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Abstract Background Unprofessional behaviours between healthcare workers are highly prevalent. Evaluations of large-scale culture change programs are rare resulting in limited evidence of intervention effectiveness. We conducted a multi-method evaluation of a professional accountability and culture change program “Ethos” implemented across eight Australian hospitals. The Ethos program incorporates training for staff in speaking-up; an online system for reporting co-worker behaviours; and a tiered accountability pathway, including peer-messengers who deliver feedback to staff for ‘reflection’ or ‘recognition’. Here we report the final evaluation component which aimed to measure changes in the prevalence of unprofessional behaviours before and after Ethos. Methods A survey of staff (clinical and non-clinical) experiences of 26 unprofessional behaviours across five hospitals at baseline before (2018) and 2.5–3 years after (2021/2022) Ethos implementation. Five of the 26 behaviours were classified as ‘extreme’ (e.g., assault) and 21 as incivility/bullying (e.g., being spoken to rudely). Our analysis assessed changes in four dimensions: work-related bullying; person-related bullying; physical bullying and sexual harassment. Change in experience of incivility/bullying was compared using multivariable ordinal logistic regression. Change in extreme behaviours was assessed using multivariable binary logistic regression. All models were adjusted for respondent characteristics. Results In total, 3975 surveys were completed. Staff reporting frequent incivility/bullying significantly declined from 41.7% (n = 1064; 95% CI 39.7,43.9) at baseline to 35.5% (n = 505; 95% CI 32.8,38.3; χ2(1) = 14.3; P

Abstract Background This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals’ capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers’ ability to cope with unexpected scenarios is key to managing change. Methods We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. Results CMO statements were refined for four initial program theories: Making it Relevant– where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement– where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss– where the effects of staff turnover were mitigated; and Community-Wide Priority– where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. Conclusions A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Abstract Background The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance. Methods A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach. Results Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience. Conclusion It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Abstract Background Unwarranted clinical variation in hospital care includes the underuse, overuse, or misuse of services. Audit and feedback is a common strategy to reduce unwarranted variation, but its effectiveness varies widely across contexts. We aimed to identify implementation strategies, mechanisms, and contextual circumstances contributing to the impact of audit and feedback on unwarranted clinical variation. Methods Realist study examining a state-wide value-based healthcare program implemented between 2017 and 2021 in New South Wales, Australia. Three initiatives within the program included audit and feedback to reduce unwarranted variation in inpatient care for different conditions. Multiple data sources were used to formulate the initial audit and feedback program theory: a systematic review, realist review, program document review, and informal discussions with key program stakeholders. Semi-structured interviews were then conducted with 56 participants to refute, refine, or confirm the initial program theories. Data were analysed retroductively using a context-mechanism-outcome framework for 11 transcripts which were coded into the audit and feedback program theory. The program theory was validated with three expert panels: senior health leaders (n = 19), Agency for Clinical Innovation (n = 11), and Ministry of Health (n = 21) staff. Results The program’s audit and feedback implementation strategy operated through eight mechanistic processes. The strategy worked well when clinicians (1) felt ownership and buy-in, (2) could make sense of the information provided, (3) were motivated by social influence, and (4) accepted responsibility and accountability for proposed changes. The success of the strategy was constrained when the audit process led to (5) rationalising current practice instead of creating a learning opportunity, (6) perceptions of unfairness and concerns about data integrity, 7) development of improvement plans that were not followed, and (8) perceived intrusions on professional autonomy. Conclusions Audit and feedback strategies may help reduce unwarranted clinical variation in care where there is engagement between auditors and local clinicians, meaningful audit indicators, clear improvement plans, and respect for clinical expertise. We contribute theoretical development for audit and feedback by proposing a Model for Audit and Feedback Implementation at Scale. Recommendations include limiting the number of audit indicators, involving clinical staff and local leaders in feedback, and providing opportunities for reflection.

