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A patient satisfaction survey was conducted with ambulatory cancer patients to identify areas that they consider priorities for change. Wait times and telephone contact with healthcare providers were the 2 areas of lowest satisfaction. Despite previous interventions to improve wait times, it is consistently the lowest ranked item for patient satisfaction. A subset of patients who were followed by a nurse navigator was more satisfied with wait times than those who were not followed by a nurse navigator. [ABSTRACT FROM AUTHOR]

Oncology patients requiring outpatient services have expectations that must be addressed to ensure continuous and improved quality of care. A convenience sample of 96 patients recruited from an oncology outpatient center completed a 26-item patient satisfaction questionnaire (SEQUS). Overall satisfaction ratings indicate that patients are satisfied with their care. Patients' perception of waiting time and lack of questioning regarding their medications by the pharmacist were identified as two areas needing improvement. Findings suggest that by identifying what is most important to patients, nurses can readily modify the care environment to enhance patient satisfaction and quality of care. [ABSTRACT FROM AUTHOR]

Study Objective: To evaluate the impact of a geriatric consultation team on the functional status of hospitalized elderly patients.Design: Randomized controlled clinical trial.Setting: University-affiliated referral Veterans Administration Medical Center.Patients: One hundred and seventy-eight hospitalized elderly men 75 years or older admitted to medical, surgical, and psychiatry services, but excluding patients admitted to intensive care units.Intervention: Eighty-eight intervention group patients received multidimensional evaluation by an interdisciplinary geriatric consultation team composed of a faculty geriatrician, geriatrics fellow, geriatric clinical nurse specialist, and a social worker trained in geriatrics. Results of the evaluation, including problem identification and recommendations, were given to the patients' physicians. Ninety control group patients received only usual care.Measurements and Main Results: Intervention and control groups were comparable initially. The major outcome variable was the Index of Independence in the Activities of Daily Living (ADL) (Katz). Thirty-nine percent of the total study population was functionally independent on admission, 27% required assistance with one to three ADL, 22% required assistance with four to six ADL, and 12% were completely dependent. Many patients remained unchanged from admission to discharge: intervention group, 38%; control group, 39%. In the intervention group, 34% improved and 28% declined; in the control group, 26% improved and 36% declined. Although these changes reflected a trend toward greater improvement in the intervention group, the results were not statistically significant.Conclusions: Among elderly patients entering an acute-care hospital, approximately 60% had some degree of, and one third had serious functional disability. Such patients are at risk for further decline during hospitalization. A geriatric consultation team was unable to alter the degree of functional decline. Geriatric units or consultation teams may have to offer direct preventive or restorative services in addition to advice if improvements are to be made. [ABSTRACT FROM AUTHOR]

Background: Head and Neck Cancer (HNC) is the eighth most prevalent global cancer. Timely recognition of symptoms is crucial for reducing mortality rates. The EVolution of a patiEnt-REported symptom-based risk stratification sySTem to redesign the suspected Head and Neck cancer referral pathway (EVEREST-HN) study aims to develop and evaluate a risk stratification tool using patient reported symptoms, which will be populated remotely in the community before the patient is seen by the clinician to hasten HNC diagnosis. EVEREST-HN will design a patient SYmptom iNput Clinical (SYNC) system to gather patient symptom data and calculate a risk score to aid clinicians in identifying high-risk cases. This identification potentially allows for high-risk patients to be seen sooner, thereby improving patient outcomes., Methods: Three workshop sessions were conducted involving a total of 17 unique participants, with several contributing to multiple sessions: nine in the co-design session, six in the validation session, and nine in the evaluation session. The co-design session employed online collaboration with patients' representatives. Thematic analysis was used to identify requirements and concerns informing the development of a low-fidelity prototype. The validation session assessed whether the prototype aligned with patient expectations. In the evaluation session, participants interacted with an online prototype and provided further feedback., Results: During the co-design workshop, participants emphasized the need for a concise and clear SYNC system questionnaire for reporting suspected HNC symptoms. Concerns were raised about questionnaire length, language clarity, and the inclusion of probing questions. Participants suggested concise questions using lay language, incorporating visual aids for topics like alcohol and tobacco use, and making the sexual activity question optional. Recommendations included diverse language options, hard copies for non-English speakers, and phone call options for those uncomfortable with screen-based technology. The validation workshop confirmed that the prototype reflected participants' ideas. Feedback highlighted the need for call-back features to help those not confident with technology and the need to present symptom questions first before social background questions. Feedback from the evaluation demonstrated a commitment to efficiency, and continuous improvement., Conclusion: This study aims to develop the SYNC system to enhance efficiency of suspected HNC referrals. The workshops highlighted the importance of end-user inclusiveness in the system development life cycle, with collaboration with stakeholders and repeated feedback, providing crucial insights for ensuring the SYNC system effectively addresses the needs and concerns of patients in the context of HNC diagnosis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Despite prevention efforts, falls in hospital are a common and ongoing safety concern, with older people more likely to fall and experience harm as a result of falls. Clinical guidelines recommend multifactorial falls risk assessment and multidomain, personalised interventions to reduce falls risks in hospitals. This article reflects on findings from a multi-site study on the implementation of multifactorial falls prevention practices that informed the development of actionable guidance. The discussion focuses on strategies used by nurse leaders, at different levels of seniority, that shaped practice on orthopaedic and older person wards. While falls risk assessment documentation was monitored routinely by senior leaders, in practice falls prevention often relied on risk screening and enhanced patient supervision. Findings suggest that nurses need to be empowered to lead practices that modify and mitigate individual falls risks where possible, with greater multidisciplinary and patient and carer involvement., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Issue Addressed: There is increasing interest across public health research, policy, and practice in place-based approaches to improve health outcomes. Practice-focused resources, such as grey literature, courses and websites, are utilised by practitioners to support the implementation of place-based approaches., Methods: A detailed search of two search engines: Google and DuckDuckGo to identify free practice-focused resources was conducted., Results: Forty-one resources met inclusion criteria, including 26 publications, 13 web-based resources and two courses. They were mainly focused on collaboration, developed by not-for-profit organisations, focused on a broad target audience, and supported people living with disadvantage. The publications we reviewed generally: clearly stated important information, such as the author of the publication; used their own evaluations, professional experience and other grey literature as supporting evidence; included specific, practical implementation strategies; and were easy to read., Conclusions: Based on findings, we recommend that: (1) the development of resources to support evidence-informed practice and governance be prioritised; (2) resources clearly state their target audience and tailor communication to this audience; (3) resources draw on evidence from a range of sources; (4) resources continue to include practical implementation strategies supported by examples and (5) resource content be adaptable to different contexts (e.g., different settings and/or target populations). SO WHAT?: This is the first review of practice-focused resources to support the implementation of place-based approaches and the findings can be used to reduce duplication of efforts and inform future research, policy, and practice, particularly the refinement of existing resources and the development of future resources., (© 2023 The Authors. Health Promotion Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of Australian Health Promotion Association.)

