoing support can make the transition smoother.

Privacy and security are also critical considerations. With the increase in data collection and sharing, ensuring the privacy and security of personal information is paramount. Implementing best practices for data protection and educating seniors about the importance of cybersecurity can help mitigate these risks.

Technology is undeniably transforming the landscape of in-home senior care, offering tools and solutions that enhance safety, communication, and health monitoring. As we continue to embrace these advancements, the quality of life for seniors will undoubtedly improve, allowing them to live more independently and with greater peace of mind.

If you’re looking to integrate advanced technology into the care plan for your elderly loved ones, or if you need professional in-home caregivers who are adept at using these technologies, contact Home Instead of South Bend. Our team is dedicated to providing the highest quality care, ensuring your loved ones receive the support they need in the comfort of their own home. Reach out to us today to learn more about our services and how we can assist you.

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• Optimising antibacterial utilisation in Argentine intensive care units: a quality improvement collaborative
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• http://orcid.org/0000-0001-6887-9275 Facundo Jorro-Baron 1 , 2 ,
• http://orcid.org/0000-0002-1647-5110 Cecilia Inés Loudet 3 , 4 ,
• Wanda Cornistein 5 ,
• Inés Suarez-Anzorena 1 ,
• Pilar Arias-Lopez 4 ,
• Carina Balasini 6 ,
• Laura Cabana 7 ,
• Eleonora Cunto 8 ,
• Pablo Rodrigo Jorge Corral 9 ,
• Luz Gibbons 10 ,
• Marina Guglielmino 1 ,
• Gabriela Izzo 11 ,
• Marianela Lescano 1 ,
• Claudia Meregalli 4 ,
• Cristina Orlandi 4 , 12 ,
• Fernando Perre 13 ,
• Maria Elena Ratto 4 ,
• Mariano Rivet 14 ,
• Ana Paula Rodriguez 1 ,
• Viviana Monica Rodriguez 5 ,
• Jacqueline Vilca Becerra 3 ,
• Paula Romina Villegas 12 ,
• Emilse Vitar 10 ,
• Javier Roberti 10 ,
• Ezequiel García-Elorrio 1 ,
• COST Collaborative Group ,
• Viviana Rodriguez 1
• 1 Quality of Care , Instituto de Efectividad Clinica y Sanitaria , Buenos Aires , Argentina
• 2 PICU , Hospital General de Niños Pedro de Elizalde , Buenos Aires , Argentina
• 3 Hospital Interzonal General de Agudos General San Martín , La Plata , Argentina
• 4 Sociedad Argentina de Terapia Intensiva , Buenos Aires , Argentina
• 5 Sociedad Argentina de Infectología , Ciudad Autónoma de Buenos Aires , Argentina
• 6 Hospital General de Agudos Dr Ignacio Pirovano , Buenos Aires , Argentina
• 7 Intensive Care Unit , Hospital Pablo Soria , Jujuy , Argentina
• 8 Intensive Care Unit , Hospital de Infecciosas Dr Francisco Javier Muñiz , Buenos Aires , Argentina
• 9 Hospital Evita de Lanús , Buenos Aires , Argentina
• 10 Instituto de Efectividad Clinica y Sanitaria , Ciudad Autónoma de Buenos Aires , Argentina
• 11 Intensive Care Unit , Hospital Simplemente Evita , Buenos Aires , Argentina
• 12 Intensive Care Unit , Hospital Francisco López-Lima , Río Negro , Argentina
• 13 Intensive Care Unit , Hospital Provincial de Neuquén Dr Castro Rendón , Neuquen , Argentina
• 14 Hospital General de Agudos Bernardino Rivadavia , Buenos Aires , Argentina
• Correspondence to Dr Facundo Jorro-Baron; fjorro{at}iecs.org.ar

Background There is limited evidence from antimicrobial stewardship programmes in less-resourced settings. This study aimed to improve the quality of antibacterial prescriptions by mitigating overuse and promoting the use of narrow-spectrum agents in intensive care units (ICUs) in a middle-income country.