Background Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner–emergency department service models. Objectives To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner–emergency department models. Design Mixed-methods realist evaluation. Methods Phase 1 (2017–8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018–21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost–consequences analysis of routine data; and case site data for ‘marker condition’ analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021–2), to conduct mixed-methods analysis for programme theory and toolkit development. Results General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner–emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner–emergency department models. Limitations The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with ‘marker conditions’). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as ‘telephone first’ and their relevance to our findings remains unexplored. Conclusion Findings suggest that general practitioner–emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner–emergency department services. Future work The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner–emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy. Study registration This study is registered as PROSPERO CRD42017069741. 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: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information. Plain language summary Hospital emergency departments are under huge pressure. Patients are waiting many hours to be seen, some with problems that general practitioners could deal with. To reduce waiting times and improve patient care, arrangements have been put in place for general practitioners to work in or alongside emergency departments (general practitioner–emergency department models). We studied the different ways of working to find out what works well, how and for whom. We brought together a lot of information. We reviewed existing evidence, sent out surveys to 184 emergency departments, spent time in the emergency departments observing how they operated and interviewing 106 staff in 13 hospitals and 24 patients who visited those emergency departments. We also looked at statistical information recorded by hospitals. Two public contributors were involved from the beginning, and we held two stakeholder events to ensure the relevance of our research to professionals and patients. Getting reliable figures to compare the various general practitioner–emergency department set-ups (inside, parallel to or outside the emergency department) was difficult. Our findings suggest that over time more people are coming to emergency departments and overall waiting times did not generally improve due to general practitioner–emergency department models. Evidence that general practitioners might admit fewer patients to hospital was mixed, with limited findings of cost savings. Patients were generally supportive of the care they received, although we could not speak to as many patients as we planned. The skills and experience of general practitioners were often valued as members of the wider emergency department team. We identified how the care provided was kept safe with: strong leaders, good communication between different types of staff, highly trained and experienced nurses responsible for streaming and specific training for general practitioners on how they were expected to work. We have produced a guide to help professionals develop and improve general practitioner–emergency department services and we have written easy-to-read summaries of all the articles we published. Scientific summary Background Emergency healthcare services are under intense pressure to meet the increasing patient demands. Many patients presenting to emergency departments (EDs) could be managed by general practitioners (GPs). We aimed to evaluate the effectiveness, safety, patient experience and system implications of the different models of GPs working in or alongside EDs (GP-ED). Objectives Identify which models are in place. Describe how the models work. Describe the outcomes of each model. Explain the relationships between contexts (C), mechanisms (M) and outcomes (O) to develop a programme theory to help inform service delivery in other settings. Design We conducted a mixed-methods realist evaluation to describe what works, for whom, in what circumstances and how over three phases. Phase 1: understanding current practice and which models are in place Rapid realist review Method We conducted a rapid realist review to develop initial theories about how different GP-ED models operate, supported by our co-applicants as an expert reference group. Results A total of 96 articles contributed to initial theories: how decisions on streaming patients to GP services are influenced; the role of GPs in EDs; patient satisfaction and safety concerns; the risk of provider-induced demand in highly visible services; and whether these services represent value for money. National survey and follow-up clinical director interviews Method We sent an online survey to 184 clinical directors (CDs) from Type 1 EDs in England and Wales to gather information on aims, implementation and delivering the GP-ED services. Thirty CDs who worked in services implemented since 2010 (a range of locations, models and sizes) were invited to take part in semistructured telephone interviews to explore: service operation, perceived successes and challenges. Results We received 77 responses out of 184 invitees (41.3%); 51 (66%) respondents used a GP-ED model. We interviewed 21 CDs. Findings were used to characterise and categorise GP-ED models to create a taxonomy, inform case study site selection and further theory development. National stakeholder event Method We held a National Stakeholder event in Bristol in 2018 (n = 48 attendees), to present findings from the review and survey, gather stakeholder feedback on a taxonomy of GP-ED models (in collaboration with researchers from the GP-ED team at the University of the West of England) and identify ‘marker conditions’ to guide data collection in Phase 2. Results The taxonomy included a description of the ‘form’ of the GP-ED models (inside the ED: Integrated with ED service delivery or a separate Parallel service; or Outside the ED: on or off the hospital site) and a description of how different constructs influence how the service may ‘function’ – as a traditional GP service or emergency medicine service. Five marker conditions were selected, including: child with a fever, cough/shortness of breath, abdominal pain, back pain and chest pain. (We added ‘headache’ as a further condition in Phase 2 of the study