Aims: To explore the nature of interactions that enable older inpatients with cognitive impairments to engage with hospital staff on falls prevention., Design: Ethnographic study., Methods: Ethnographic observations on orthopaedic and older person wards in English hospitals (251.25 h) and semi-structured qualitative interviews with 50 staff, 28 patients and three carers. Findings were analysed using a framework approach., Results: Interactions were often informal and personalised. Staff qualities that supported engagement in falls prevention included the ability to empathise and negotiate, taking patient perspectives into account. Although registered nurses had limited time for this, families/carers and other staff, including engagement workers, did so and passed information to nurses., Conclusions: Some older inpatients with cognitive impairments engaged with staff on falls prevention. Engagement enabled them to express their needs and collaborate, to an extent, on falls prevention activities. To support this, we recommend wider adoption in hospitals of engagement workers and developing the relational skills that underpin engagement in training programmes for patient-facing staff., Implications for Profession and Patient Care: Interactions that support cognitively impaired inpatients to engage in falls prevention can involve not only nurses, but also families/carers and non-nursing staff, with potential to reduce pressures on busy nurses and improve patient safety., Reporting Method: The paper adheres to EQUATOR guidelines, Standards for Reporting Qualitative Research., Patient or Public Contribution: Patient/public contributors were involved in study design, evaluation and data analysis. They co-authored this manuscript., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Introduction: Between 2009/2010 and 2019/2020, England witnessed an increase in suspected head and neck cancer (sHNC) referrals from 140 to 404 patients per 100 000 population. 1 in 10 patients are not seen within the 2-week target, contributing to patient anxiety. We will develop a pathway for sHNC referrals, based on the Head and Neck Cancer Risk Calculator. The evolution of a patient-reported symptom-based risk stratification system to redesign the sHNC referral pathway (EVEREST-HN) Programme comprises six work packages (WPs). This protocol describes WP1 and WP2. WP1 will obtain an understanding of language to optimise the SYmptom iNput Clinical (SYNC) system patient-reported symptom questionnaire for sHNC referrals and outline requirements for the SYNC system. WP2 will codesign key elements of the SYNC system, including the SYNC Questionnaire, and accompanying behaviour change materials., Methods and Analysis: WP1 will be conducted at three acute National Health Service (NHS) trusts with variation in service delivery models and ensuring a broad mixture of social, economic and cultural backgrounds of participants. Up to 150 patients with sHNC (n=50 per site) and 15 clinicians (n=5 per site) will be recruited. WP1 will use qualitative methods including interviews, observation and recordings of consultations. Rapid qualitative analysis and inductive thematic analysis will be used to analyse the data. WP2 will recruit lay patient representatives to participate in online focus groups (n=8 per focus group), think-aloud technique and experience-based codesign and will be analysed using qualitative and quantitative approaches., Ethics and Dissemination: The committee for clinical research at The Royal Marsden, a research ethics committee and the Health Research Authority approved this protocol. All participants will give informed consent. Ethical issues of working with patients on an urgent cancer diagnostic pathway have been considered. Findings will be disseminated via journal publications, conference presentations and public engagement activities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable., Aim: To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England., Design: Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews ( n  = 50), patient and carer interviews ( n  = 31) and record review ( n  = 60)., Setting: Three Trusts, one orthopaedic and one older person ward in each., Results: Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling., Limitations: Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted., Conclusions: (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling., Future Work: (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English., Study Registration: This study is registered as PROSPERO CRD42020184458., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Background: Inpatient falls are the most common safety incident reported by hospitals worldwide. Traditionally, responses have been guided by categorising patients' levels of fall risk, but multifactorial approaches are now recommended. These target individual, modifiable fall risk factors, requiring clear communication between multidisciplinary team members. Spoken communication is an important channel, but little is known about its form in this context. We aim to address this by exploring spoken communication between hospital staff about fall prevention and how this supports multifactorial fall prevention practice., Methods: Data were collected through semistructured qualitative interviews with 50 staff and ethnographic observations of fall prevention practices (251.25 hours) on orthopaedic and older person wards in four English hospitals. Findings were analysed using a framework approach., Findings: We observed staff engaging in 'multifactorial talk' to address patients' modifiable risk factors, especially during multidisciplinary meetings which were patient focused rather than risk type focused. Such communication coexisted with 'categorisation talk', which focused on patients' levels of fall risk and allocating nursing supervision to 'high risk' patients. Staff negotiated tensions between these different approaches through frequent 'hybrid talk', where, as well as categorising risks, they also discussed how to modify them., Conclusion: To support hospitals in implementing multifactorial, multidisciplinary fall prevention, we recommend: (1) focusing on patients' individual risk factors and actions to address them (a 'why?' rather than a 'who' approach); (2) where not possible to avoid 'high risk' categorisations, employing 'hybrid' communication which emphasises actions to modify individual risk factors, as well as risk level; (3) challenging assumptions about generic interventions to identify what individual patients need; and (4) timing meetings to enable staff from different disciplines to participate., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals., Methods: A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers., Results: Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging., Conclusions: Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients' individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate., Trial Registration: PROSPERO: CRD42020184458., (© 2023. The Author(s).)