Methods We established a quality improvement collaborative (QIC) model involving nine Argentine ICUs over 11 months with a 16-week baseline period (BP) and a 32-week implementation period (IP). Our intervention package included audits and feedback on antibacterial use, facility-specific treatment guidelines, antibacterial timeouts, pharmacy-based interventions and education. The intervention was delivered in two learning sessions with three action periods along with coaching support and basic quality improvement training.

Results We included 912 patients, 357 in BP and 555 in IP. The latter had higher APACHE II (17 (95% CI: 12 to 21) vs 15 (95% CI: 11 to 20), p=0.036), SOFA scores (6 (95% CI: 4 to 9) vs 5 (95% CI: 3 to 8), p=0.006), renal failure (41.6% vs 33.1%, p=0.009), sepsis (36.1% vs 31.6%, p<0.001) and septic shock (40.0% vs 33.8%, p<0.001). The days of antibacterial therapy (DOT) were similar between the groups (change in the slope from BP to IP 28.1 (95% CI: −17.4 to 73.5), p=0.2405). There were no differences in the antibacterial defined daily dose (DDD) between the groups (change in the slope from BP to IP 43.9, (95% CI: −12.3 to 100.0), p=0.1413).

The rate of antibacterial de-escalation based on microbiological culture was higher during the IP (62.0% vs 45.3%, p<0.001).

The infection prevention control (IPC) assessment framework was increased in eight ICUs.

Conclusion Implementing an antimicrobial stewardship program in ICUs in a middle-income country via a QIC demonstrated success in improving antibacterial de-escalation based on microbiological culture results, but not on DOT or DDD. In addition, eight out of nine ICUs improved their IPC Assessment Framework Score.

• Quality improvement methodologies
• Antibiotic management
• Critical care
• Collaborative, breakthrough groups

Data availability statement

Data are available in a public, open access repository. https://osf.io/5v7xa/?view_only=111e421428c5463385190685e6fa1cca .

https://doi.org/10.1136/bmjqs-2024-017069

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Collaborators Collaborative Group COST: Natalí Ini, Juan Pedro Alonso, (Institute for Clinical Effectiveness and Health Policy -IECS- Buenos Aires, Argentina). Marisol García Sarubbio, Agustina Paglia, María Cecilia García, Silvia Laura Fernández, (HIGA San Martín de La Plata - Buenos Aires, Argentina). Olga Zulema Tejerina, Cristian Efrain Tejerina, Dalma Fabian, Aylén Gutierrez, Julián Vercellone, Susana Noemi Tejerina, (Hospital Pablo Soria - Jujuy, Argentina). Viviana Chediack, María Julieta Ochoa, Cintia Hernaiz, Cecilia Domínguez, (Hospital Muñiz - CABA, Argentina). Alicia Sirino, Cecilia del Valle Barrios, Ana Valeria Lugo, Flavia Nitto, Fernando Luna, (Hospital Pirovano – CABA, Argentina). Laura Valeria Aldana, María Fernanda Formiga Fresser, (Hospital Francisco López Lima - Río Negro, Argentina). Ainoa Echegoyen, Nelson Linares, (Hospital Castro Rendón – Neuquén, Argentina). Luciano Inowlocki Calejman, Mariana Casas Alvarez, Johnny Rodríguez Galán, Graciela Farfan, Luz Torrico García, (Hospital Rivadavia - CABA, Argentina). Eva Rodríguez Caicedo, Verónica Bortoli, Eliseo Velasquez Chambi, Vanesa Arce Villanueva, Eduardo Zamora Mendizabal, Gustavo Figueroa Ojeda, Ángeles Rodríguez Altamirano, Ytala Talamas Hurtado, (Hospital Simplemente Evita - Buenos Aires, Argentina). Carlos Gustavo Ruiz Pulgar, Edson Gozales Aguilar, Carla Daniela Bautista Numbela, Lilia Elisa Müller, Virginia Soledad Quiroga, (Hospital Evita de Lanús - Buenos Aires, Argentina).