to enhance patient interview recruitment.) National patient safety data collection and analysis Method We searched Coroners’ Reports to Prevent Future Deaths (2013–8) and National Reporting and Learning System (NRLS) patient safety incident reports (2005–15) relating to diagnostic errors in GP-ED services. We coded these using the Patient Safety Classification System (PISA) framework and developed initial safety theories to inform data collection in Phase 2. Results We identified 9 relevant Coroners’ Reports and 217 NRLS reports. Initial theories were developed around: difficulty with triage and streaming processes; errors in clinical decision-making; and inadequate referral pathways and communication between services. Phase 2: case study mixed-methods data collection and analysis to describe how the general practitioner–emergency department models work and outcomes Qualitative data analysis Method We selected 13 case study sites reflecting different GP-ED models (3 Integrated, 4 Parallel, 3 Outside and 3 with no GP-ED model), different locations, sizes of ED and experience delivering the service. We visited all sites (2–4 days) and conducted observations and realist interviews with staff to refine initial theories. We requested local patient safety incident reports related to the GP-ED model and invited patients presenting with marker conditions for interviews to describe their experience. We analysed data from the multiple data sources and applied knowledge from conceptual frameworks and formal theories to refine our initial theories. We then mapped context–mechanism–outcome configurations against different GP-ED models to compare across different types of service. We presented findings at a second national event on 3 December 2019 (n = 70 attendees) for stakeholder feedback. Results Across all sites, we interviewed 106 staff members, collected 14 anonymised local patient safety incident reports, invited 748 patients to take part in telephone interviews and subsequently interviewed 24 patients. Theories were refined to describe: how streaming processes were influenced by nurse experience, guidance and overall operational and strategic management; how GPs found working in EDs influenced their clinical decision-making to maintain a usual GP approach or adopt an ED clinician approach, mitigating safety risks; factors that facilitate teamwork and communication between GP-ED services and the ED; how separate, visible GP-ED services are perceived to contribute to provider-induced demand; and patients’ expectations and experiences of using services. Routine data analysis Method We obtained patient-level data relating to ED attendances and subsequent hospital admissions from hospital episode statistics accident and emergency and admitted patient care (APC) data sets, via NHS Digital for study sites located in England; and from emergency department data set and patient episode database for Wales data sets (via secure anonymised information linkage) for one study site located in Wales. We summarised the attendance-level data as time series (per site, aggregating data for each study fortnight) for the following ED variables: Attendances; Reattendances; Hospital admissions (defined by patient record appearing in the APC data set); Investigations and Treatments; Time in ED; length of stay (LOS) of hospital admission. For all variables, we used standard time series analysis methods to assess the nature and extent of linear trends and seasonality in data before and after an intervention point at intervention sites. Results Data from 1 October 2010 to 30 September 2018 were eligible for inclusion and were of variable quality, tending to decrease as the level of integration between to GP-ED model and the ED decreased. We are more confident in the interpretations made about some outcomes (attendances, reattendances, admissions, LOS) than others (investigations, treatments, average time in ED) due to data quality. In general, at the GP-ED model sites, attendances increased over time. Reattendances within 28 days in the post-intervention period increased over that in the pre-intervention period in eight of the nine sites assessed. Overall, intervention sites also demonstrated a consistent trend of increasing average time in the ED across both the pre- and post-intervention phases. A mixed picture was seen in relation to hospital admissions in the Integrated and Parallel sites, with data quality issues at the Outside sites. Average length of hospital stay showed a mixed picture over all intervention sites. Cost–consequences analysis Method We conducted a cost–consequences analysis (CCA) using the routine data described above to consider the costs and resource consequences resulting from, or associated with, the use of the GP-ED model types compared to control sites. Results Negligible incremental ED attendance cost differences were observed between the model types and the control with an extremely small increased cost [£0.70, standard error (SE) £0.07] observed when looking at all models combined over control, though a saving of £72 (SE £3.18) when looking at inpatient admissions. When looking at ED visits by individual models, the Integrated model saw a small cost saving (£8.73, SE £0.07), but small cost increases were seen in the Parallel model (£9.51, SE £0.08) and the Outside model (£16.30, SE £0.16). With respect to inpatient admissions, all models saw small cost savings [£25 (SE £4.16) to £215 (SE £9.05)] with the Outside model showing the largest saving (£215, SE £9.05). Marker condition analysis Method We used a CCA as above to evaluate the management of six marker conditions at a Parallel GP-ED model as a case study site (the only site with data available during the pandemic period). Anonymised patient-level data were used to compare proportions of patients admitted to hospital (Pearson’s chi-squared test), and times (non-parametric Mann–Whitney U-test) for ED clinicians and GPs. A backward enter stepwise approach was taken with non-statistically significant variables (p > 0.05) removed. Results Emergency department clinicians saw most patients and those patients categorised as being more severely unwell. Across all marker conditions, GPs managed patients more quickly – the main driver being the time taken from treatment to discharge. Across all marker conditions, the trend was for GPs to admit fewer patients to inpatient care, compared with ED clinicians. This trend was more evident (and for some reaching statistical significance) among those requiring the lowest levels of intervention. Reattendance rates at 7 days were equal for both GPs and ED clinicians. Phase 3: mixed-method analysis, programme theory and toolkit development