Effective strategic workforce planning for integrated and co-ordinated health and social care is essential if future services are to be resourced such that skill mix, clinical practice and productivity meet population health and social care needs in timely, safe and accessible ways globally. This review presents international literature to illustrate how strategic workforce planning in health and social care has been undertaken around the world with examples of planning frameworks, models and modelling approaches. The databases Business Source Premier, CINAHL, Embase, Health Management Information Consortium, Medline and Scopus were searched for full texts, from 2005 to 2022, detailing empirical research, models or methodologies to explain how strategic workforce planning (with at least a one-year horizon) in health and/or social care has been undertaken, yielding ultimately 101 included references. The supply/demand of a differentiated medical workforce was discussed in 25 references. Nursing and midwifery were characterised as undifferentiated labour, requiring urgent growth to meet demand. Unregistered workers were poorly represented as was the social care workforce. One reference considered planning for health and social care workers. Workforce modelling was illustrated in 66 references with predilection for quantifiable projections. Increasingly needs-based approaches were called for to better consider demography and epidemiological impacts. This review's findings advocate for whole-system needs-based approaches that consider the ecology of a co-produced health and social care workforce., Competing Interests: Declaration of Competing Interest There are no conflicts of interest to be declared either in the undertaking of this review or the submission of this manuscript of the review to `Health Policy’., (Copyright © 2023. Published by Elsevier B.V.)

Inpatient falls are an international patient safety concern, accounting for 30-40% of reported safety incidents in acute hospitals. They can cause both physical (e.g. hip fractures) and non-physical harm (e.g. reduced confidence) to patients. We used an approach known as a realist review to identify theories about what interventions might work for whom in what contexts, focusing on what supports and constrains effective use of multifactorial falls risk assessment and falls prevention interventions. One of these theories suggested that staff will integrate recommended practices into their work routines if falls risk assessment tools, including health IT, are quick and easy to use and facilitate existing work routines. Synthesis of empirical studies undertaken in the process of testing and refining this theory has implications for the design of health IT, suggesting that while health IT can support falls prevention through automation, such tools should also allow for incorporation of clinical judgement., (©2022 AMIA - All rights reserved.)