Contributors FJ-B had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis, also is responsible for the overall content as guarantor. FJ-B conducted the study as data and implementation coordinator planned, reported and submitted the study for publication. CIL, WC and VR conducted the study as subject matter experts, planned and reported the study. JR conducted the formative research as coordinator, planned and reported the study. EG-E planned and reported the study. LG and EV conducted the study as data experts and reported the study. APR and MG conducted the study as data coordinators and reported the study. PA-L and MER conducted the study as data coordinators. IS-A, ML, CM and VMR conducted the study as coaching for improvement. CB, LC, EC, PRJC, GI, CO, FP, MR and PRV conducted the study as centre coordinators. Natalí Ini and Juan Pedro Alonso conducted the formative research as interviewers. People in the COST Collaborative group conducted the study as data collectors or facilitators of implementation.

Funding This study was funded by Pfizer Foundation (PFIZER COMPETITIVE GRANT PROGRAM ID: 68339261).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• v.6(2); Apr-Jun 2018

Health Information Technology in Healthcare Quality and Patient Safety: Literature Review

Sue s feldman.

1 Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, AL, United States

Scott Buchalter

2 Pulmonary and Critical Care, The University of Alabama at Birmingham Medical Center, Birmingham, AL, United States

Leslie W Hayes

3 Department of Pediatrics, The University of Alabama at Birmingham Medical Center, Birmingham, AL, United States

The area of healthcare quality and patient safety is starting to use health information technology to prevent reportable events, identify them before they become issues, and act on events that are thought to be unavoidable. As healthcare organizations begin to explore the use of health information technology in this realm, it is often unclear where fiscal and human efforts should be focused.

The purpose of this study was to provide a foundation for understanding where to focus health information technology fiscal and human resources as well as expectations for the use of health information technology in healthcare quality and patient safety.

A literature review was conducted to identify peer-reviewed publications reporting on the actual use of health information technology in healthcare quality and patient safety. Inductive thematic analysis with open coding was used to categorize a total of 41 studies. Three pre-set categories were used: prevention, identification, and action. Three additional categories were formed through coding: challenges, outcomes, and location.

This study identifies five main categories across seven study settings. A majority of the studies used health IT for identification and prevention of healthcare quality and patient safety issues. In this realm, alerts, clinical decision support, and customized health IT solutions were most often implemented. Implementation, interface design, and culture were most often noted as challenges.

Conclusions

This study provides valuable information as organizations determine where they stand to get the most “bang for their buck” relative to health IT for quality and patient safety. Knowing what implementations are being effectivity used by other organizations helps with fiscal and human resource planning as well as managing expectations relative to cost, scope, and outcomes. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture, and bridge knowledge with developers would be a valuable resource allocation to consider.

Introduction

It has long been known and accepted that healthcare in the US is too expensive and the outcomes are less than predictable [ 1 ]. The turn of the century brought with it a realization that healthcare, like other industries, could use data to increase our awareness of seemingly uncontrollable costs and unpredictable outcomes. With almost two decades of compiling, analyzing, mashing up data, and trying to make sense of how the data inform multiple layers of healthcare, it is time to look beyond the awareness that the data provide, and instead develop an understanding of how to use the data for predictable and actionable purposes, especially with regard to healthcare quality and patient safety. The literature is mixed on the degree to which health information technology (IT) as a valuable suite of tools, applications, and systems that have contributed to actual savings and efficiencies [ 1 - 4 ]. However, the area of healthcare quality and patient safety lends itself to many of the same business intelligence and predictability advantages that are seen in the credit card industry [ 5 - 7 ].

Much like the Triple Aim of Healthcare, the credit card industry is working toward decreased costs (fraud), increased quality (better transactions), and increased satisfaction (happier merchants and happier cardholders). The credit card industry began using business intelligence to predict behavior that suggested fraud, developed process maps for transaction processing, and offered perks to merchants and cardholders. Just as the credit card industry learned from healthcare, healthcare can borrow from the credit card industry to use healthcare intelligence for prevention, identification, and action related to healthcare quality and patient safety events.