Mixed-methods analyses Method We conducted mixed-methods analyses to further refine our theories through two approaches: firstly, to identify questions raised through the qualitative data analysis to support, refute or refine through quantitative data analyses; then to identify noteworthy findings from the statistical analysis and cross-check with both the qualitative and marker conditions analyses. Results Streaming The marker condition and qualitative data analysis indicated the potential for GPs to improve the flow of the least unwell patients through the ED. However, at the whole ED level examined by the routine data, the analysis demonstrated increased time in the ED for patients at most sites. Therefore, our theories related to streaming and patient flow have limited support from quantitative data. General practitioner role Marker condition data from a single Parallel case study site showed that patients spent less time in the department and were less likely to be admitted, with no difference in reattendance rates at 7 days. Data on investigation use were of poor quality and not included in the analysis. Routine data for all intervention sites and three control sites also showed poor quality of investigation data. Any influence on time in the department and hospital admissions described in the marker condition data was not seen consistently in routine data analysis. While the marker conditions analysis supports the theory that a GP approach in an ED setting can be different to an ED clinician approach, it remains unclear whether this is due to individual clinicians’ management behaviours or service level differences in ways of working. The quantitative data did not identify particular GP-ED models associated with favourable outcomes potentially attributable to facilitating the ‘GP role’. Safety The routine data indicated increasing rates of reattendance at 28 days across most intervention and control sites. This may reflect changes in levels of morbidity among the population, public behaviours or service configurations (including availability of services elsewhere, notably in-hours primary care) rather than necessarily representing a change in the quality of the care provided at the ED. The marker condition data suggested that GP care in the ED appeared to be as safe as ED clinician care using reattendances within 7 days as a proxy. We have not identified data to develop our theory about strength of communication and teamworking within the ED. Patient experience While the marker conditions analysis indicated that patients attending ED who required the fewest investigations and treatments might be more satisfied by being seen by a GP due to a shorter ED stay, we could not identify any particular GP-ED model that appeared most likely to consistently decrease department stay. Demand Our theory about provider-induced demand in distinct and visible services is not supported by the data on ED attendances over the study period, but our qualitative findings suggest that there is a perceived additional demand for primary care at an ED in services where the primary care service is visible, easily accessible and more well known in the local area. Programme theory development We developed a programme theory, as the principal out of the research, presented as the patient journey through the three GP-ED models, to highlight similarities and differences. We recognise that each site had unique characteristics, so this represents a high-level summary of key features, rather than a description of every possible variation. At Integrated models, the streaming process is less influential. The ‘invisibility’ of the GP service means its impact on patient expectations is also more limited, but it allows for GPs to take on supervision of junior ED doctors, described positively at some sites. At Outside models, the process of ensuring that the right patient saw the GP was more complex, and open to potential problems. Their high visibility and accessibility were likely to have a greater impact on patients’ expectations and experiences. At these sites, GPs often took on a supervisory role for a wider primary care team. Parallel models showed the most variation in the way services were set up and the clarity of the GP role: some more like Integrated models others, Outside models. Toolkit We worked with study co-applicants and a stakeholder group of CDs to translate the research findings and programme theory into guidance for implementing and delivering GP-ED services. Some key points include: A culture including strong clinical leadership, encouraging mutual respect, interprofessional communication and teamworking is essential. To ensure that patients are efficiently and safely streamed, nurses should be highly trained and experienced; streaming pathways/protocols must be clear with senior oversight and include quality improvement systems. Training for GPs based on the type of GP-ED model in use and their intended role. Patients need to be informed about reasons for being streamed to different clinicians to help manage expectations. Conclusion General practitioners commonly work in EDs, but delivery models vary widely in terms of the scope of the GP role and the scale of the GP service. We developed a taxonomy to describe GP-ED models (Integrated, Parallel, Outside) and present a programme theory to describe how these models were observed to operate. Routine data were heterogeneous and of variable quality limiting analysis, including verification of the proposed theories, but trends were noted across intervention sites for: increased time spent in the ED, increased ED attendances and reattendances and mixed findings for hospital admissions. Findings suggest that GP-ED service models do not meet the aim of reducing ED waiting times and improving patient flow, with limited evidence of cost savings. Qualitative data indicated that GPs were often valued as members of the wider ED team, with significant appetite to utilise their specific skillset to provide care in the ED. We developed a toolkit, based on our findings, to provide guidance for implementing and delivering GP-ED services. Study registration This study is registered as PROSPERO CRD42017069741. 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: 15/145/04) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Abstract Background The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. Methods We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript. Results We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose. Conclusions We have scrutinised the meaningful use of the PISA classification system’s application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems.