Background: Dashboards can support data-driven quality improvements in health care. They visualize data in ways intended to ease cognitive load and support data comprehension, but how they are best integrated into working practices needs further investigation., Objective: This paper reports the findings of a realist evaluation of a web-based quality dashboard (QualDash) developed to support the use of national audit data in quality improvement., Methods: QualDash was co-designed with data users and installed in 8 clinical services (3 pediatric intensive care units and 5 cardiology services) across 5 health care organizations (sites A-E) in England between July and December 2019. Champions were identified to support adoption. Data to evaluate QualDash were collected between July 2019 and August 2021 and consisted of 148.5 hours of observations including hospital wards and clinical governance meetings, log files that captured the extent of use of QualDash over 12 months, and a questionnaire designed to assess the dashboard's perceived usefulness and ease of use. Guided by the principles of realist evaluation, data were analyzed to understand how, why, and in what circumstances QualDash supported the use of national audit data in quality improvement., Results: The observations revealed that variation across sites in the amount and type of resources available to support data use, alongside staff interactions with QualDash, shaped its use and impact. Sites resourced with skilled audit support staff and established reporting systems (sites A and C) continued to use existing processes to report data. A number of constraints influenced use of QualDash in these sites including that some dashboard metrics were not configured in line with user expectations and staff were not fully aware how QualDash could be used to facilitate their work. In less well-resourced services, QualDash automated parts of their reporting process, streamlining the work of audit support staff (site B), and, in some cases, highlighted issues with data completeness that the service worked to address (site E). Questionnaire responses received from 23 participants indicated that QualDash was perceived as useful and easy to use despite its variable use in practice., Conclusions: Web-based dashboards have the potential to support data-driven improvement, providing access to visualizations that can help users address key questions about care quality. Findings from this study point to ways in which dashboard design might be improved to optimize use and impact in different contexts; this includes using data meaningful to stakeholders in the co-design process and actively engaging staff knowledgeable about current data use and routines in the scrutiny of the dashboard metrics and functions. In addition, consideration should be given to the processes of data collection and upload that underpin the quality of the data visualized and consequently its potential to stimulate quality improvement., International Registered Report Identifier (irrid): RR2-10.1136/bmjopen-2019-033208., (©Natasha Alvarado, Lynn McVey, Mai Elshehaly, Joanne Greenhalgh, Dawn Dowding, Roy Ruddle, Chris P Gale, Mamas Mamas, Patrick Doherty, Robert West, Richard Feltbower, Rebecca Randell. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 23.11.2021.)

Introduction: Falls are the most common type of safety incident reported by acute hospitals and can cause both physical (eg, hip fractures) and non-physical harm (eg, reduced confidence) to patients. It is recommended that, in order to prevent falls in hospital, patients should receive a multifactorial falls risk assessment and be provided with a multifactorial intervention, tailored to address the patient's identified individual risk factors. It is estimated that such an approach could reduce the incidence of inpatient falls by 25%-30% and reduce the annual cost of falls by up to 25%. However, there is substantial unexplained variation between hospitals in the number and type of assessments undertaken and interventions implemented., Methods and Analysis: A realist review will be undertaken to construct and test programme theories regarding (1) what supports and constrains the implementation of multifactorial falls risk assessment and tailored multifactorial falls prevention interventions in acute hospitals; and (2) how, why, in what contexts and for whom tailored multifactorial falls prevention interventions lead to a reduction in patients' falls risk. We will first identify stakeholders' theories concerning these two topics, searching Medline (1946-present) and Medline In-Process & Other Non-Indexed Citations, Health Management Information Consortium (1983-present) and CINAHL (1981-present). We will then test these theories systematically, using primary studies to determine whether empirical evidence supports, refutes or suggests a revision or addition to the identified theories., Ethics and Dissemination: The study does not require ethical approval. The review will provide evidence for how to implement multifactorial falls risk assessment and prevention strategies in acute hospital settings. This will be disseminated to academic and clinical audiences and will provide the basis for a future multi-site study through which the theories will be further refined., Systematic Review Registration: PROSPERO CRD42020184458., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Secondary use of data via integrated health information technology is fundamental to many healthcare policies and processes worldwide. However, repurposing data can be problematic and little research has been undertaken into the everyday practicalities of inter-system data sharing that helps explain why this is so, especially within (as opposed to between) organisations. In response, this article reports one of the most detailed empirical examinations undertaken to date of the work involved in repurposing healthcare data for National Clinical Audits., Methods: Fifty-four semi-structured, qualitative interviews were carried out with staff in five English National Health Service hospitals about their audit work, including 20 staff involved substantively with audit data collection. In addition, ethnographic observations took place on wards, in 'back offices' and meetings (102 h). Findings were analysed thematically and synthesised in narratives., Results: Although data were available within hospital applications for secondary use in some audit fields, which could, in theory, have been auto-populated, in practice staff regularly negotiated multiple, unintegrated systems to generate audit records. This work was complex and skilful, and involved cross-checking and double data entry, often using paper forms, to assure data quality and inform quality improvements., Conclusions: If technology is to facilitate the secondary use of healthcare data, the skilled but largely hidden labour of those who collect and recontextualise those data must be recognised. Their detailed understandings of what it takes to produce high quality data in specific contexts should inform the further development of integrated systems within organisations., (© 2021. The Author(s).)