The Institute for Healthcare Improvement (IHI) suggests that reliability around healthcare is a three-part cycle of failure prevention, failure identification, and process redesign and defines reliability as “failure-free operation over time.” [ 8 ]. Other areas of healthcare have used information systems to provide continuous monitoring with real-time, or near real-time reporting as a means of achieving reliability [ 9 ]. As such, it makes sense to think about the role of health IT in reliability as it relates to healthcare quality and patient safety. A review of the literature suggests that healthcare organizations are using health IT for healthcare quality and patient safety and that they have replaced redesign in Figure 1 with action as shown in Figure 2 [ 10 - 12 ]. Action, in this case, allows for health IT to be implemented after a potential healthcare quality or patient safety event has occurred and does not necessarily require a redesign. Ordering alerts in the electronic health record are an example of action; the event has occurred (the order has been entered) and health IT in the form of an alert is initiated to stop the potentially unsafe order from being filled by the pharmacy.

Improving the reliability of healthcare.

Improving the reliability of healthcare quality and patient safety.

Having an understanding of this cycle helps to create awareness around where various applications of health IT find their “best fit” in improving the reliability of healthcare quality and patient safety. A distinct advantage of this being a “cycle” is that there is no defined beginning and ending point, but rather an insertion point. This is all to say that the cycle should not be interpreted as starting with prevention and ending with action.

Health Information Technology for Prevention of Quality and Safety Events

Health IT for prevention of quality and safety events involves the use of health IT to prevent a quality and safety event from even happening . Automated reminders and alerts are useful in providing essential information that supports safe and effective clinical decisions [ 13 ]. Such alerts in the electronic health record (EHR) are a standard mechanism for the use of health IT for prevention of potential missed quality and patient safety events. For example, immunization alerts have led to a 12% increase in well-child and a 22% increase in sick child immunization administration [ 14 ] and drug alerts have been associated with a 22% decrease in medication prescription errors [ 15 ]. Soft-stops can provide key information about a potential quality or patient safety issue. They may offer choices but usually, require only that the user acknowledge the alert to proceed.

A hard-stop, on the other hand, prevents the user from moving forward with an order or intervention that would be potentially dangerous to a patient. Hard-stops may allow continuation of the process, but only if significant required action is taken by the user, such as a call to or consultation with an expert (such as a pharmacist or a medical specialist). In some cases, soft-stops might be ignored or overridden because of such issues as alert fatigue, poor implementation, or poor interface design [ 16 , 17 ]. Hard-stops, when appropriately designed, have been shown to be more successful in changing an unsafe plan or preventing a potentially dangerous intervention [ 18 , 19 ].

Health Information Technology for Identification of Quality and Safety Events

Health IT for identification of quality and safety events involves health IT that is used to identify a quality and safety event when it is about to occur . Health insurance providers increasingly place pressure on healthcare systems to reduce the cost of care delivery and improve patient outcomes. This pressure may exist through tiered reimbursement structures, benefitting those systems which meet or exceed specific benchmarks of performance. Growing pressure from these payers takes the form of non-reimbursement for care determined by the payer to be unnecessary or in excess of “standard care.” Health IT can be used to find the EHR populations of patients for whom reimbursement might be lower than expected. One such example to consider is the length of stay for a particular procedure. While the use of health IT can produce reports and dashboards that are helpful for decision-making relative to reimbursement trends and practices for lengths of stay for that diagnosis, it is crucial that thoughtful consideration be given for appreciating any unintended consequences. For example, when reducing the length of stay, unintended readmissions are an important metric to follow.

Health Information Technology for Action in Quality and Safety Events

Health IT for action of quality and safety events involves health IT that is used to a ct on a quality and safety event once it has already occurred. That is to say that these are actions that were reported in the literature that were taken as a result of an event. Health IT for action differs from health IT for prevention in that the former is a reaction directly correlated to an event reported in the article, whereas the latter is reported in the article as a preemptive measure, in advance of an event.