Abstract Background Out of pocket (OOP) costs vary substantially by health condition, procedure, provider, and service location. Evidence of whether this variation is associated with indicators of healthcare quality and/or health outcomes is lacking. Methods The current review aimed to explore whether higher OOP costs translate into better healthcare quality and outcomes for patients in inpatient settings. The review also aimed to identify the population and contextual-level determinants of inpatient out-of-pocket costs. A systematic electronic search of five databases: Scopus, Medline, Psych Info, CINAHL and Embase was conducted between January 2000 to October 2022. Study procedures and reporting complied with PRISMA guidelines. The protocol is available at PROSPERO (CRD42022320763). Findings A total of nine studies were included in the final review. A variety of quality and health outcomes were examined in the included studies across a range of patient groups and specialities. The scant evidence available and substantial heterogeneity created challenges in establishing the nature of association between OOP costs and healthcare quality and outcomes. Nonetheless, the most consistent finding was no significant association between OOP cost and inpatient quality of care and outcomes. Interpretation The review findings overall suggest no beneficial effect of higher OOP costs on inpatient quality of care and health outcomes. Further work is needed to elucidate the determinants of OOP hospital costs. Funding This study was funded by Medibank Better Health Foundation.

Abstract An understanding of factors influencing implementation is essential to realise the benefits of population-based reproductive genetic carrier screening programs. The aim of this study was to synthesise data collected during the Australian Reproductive Genetic Carrier Screening Project (Mackenzie’s Mission) to track how priorities shifted over time and identify important factors during scaling-up and for sustainment. We used a multi-method qualitative approach to integrate longitudinal project data collected from 10 project committees with 16 semi-structured interviews conducted with study team members. Both datasets were analysed using the Consolidated Framework for Implementation Research (CFIR) to identify constructs of interest within early, mid-point, and future implementation phases. Several CFIR constructs were present across implementation. The complexity of implementation presented challenges that were overcome through a quality-designed and packaged product, formal and informal networks and communication, and access to knowledge and information. Addressing the diverse consumer needs through resources and increasing community and non-genetic speciality engagement remained a priority throughout and for future sustainment. Going forward, further addressing program complexities and securing funding were emphasised. By applying an implementation framework, findings from this study may be useful for future effort towards building and/or sustaining reproductive genetic carrier screening programs.

Abstract Background A broad-based international shift to virtual care models over recent years has accelerated following COVID-19. Although there are increasing numbers of studies and reviews, less is known about clinicians’ and consumers’ perspectives concerning virtual modes in contrast to inpatient modes of delivery. Methods We conducted a mixed-methods study in late 2021 examining consumers’ and providers’ expectations of and perspectives on virtual care in the context of a new facility planned for the north-western suburbs of Sydney, Australia. Data were collected via a series of workshops, and a demographic survey. Recorded qualitative text data were analysed thematically, and surveys were analysed using SPSS v22. Results Across 12 workshops, 33 consumers and 49 providers from varied backgrounds, ethnicities, language groups, age ranges and professions participated. Four advantages, strengths or benefits of virtual care reported were: patient factors and wellbeing, accessibility, better care and health outcomes, and additional health system benefits, while four disadvantages, weaknesses or risks of virtual care were: patient factors and wellbeing, accessibility, resources and infrastructure, and quality and safety of care. Conclusions Virtual care was widely supported but the model is not suitable for all patients. Health and digital literacy and appropriate patient selection were key success criteria, as was patient choice. Key concerns included technology failures or limitations and that virtual models may be no more efficient than inpatient care models. Considering consumer and provider views and expectations prior to introducing virtual models of care may facilitate greater acceptance and uptake.