Rationale, Aims, and Objectives: Healthcare systems worldwide devote significant resources towards collecting data to support care quality assurance and improvement. In the United Kingdom, National Clinical Audits are intended to contribute to these objectives by providing public reports of data on healthcare treatment and outcomes, but their potential for quality improvement in particular is not realized fully among healthcare providers. Here, we aim to explore this outcome from the perspective of hospital boards and their quality committees: an under-studied area, given the emphasis in previous research on the audits' use by clinical teams., Methods: We carried out semi-structured, qualitative interviews with 54 staff in different clinical and management settings in five English National Health Service hospitals about their use of NCA data, and the circumstances that supported or constrained such use. We used Framework Analysis to identify themes within their responses., Results: We found that members and officers of hospitals' governing bodies perceived an imbalance between the benefits to their institutions from National Clinical Audits and the substantial resources consumed by participating in them. This led some to question the audits' legitimacy, which could limit scope for improvements based on audit data, proposed by clinical teams., Conclusions: Measures to enhance the audits' perceived legitimacy could help address these limitations. These include audit suppliers moving from an emphasis on cumulative, retrospective reports to real-time reporting, clearly presenting the "headline" outcomes important to institutional bodies and staff. Measures may also include further negotiation between hospitals, suppliers and their commissioners about the nature and volume of data the latter are expected to collect; wider use by hospitals of routine clinical data to populate audit data fields; and further development of interactive digital technologies to help staff explore and report audit data in meaningful ways., (© 2020 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Adapting dashboard design to different contexts of use is an open question in visualisation research. Dashboard designers often seek to strike a balance between dashboard adaptability and ease-of-use, and in hospitals challenges arise from the vast diversity of key metrics, data models and users involved at different organizational levels. In this design study, we present QualDash, a dashboard generation engine that allows for the dynamic configuration and deployment of visualisation dashboards for healthcare quality improvement (QI). We present a rigorous task analysis based on interviews with healthcare professionals, a co-design workshop and a series of one-on-one meetings with front line analysts. From these activities we define a metric card metaphor as a unit of visual analysis in healthcare QI, using this concept as a building block for generating highly adaptable dashboards, and leading to the design of a Metric Specification Structure (MSS). Each MSS is a JSON structure which enables dashboard authors to concisely configure unit-specific variants of a metric card, while offloading common patterns that are shared across cards to be preset by the engine. We reflect on deploying and iterating the design of OualDash in cardiology wards and pediatric intensive care units of five NHS hospitals. Finally, we report evaluation results that demonstrate the adaptability, ease-of-use and usefulness of QualDash in a real-world scenario.

Background: National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians' time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation., Methods: We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism = Outcome configurations., Results: We identified five mechanisms that explained provider interactions with NCA feedback: reputation, professionalism, competition, incentives, and professional development. Professionalism and incentives underpinned most frequent interaction with feedback, providing opportunities to stimulate quality improvement. Feedback was used routinely in these ways where it was generated from data stored in local databases before upload to NCA suppliers. Local databases enabled staff to access data easily, customise feedback and, importantly, the data were trusted as accurate, due to the skills and experience of staff supporting audit participation. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity across providers. Challenges accessing supplier data in a timely way and concerns about the quality of data submitted across providers were reported to constrain use of this mode of feedback., Conclusion: The findings suggest that there are a number of mechanisms that underpin healthcare providers' interactions with NCA feedback. However, there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely, providing opportunities to stimulate quality improvement, within clinical services resourced to collect accurate data and to maintain local databases from which feedback could be customised for the needs of the service.

Healthcare organizations worldwide use quality dashboards to provide feedback to clinical teams and managers, in order to monitor care quality and stimulate quality improvement. However, there is limited evidence regarding the impact of quality dashboards and audit and feedback research focuses on feedback to individual clinicians, rather than to clinical and managerial teams. Consequently, we know little about what features a quality dashboard needs in order to provide benefit. We conducted 54 interviews across five healthcare organizations in the National Health Service in England, interviewing personnel at different levels of the organization, to understand how national (UK) clinical audit data are used for quality improvement and factors that support or constrain use of these data. The findings, organized around the themes of choosing performance indicators, assessing performance, identifying causes, communicating from ward to board, and data quality, have implications for the design of quality dashboards, which we have translated into a series of requirements., (©2019 AMIA - All rights reserved.)

Introduction: National audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet)., Methods and Analysis: Realist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period., Ethics and Dissemination: The study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial., Competing Interests: Competing interests: CG is a member of the MINAP Academic and Steering Groups. RF is the principal investigator for PICANet and RP was previously Principal Investigator for PICANet., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

National Clinical Audit (NCA) data are collected from all National Health Service providers in the UK, to measure the quality of care and stimulate quality improvement initatives. As part of a larger study we explored how NHS providers currently collect NCA data and the resources involved. Study results highlight a dependence on manual data entry and use of professional resources, which could be improved by exploring how routine clinical data could be captured more effectively.

Aim: The aim of this study was to describe the process of how nurse and physician managers in formalized dyads work together to address clinical management issues in the surgical division of one hospital setting., Background: Nurse and physician managers are uniquely positioned to co-lead and transform healthcare delivery. However, little is known about how this management dyad functions in the healthcare setting., Design: A constructivist grounded theory approach was used to investigate the process of how nurse and physician managers work together in formalized dyads in an urban Canadian university affiliated teaching hospital., Methods: Data collection occurred from September 2013-August 2014. Data included participant observation (n = 142 hours) and intensive interviews (n = 36) with nurse-physician manager dyads (12 nurses, 9 physicians) collected in a surgical department. Theoretical sampling was used to elaborate on properties of emerging concepts and categories., Results/findings: A substantive theory on 'intentional partnering' was generated. Nurses' and physicians' professional agendas, which included their interests and purposes for working with each other served as the starting point of 'intentional partnering'. The theory explains how nurse and physician managers align their professional agendas through the processes of 'accepting mutual necessity', 'daring to risk (together)' and 'constructing a shared responsibility'. Being credible, earning trust and safeguarding respect were fundamental to communicating effectively., Conclusion: Intentional partnering elucidates the relational components of working together and the strategizing that occurs as each partner deliberates on what he or she is willing to accept, risk and put into place to reap the benefits of collaborating., (© 2017 John Wiley & Sons Ltd.)