Because of their standardization, there are several clinical care pathways that lend themselves to clinical decision support. One such clinical care pathway is sepsis. Despite nearly two decades of advances in early sepsis care, sepsis outcomes persist to be poor, and sepsis remains a leading cause of death worldwide and accounts for significant morbidity and mortality [ 20 ]. In light of this, there is a growing national push to increase early identification and treatment of sepsis with a goal of improving outcomes. Patients with sepsis are some of the most critically ill patients admitted to hospitals, and survival depends heavily upon timely and early administration of key interventions followed quickly by assessing and acting on results of these interventions [ 21 ]. Some examples include administration of IV antibiotics and aggressive IV fluids within one hour [ 21 ]. Examples of assessments of interventions include measuring specific physical and laboratory values that provide crucial information about the patient response. All too often, clinicians are faced with an overabundance of data, that while all necessary, may not be relevant to the issue at hand. For example, lab results might be presented in their entirety, when in practice, there are only 3 or 4 tests that will drive decision-making. The difficulty is how to separate the noise (non-essential at that moment) from the signal (essential at that moment). Health IT solutions, such as dashboards and other solutions can be used to ensure that essential data are in a primary viewing position and non-essential data in a secondary viewing position (perhaps on drill down, for example).

This paper will provide foundational knowledge and understanding for organizations of where to focus health IT fiscal and human resources. It will also provide information relative to some of the challenges that can be expected in implementing health IT for quality and patient safety.

This review of the literature took a structured approach using PubMed and a combination of keywords. Since PubMed indexes peer-reviewed articles from biomedical information, it was felt that this was the most appropriate and inclusive source. A healthcare-focused librarian, under the direction of all authors, conducted the literature search. The articles for final selection were discussed and decided upon among the authors. The structured approach was guided by the model illustrated in Figure 3 .

Literature search process.

The process to article inclusion involved three passes to collect publications related to health IT in quality and patient safety for peer-reviewed studies published between 2012-2017, inclusive. The first pass, (shown as “1” in Figure 3 ), used high-level keywords and returned 86 full-text articles. From the articles gathered, additional keywords were added to the search. After deduplication and citation review, the second pass (shown as “2” in Figure 3 ) added 67 unique full-text articles. After deduplication and citation review, the third pass (shown as “3” in Figure 3 ) added 11 unique full-text articles, for a total of 164 unique full text articles. Each article was further analyzed to identify the degree to which the article discussed health IT in healthcare quality and patient safety. To be considered for inclusion, the study needed to report on the actual use of health IT in healthcare quality and patient safety. Forty-one studies met these criteria. Those studies with their contributions to the results are shown in the results section of this paper.

Qualitative data analysis software (Atlas.ti 8 for Windows) was used in directed content analysis as a method to categorize and code the 41 studies relative to how health IT was used in healthcare quality and patient safety. All 41 documents were uploaded into the document manager in Atlas.ti as Primary Documents (PD). During this process, the article title was used as the PD name. Inductive thematic analysis with open coding was used under the three pre-set categories of prevention, identification, and action [ 22 ]. This allowed for capturing descriptions of how health IT was used in each circumstance.

For example, prevention included descriptions of any use of health IT to prevent quality issues or potential safety events, identification included any descriptions of the use of health IT to identify quality issues or safety events, and action included any descriptions of the use of health IT to act on quality issues or safety events that have occurred. When content was noted that did not fit into the three pre-set categories, an additional category was created. Additional categories were created to capture challenges relative to the use of health IT in quality and patient safety. Since some papers discussed how the use of health IT impacted health outcomes, an additional category was created for outcomes. Lastly, an additional category was created to capture the study settings or location.

The coding structure was agreed upon by all authors, and one author conducted the coding. After all of the studies were coded, two additional passes were made through the data. The first pass was to ensure that all information from the studies that should be coded was actually coded and coded to the correct code (ie, was a passage that described prevention actually coded to prevention?). The second pass was to consider sub-categories for consolidation. Six sub-categories were consolidated.

The purpose of examining co-occurrences is to understand what, if any, relation exists between concepts [ 22 , 23 ]. Within Atlas.ti, a co-occurrence table was run to find codes that co-occur across the literature, the purpose of which was to illuminate the areas most discussed. This table was then exported to Microsoft Excel for further analysis.

Network maps are a means by which analysis can be visualized in relationships to provide a different perspective on the codes, categories, etc., and with that visualization, provide a mechanism for moving codes around [ 22 ]. Those presented in the results do not differ from the final coding structure, but instead are used to provide a visual representation.

Literature reviews can be conducted using a qualitative approach [ 24 , 25 ] with the results displayed in a variety of ways to support models and show connections [ 22 ]. As such, this review presents qualitative findings to support the “improving the reliability of healthcare quality and patient safety” model introduced earlier in this paper and shows connections via network mappings in Figure 6 through Figure 7 and co-occurrences in Table 2 .