Abstract Background Unprofessional behaviour among hospital staff is common. Such behaviour negatively impacts on staff wellbeing and patient outcomes. Professional accountability programs collect information about unprofessional staff behaviour from colleagues or patients, providing this as informal feedback to raise awareness, promote reflection, and change behaviour. Despite increased adoption, studies have not assessed the implementation of these programs utilising implementation theory. This study aims to (1) identify factors influencing the implementation of a whole-of-hospital professional accountability and culture change program, Ethos, implemented in eight hospitals within a large healthcare provider group, and (2) examine whether expert recommended implementation strategies were intuitively used during implementation, and the degree to which they were operationalised to address identified barriers. Method Data relating to implementation of Ethos from organisational documents, interviews with senior and middle management, and surveys of hospital staff and peer messengers were obtained and coded in NVivo using the Consolidated Framework for Implementation Research (CFIR). Implementation strategies to address identified barriers were generated using Expert Recommendations for Implementing Change (ERIC) strategies and used in a second round of targeted coding, then assessed for degree of alignment to contextual barriers. Results Four enablers, seven barriers, and three mixed factors were found, including perceived limitations in the confidential nature of the online messaging tool (‘Design quality and packaging’), which had downstream challenges for the capacity to provide feedback about utilisation of Ethos (‘Goals and Feedback’, ‘Access to Knowledge and Information’). Fourteen recommended implementation strategies were used, however, only four of these were operationalised to completely address contextual barriers. Conclusion Aspects of the inner setting (e.g., ‘Leadership Engagement’, ‘Tension for Change’) had the greatest influence on implementation and should be considered prior to the implementation of future professional accountability programs. Theory can improve understanding of factors affecting implementation, and support strategies to address them.

Abstract Background Integrated care is a model recognised internationally, however, there is limited evidence about its usability in the community. This study aimed to elicit community and provider views about integrated care and how implementation could meet their healthcare needs in a new hospital. Methods Using a qualitative approach, consumer and provider views on the strengths, barriers and enablers for integrated care were collected via a series of online workshops and supplementary interviews. Results A total of 22 consumers and 49 providers participated in 11 focus groups; all perceived integrated care to be an accessible and efficient model that offers a high level of care which enhanced staff and patient well-being. Providers expressed concerns about longer waiting times and safety risks associated with communication gaps and insufficient staff. Enablers include supporting consumers in navigating the integrated care process, co-ordinating and integrating primary care into the model as well as centralising patient electronic medical records. Discussion Primary, tertiary and community linkages are key for integrated care. Successful interoperability of services and networks requires an investment in resources and infrastructure to build the capability for providers to seamlessly access information at all points along the patient pathway. Conclusion Integrated care is perceived by consumers and providers to be a flexible and patient-focused model of healthcare that offers benefits for a hospital of the future.

The concept of safety culture in healthcare—a culture that enables staff and patients to be free from harm—is characterized by complexity, multifacetedness, and indefinability. Over the years, disparate and unclear definitions have resulted in a proliferation of measurement tools, with lack of consensus on how safety culture can be best measured and improved. A growing challenge is also achieving sufficient response rates, due to “survey fatigue,” with the need for survey optimisation never being more acute. In this paper, we discuss key challenges and complexities in safety culture assessment relating to definition, tools, dimensionality and response rates. The aim is to prompt critical reflection on these issues and point to possible solutions and areas for future research.

Abstract Background Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories. Methods We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners’ reports to prevent future deaths (30.7.13–14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05–30.11.15). Results Nine Coroners’ reports (from 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children. Conclusion Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.

Despite good quality evidence for benefits with its use, challenges have been encountered in the correct and consistent implementation of the surgical safety checklist (SSC). Previous studies of the SSC have reported a discrepancy between what is documented and what is observed in real time. A baseline observational audit at our institution demonstrated compliance of only 3.5% despite a documented compliance of 100%. This project used quality improvement principles of identifying the problem and designing strategies to improve staff compliance with the SSC. These included changing the SSC from paper-based to a reusable laminated form, a broad multidisciplinary education and marketing campaign, targeted coaching and modifying the implementation in response to ongoing staff feedback. Five direct observational audits were undertaken over four Plan–Do–Study–Act cycles to capture real-time information on staff compliance. Two staff surveys were also undertaken. Compliance with the SSC improved from 3.5% to 63% during this study. Staff reported they felt the new process improved patient safety and that the new SSC was easily incorporated into their workflow. Improving compliance with the SSC requires deep engagement with and cooperation of surgical, anaesthesia and nursing teams and understanding of their work practices and culture. The prospective observational audit highlighted an initial 3.5% compliance rate compared with 100% based on an audit of the patient notes. Relying solely on a retrospective paper-based model can lead to hospitals being unaware of significant safety and quality issues. While in-person prospective observations are more time-consuming and resource-consuming than retrospective audits, this study highlights their potential utility to gain a clear picture of actual events. The significant variation between documented and observed data may have considerable implications for other retrospective studies which rely on human-entered data for their results.