Aim: In sick children who are unable to be weighed estimation of weight is often required, but the routinely used equations lack accuracy and precision. This study aimed to develop a novel equation (Children's European Estimator of Weight-CEEW) using measurements of mid-upper arm circumference (MUAC) and other predictors in multinational groups of sick children in Europe., Methods: Weight estimation equations were developed in 2086 children from the UK, Greece and the Netherlands, using a combination of demographics, MUAC and height measurements. The final CEEW equations were compared against the performance of the European Resuscitation Council (ERC), Advanced Paediatric Life Support (APLS) and the Cattermole equations., Results: Two final CEEW equations were developed, incorporating measurements of age, gender and MUAC, with (CEEW1) or without (CEEW2) the inclusion of height. Both equations presented very high coefficients of determination (R 2 >96.5%), minimal mean prediction error and narrower limits of agreement than the comparator equations. 88% (CEEW1) and 77% (CEEW2) of weight estimates fell within 15% of measured body weight. These figures compared with less than 57%, 57% and 37% for the ERC, APLS and Cattermole equations respectively., Conclusion: The CEEW equations performed substantially better than other routinely used equations for weight estimation. An electronic application for mobile use is presented., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Context: HealthSpan Physicians (HSP), an integrated medical system in Northeast Ohio, partnered with the Young Men's Christian Association (YMCA) of Greater Cleveland to implement a referral system for the evidence-based Diabetes Prevention Program (DPP) throughout HSP. The YMCA of USA employs a cost-effective, customized version of the original DPP in which coaches take the place of in-house clinical staff. Efficacy of the YMCA DPP was shown earlier in the DEPLOY Study., Objective: To improve outcomes of metrics used in the DEPLOY Study., Design: Observational study focusing on engagement, persistence, recruitment, and adherence to the DPP. In August 2014, HSP mailed an invitation to 2200 patients identified as both Medicare eligible and at risk of prediabetes to attend no-obligation information sessions about the DPP. After these sessions, YMCA staff called interested participants and asked them to enroll in and to commit to the program. Motivation and reinforcement were provided to patients through YMCA-provided signs, brochures, and posters; the HSP Web site; and in-person conversations with primary care physicians., Main Outcome Measures: Average weight loss at the end of 16 weeks in the program and average retention through Session 9., Results: Of the 2200 patients contacted, 351 (16.0%) responded by attending the information session, and 228 enrolled in the YMCA DPP (11.3%) and persisted through at least Week 9. This result is an improvement over the 1.7% of eligible enrollees who responded to the DEPLOY Study's mailing., Conclusions: A marketing approach to implementing the YMCA DPP in an integrated medical system results in excellent outcomes., Competing Interests: Statement The author(s) have no conflicts of interest to disclose.

Background: ICU nurses often report that timely informational and supportive resources would ease distress for clients and providers alike., Objectives: This pilot study was aimed to explore the role of a comprehensive information and support programme in enhancing the work environment, task performance and reducing emotional distress amongst ICU nurses., Research Methodology/design: Through a mixed quantitative and qualitative design, nurses were invited to complete self-report questionnaires (n=25) and to participate in focus groups (n=7) prior to (T1) and 6 weeks after the implementation of the supportive programme (T2)., Results: Measures of physical and mental effort were found to be significantly lower (t=2.45, p=0.02) at post test (T2). Statistical trends towards significance were observed for higher performance satisfaction (t=1.70, p=0.10) and lower emotional distress (t=2.00, p=0.06) at T2. Focus group data revealed that nurses felt more supported in their work, had more satisfaction with work tasks accomplished and felt more emotionally supported with the programme being in place., Conclusions: Preliminary data from this pilot study suggest that a comprehensive information and support programme designed to support nurses in the ICU can enhance well being and workplace related factors. Work is currently underway to document the program's impact on family members in the ICU. Future studies should document further how and when similar programme contribute to enhance the workplace for other ICU staff., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

This article describes how a series of patient satisfaction surveys on a palliative care unit were used to help influence the care provided to patients and their families. Innovative interventions aimed at addressing areas of lower satisfaction identified in the initial survey are described. The results from a follow-up survey provided the opportunity to evaluate whether our interventions were effective in improving patient satisfaction and highlight new areas of concern needing to be addressed.