IDENTIFICATION Network Diagram (G=groundedness, D=density).

PREVENTION Network Diagram (G=groundedness, D=density).

a IT: information technology.

Table 1 provides a listing of the articles and their contribution in this results section to support the model ( Figure 2 ), network maps ( Figure 4 through Figure 7 ), and co-occurrences ( Table 2 ).

Article contribution to results (in alphabetical order). An “X” indicates the area of the results contribution and “—” indicates no contribution.

ACTION Network Diagram (G=groundedness, D=density).

From the 41 studies that fit the inclusion criteria, any element in which the authors discussed the use of health IT for healthcare quality and patient safety was identified, even if it did not fit into the three previously determined categories. This process yielded a total of 50 codes across five categories: action (7/41, 17.1%), challenges (12/41, 29.3%), identification (10/41, 24.4%), outcomes (5/41, 12.2%), and prevention (16/41, 39.0%) across seven study settings. Just under a quarter of the studies identified a study setting: anesthesia (2/41, 4.9%), behavioral health (1/41, 2.4%), emergency department (2/41, 4.9%), any intensive care unit (3/41, 7.3%), clinical diagnostic laboratory (1/41, 2.4%), pediatrics (2/41, 4.9), surgery (1/41, 2.4%).

Across all of the articles, there were 63 and 92 descriptions of the use of health IT for identification and prevention of healthcare quality and patient safety issues, respectively. Health IT for action and the challenges associated with health IT for healthcare quality and patient safety was described 41 and 43 times, respectively.

The findings from the literature review are presented by the categories outlined in the previously introduced model for improving the reliability of healthcare quality and patient safety.

The first exploration was across the literature that discussed health IT for prevention of quality and patient safety issues to see exactly how organizations were reporting health IT use to prevent a quality and safety event from even happening . The greatest areas of use were around alerts [ 30 , 31 , 44 , 56 , 58 ], clinical decision support [ 39 , 44 , 47 , 56 ], implementation [ 10 , 32 , 37 , 38 , 56 ], interface design [ 26 , 34 , 42 , 45 , 56 , 59 ], and customized health IT solutions [ 29 , 30 , 32 , 34 , 46 - 50 , 56 , 58 , 59 ]. Customized health IT solutions were anything that described the use of health IT but lacked any specificity beyond that described in this section. For example, this could be something as simple as checklists or as complex as algorithmic diagnostic trees. To clarify, alerts are a subset of clinical decision support. Since so many of the occurrences specified alerts and clinical decision support separately, these were coded separately. Clinical decision support, by definition, includes alerts, clinical care guidelines, condition-specific orders sets, clinical reports and/or summaries, documentation templates, diagnostic support, and clinical reference support. Implementation and interface design were each described in terms of having been poorly implemented or poorly designed and having implications on utility in healthcare quality and safety.

Identification

The next exploration was across the literature that discussed health IT for identification of quality and patient safety issues; in other words, how health IT was used to identify a quality and safety event when it is about to occur . In this regard, similar to prevention (but described differently in the included studies), alerts [ 26 , 30 , 31 , 44 , 56 , 58 ], clinical decision support [ 30 , 31 , 39 , 44 , 56 , 58 ], implementation [ 10 , 32 , 38 , 56 ], and customized health IT solutions [ 10 , 30 , 31 , 34 , 46 - 49 , 52 , 56 , 58 ] were most prominent. For example, alerts, clinical decision support, and customized health IT solutions were all described in the literature as having been implemented to identify a potential quality or patient safety issue, yet the literature also described how the implementation of these could have been better in terms of providing more training to those on the receiving end of the alerts, clinical decision support, or other customized health IT solutions.

OUTCOMES Network Diagram (G=groundedness, D=density).

The third exploration was across the literature that discussed health IT for action on a quality and safety event once it has already occurred. That is to say that these are actions that were reported in the literature that were taken as a result of an event. In regards to action, the major areas were documentation [ 10 , 32 , 37 , 41 , 46 , 56 , 58 ], implementation [ 10 , 32 , 37 , 58 ], and culture [ 10 , 29 , 41 , 53 , 58 ] relative to the use of health IT.