Background: Informational support to family members of ICU patients has significant potential for reducing their psychological distress, enabling them to better cope and support the patient., Objectives: To describe family member perception of informational support, anxiety, satisfaction with care, and their interrelationships, to guide further refinement of a local informational support initiative and its eventual evaluation., Methodology/design: This cross-sectional descriptive correlational pilot study collected data from a convenience sample of 29 family members using self-report questionnaires., Setting: 22-bed medical-surgical intensive care unit of a 659-bed university affiliated teaching hospital in Montreal, Quebec, Canada., Results: Mean informational support, assessed with a modified version of the CCFNI (Molter and Leske, 1983), was 55.41(SD=13.28; theoretical range of 20-80). Mean anxiety, assessed with the State Anxiety Scale (Spielberger et al., 1983) was 45.41 (SD=15.27; theoretical range of 20-80). Mean satisfaction with care, assessed using Androfact (Version 4.0, 2001), was 83.09 (SD=15.49; theoretical range of 24-96). A significant positive correlation was found between informational support and satisfaction with care (r=0.741, p<.001). No significant relationships were noted between informational support and anxiety nor between satisfaction with care and anxiety., Conclusion: Findings are related to the ultimate objectives of refining a local informational support initiative and its eventual evaluation, and in so doing, are of more widespread interest to others striving to make evidence based improvements to the care of similar populations., (Copyright 2009 Elsevier Ltd. All rights reserved.)

This qualitative study explored the meaning of quality of life (QOL) from the perspective of palliative care patients by examining their lived experiences and their perceptions of what contributes to their QOL. Ten in-patients--five women and five men--took part in in-depth, semi-structured interviews. When asked about their QOL, they spoke about three distinct aspects: the meaning of a quality life at this stage in their illness trajectory, the experience of living with the illness, and factors that contributed to their QOL. Patients' approach to life, illness life, and ideal quality life were found to create a sphere of influence that shaped their end-of-life experience. At the heart of living a quality end of life for these patients was their ability to "do the things that I usually do," "be helpful to others," and "live in a caring environment," The findings highlight the importance of understanding each of these factors: patients' approach to life, illness life, and ideal quality of life, and what they mean to patients in order to tailor interventions to enhance their QOL.

At the end of 2007, Medicare reported the increase in medical imaging costs overtook increases in pharmaceutical costs for the first time. Imaging costs accounted for a 20% increase, while pharmaceuticals accounted for just 10%. There are two common areas where imaging costs impact overall healthcare spending: unnecessary exams and operational management. This article does not suggest alternatives to today's imaging management practices. It provides economic information, which may be valuable to imaging managers who want to gauge the costs of operating their own departments to what is going on in the industry.

The holding area, as the patient's first introduction to the surgical suites, has the potential to set the tone for the entire surgical experience. To identify targets for improvement efforts in the holding area, a convenience sample of 51 surgical patients completed a 12-item patient satisfaction survey developed using Androfact before discharge from hospital. Results reveal 5 aspects that fall below the desired benchmark satisfaction rate of 80%: staff holding personal conversations in the patients' presence, being offered distraction materials while waiting, pleasantness of the physical environment, reassurance that family members would be kept up-to-date during the surgical procedure, and comfort to provide personal information without worrying that others were listening. Discussion of findings indicates priorities for improvement efforts in the holding area.

Cardiology patients have important learning needs. A 21-item patient satisfaction questionnaire was mailed to 384 cardiology patients 1 week after discharge. Satisfaction ratings indicated that the 161 respondents were satisfied with their care: however, they wanted more information regarding the management of their symptoms and activity level at home. Nurses' interviews revealed that they assessed the availability of follow-up care upon discharge. The results suggest that patients are not satisfied with the information they receive before discharge. Also, nurses and patients have different perceptions about the information patients need. These differences need to be taken into consideration when designing discharge teaching interventions.

Objectives: To compare the effects of nurse case management with usual care provided to community-dwelling frail older people in regard to quality of life, satisfaction with care, functional status, admission to hospital, length of hospital stay, and readmission to emergency department., Design: Randomized controlled trial., Setting: University hospital and two proximal community health centers., Participants: 427 frail older people (> or = 70 years of age and at risk for repeated hospital admissions) discharged home from the emergency department., Experimental: Nurse case management, which consisted of coordination and provision of healthcare services by nurses, both in and out of hospital, for a 10-month period., Control: Usual care, which varied by healthcare provider and community health center., Measurements: Outcomes were assessed 10 months post-randomization by telephone and/or home interview and by medical record review. Questionnaires included the SF-36, CSQ-8, and OARS., Results: No significant differences were found in quality of life, satisfaction with care, functional status, admission to hospital, or length of hospital stay. Nurse-case-managed older adults were readmitted to the emergency department significantly more often than their usual care counterparts., Conclusions: Frail older people receiving nurse case management are more likely to use emergency health services without a concomitant increase in health benefits.