The findings from the review of the literature show that implementation appeared in prevention, identification, and action. Implementation in general has been demonstrated in the literature as a challenge, and that was revealed in this literature review also. Culture was most often referred to as needing to create a culture of quality and patient safety in order for health IT to be embraced. Organizations that started working on culture change before implementation of health IT solutions suggested that health IT for acting on quality and patient safety events was more favorable. Therefore, the analysis was run with challenges which suggests the major areas are: culture, implementation, and interface design.

Co-occurrences

Employing the Improving the reliability of healthcare quality and patient safety model introduced in Figure 2 and adding challenges, six critical co-occurrences emerged (see Table 2 ).

As described earlier, co-occurrences expose relationships exists between concepts [ 22 , 23 ]. The top co-occurring codes in Table 2 create a macro level view of how health IT was most commonly used for quality and patient safety relative to the “improving the reliability of healthcare quality and patient safety” model introduced in Figure 2 . However, it is also important to understand the universe of ways in which organizations used health IT for quality and patient safety; in other words, the art of the possible when using health IT for quality and patient safety. Network maps provide a mechanism by which to visualize the connectedness of all data coded across all 41 articles included in this analysis. These maps, along with some quantitative information increase understanding at this universe level (macro and micro views).

In the network diagrams that follow (which also represent the coded categories and sub-categories), G signifies the level of groundedness of the particular code. Groundedness, in this case, indicates the frequency of the code relative to the code category. D signifies the level of density or connectedness of the particular code. Density, in this case, indicates the number of other codes to which this code is connected. For example, under ACTION, Figure 4 , the code action: culture shows G6, D2. ACTION is the code category and action: culture is the code “culture” under the ACTION code category (this coding structure helps to maintain alpha order). This can be read as the following: “Culture was described six times across all 41 papers relative to ACTION and is connected to two code categories total.” Because it would make the network diagrams unwieldy, not shown in the exhibits is the specificity around the groundedness or the density. See Figures 4 through Figure 7 .

Principal Findings

This scan of the literature is intended to inform practice. The information from this study could be useful as organizations determine where they stand to get the most “bang for their buck” relative to health IT for quality and patient safety. Centered around the Improving the Reliability of Healthcare Quality and Safety model introduced in Figure 2 and the macro level uses of health IT for quality and patient safety outlined in Table 2 , organizations in the planning stages may want to begin with alerts and clinical decision support, understanding that alerts are a subset of clinical decision support. This information also helps with resource planning. For example, implementation appeared in all three categories of the Improving the Reliability of Healthcare Quality and Safety model. Additionally, culture was shown to be a challenge. Organizational leaders know that changing culture can be a long and intensive process. The findings from this scan of the literature suggest that having organizational champion leaders that can shepherd implementation, impact culture, and bridge knowledge with developers would be a valuable resource allocation to consider.

Health IT must meet quality improvement at the intersection with care delivery. From a clinical perspective, this is experienced on several levels, and the solution depends, in part, on the clinical problem to be addressed. Some typical examples of health IT interventions illuminated in the findings include: (1) reminders and alerts, (2) decision support tools, (3) checklists (including order sets and protocols), and (4) soft- and hard-stops.

As noted, this scan of the literature is provided as a means to inform practice. It does not consider further model modification, and this represents an area of future research in the application of health IT for quality and patient safety.

Limitations

This study is limited in that it used PubMed as a single source for the searching and one coder coded all studies. A more comprehensive and systematic review would include multiple databases and multiple coders. Although all authors reviewed the codes, multiple coders would ensure intercoder reliability, which cannot be assured in this study. Additionally, since all studies reviewed did not include locations, generalizability to all areas of clinical care cannot be certain.

A review of the literature for this study concluded that organizations in the planning stages of using health IT to improve quality and safety may want to begin with reminders and alerts, decision support tools, and checklists.

Acknowledgments

The authors acknowledge and appreciate the careful, detailed, and thoughtful comments by the reviewers whose suggestions strengthened this paper.

Abbreviations

Conflicts of Interest: None declared.