A simple phone call was the impetus for a group of hospitals in northern New Jersey to create a consortium that would meet their collective need to supply continuing education credits for their RTs. Many of the seven original member-hospitals had eliminated continuing education reimbursement and other resources were unavailable. Yet hospital RTs still needed to fulfill American Registry of Radiologic Technologists (ARRT) requirements. The mission of the consortium was to provide a variety of topics that would meet the criteria for continuing education credits, as mandated by the ARRT. The idea was so simple, the seven original hospital members wondered why they hadn't thought of it earlier. If each member hospital offered a three-credit seminar, collectively the consortium could offer 21 credits per year for their employees, more than enough to meet ARRT requirements. The group gave itself a name--Northern New Jersey Council for Continuing Education--and quickly began to create a policy and procedure manual. It came up with basic rules for attendance, voting privileges and a goal for expanding its membership. The newly created manual detailed member responsibilities and instructions for holding seminars. The manual outlined responsibilities for collecting fees, registration, attendance and certification. The consortium agreed on a consistent format for advertising, letterhead and certificates for seminars. Each member was required to submit a course outline for the consortium's approval, which allowed a variety of both technical and nontechnical topics. Some members organized their own seminars, after submitting an application to the ASRT for approval. Others worked with various vendors who were happy to provide a seminar to a group of customers, rather than to individual customers. After three years, the consortium has proved beneficial to all involved. Most of all, it has met the members' goal of providing continuing education with limited resources.

Objective: To determine predictors of 2-year post-hospitalization mortality in a cohort of elderly hospitalized patients originally assembled to assess the impact of a Geriatric Consultation Team (GCT)., Design: Two-year follow-up of an inception cohort., Setting: University-affiliated tertiary care VA Medical Center., Patients: One hundred sixty-seven veterans age 75 or older discharged following hospitalization on medical, surgical, or psychiatry services but not intensive care units., Intervention: None specifically studied here though cohort was previously part of randomized control trial of a Geriatric Consultation Team., Measurement: Mortality during 2 years of post-hospitalization follow-up., Results: Two-year post-hospitalization mortality was 28 percent with no difference between the original GCT and control groups. For the entire sample, age, mental status, admission or discharge ADLs (but not change in ADL status), number of admission problems, number of discharge diagnoses, and discharge site were significant predictors of mortality in univariate analysis. Only discharge ADLs and discharge site remained significant in multivariate analysis., Conclusion: Measures of ADLs during hospitalization are stronger predictors of mortality following hospitalization than disease diagnoses. Impaired ADLs and placement other than at home are significant predictors of mortality, suggesting that the decision for nursing home placement contains other independently predictive information within it and/or that the subsequent nursing home period produces excess mortality. As had been indicated in short-term follow-up, there was no survival advantage for the Geriatric Consultation Group.

We conducted a phase II study of intraperitoneal (IP) cisplatin (CDDP) and etoposide (VP-16) as salvage therapy in patients with ovarian cancer who had persistent disease or who had relapsed after primary systemic chemotherapy and had residual disease of less than 2 cm. Two hundred eleven courses of IP chemotherapy consisting of CDDP 200 mg/m2 and VP-16 350 mg/m2 were administered. All patients received intravenous (IV) thiosulfate protection. Treatment was given once every 4 weeks for a median of six cycles. Twenty-four of 37 assessable patients were clinically free of disease at the end of treatment (normal physical exam, computed tomographic [CT] scan, CA-125 and peritoneal cytology); one patient had a partial response. Ten of these 24 patients consented to reexploration at the end of treatment, and nine were in pathologic complete remission, while one patient had positive peritoneal washings as her only evidence of persistent disease. The median survival of the 37 patients was 26 months from the first day of IP treatment and 51 months from diagnosis. The major toxicity was myelosuppression, with median nadir WBC, granulocyte, and platelet counts of 2,400, 684, and 134,000/mm3, respectively. There was no cumulative renal damage, hypomagnesemia, or chemical peritonitis. We conclude that IP CDDP and VP-16 can produce pathologic complete remissions when used as a second-line regimen for patients with ovarian cancer who have received systemic cisplatin-based therapy and have less than 2 cm disease.

Treatment options for patients with ovarian cancer who have failed systemic and intraperitoneal (ip) cisplatin-based chemotherapy are limited. We conducted a phase I clinical study of ip thiotepa in patients with refractory ovarian cancer to determine the maximum tolerated dose (MTD). Ten patients were given 39 courses of thiotepa (median number of courses per patient, 3.5; range, 1-10+). All patients had received prior ip cisplatin; 7 also had received iv cisplatin, and 5 had three or more prior regimens. Thiotepa (30-80 mg/m2) was given ip in 2 liters normal saline every 4 weeks. The therapy was well tolerated. There was no vomiting, stomatitis, alopecia, or peritonitis. The dose-limiting toxicity was myelosuppression. With repeated doses, patients had a delayed marrow recovery and required a 1- to 2-week delay in treatment. Six patients had stable disease (duration 2-14+ months; median duration 5 months); 1 patient had a 50% decrease in CA-125 level, and 1 patient with no measurable disease remained clinically disease-free. In summary, ip thiotepa had clinical activity in heavily pretreated patients with refractory ovarian cancer with disease stabilization seen in 6 of 9 evaluable patients and a partial response seen in 1 patient. Myelosuppression was the only toxicity encountered. A dose of 60 mg/m2 ip is recommended for phase II studies.