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This randomised phase III study in advanced non-small cell lung cancer (NSCLC) patients was conducted to compare vinorelbine/carboplatin (VC) and gemcitabine/carboplatin (GC) regarding efficacy, health-related quality of life (HRQOL) and toxicity. Chemonaive patients with NSCLC stage IIIB/IV and WHO performance status 0–2 were eligible. No upper age limit was defined. Patients received vinorelbine 25 mg m−2 or gemcitabine 1000 mg m−2 on days 1 and 8 and carboplatin AUC4 on day 1 and three courses with 3-week cycles. HRQOL questionnaires were completed at baseline, before chemotherapy and every 8 weeks until 49 weeks. During 14 months, 432 patients were included (VC, n=218; GC, n=214). Median survival was 7.3 vs 6.4 months, 1-year survival 28 vs 30% and 2-year survival 7 vs 7% in the VC and GC arm, respectively (P=0.89). HRQOL, represented by global QOL, nausea/vomiting, dyspnoea and pain, showed no significant differences. More grade 3–4 anaemia (P<0.01), thrombocytopenia (P<0.01) and transfusions of blood (P<0.01) or platelets (P<0.01) were observed in the GC arm. There was more grade 3–4 leucopoenia (P<0.01) in the VC arm, but the rate of neutropenic infections was the same (P=0.87). In conclusion, overall survival and HRQOL are similar, while grade 3–4 toxicity requiring interventions are less frequent when VC is compared to GC in advanced NSCLC.British Journal of Cancer (2007) 97, 283–289. doi:10.1038/sj.bjc.6603869 www.bjcancer.com Published online 26 June 2007 [ABSTRACT FROM AUTHOR]

This randomised multicentre trial was conducted to establish the optimal duration of palliative chemotherapy in advanced non-small-cell lung cancer (NSCLC). We compared a policy of three vs six courses of new-generation platinum-based combination chemotherapy with regard to effects on quality of life (QoL) and survival. Patients with stage IIIB or IV NSCLC and WHO performance status (PS) 0-2 were randomised to receive three (C3) or six (C6) courses of carboplatin (area under the curve (AUC) 4, Chatelut's formula, equivalent to Calvert's AUC 5) on day 1 and vinorelbine 25 mg m(-2) on days 1 and 8 of a 3-week cycle. Key end points were QoL at 18 weeks, measured with EORTC Quality of Life Questionnaire (QLQ)-C30 and QLQ-LC13, and overall survival. Secondary end points were progression-free survival and need of palliative radiotherapy. Two hundred and ninety-seven patients were randomised (C3 150, C6 147). Their median age was 65 years, 30% had PS 2 and 76% stage IV disease. Seventy-eight and 54% of C3 and C6 patients, respectively, completed all scheduled chemotherapy courses. Compliance with QoL questionnaires was 88%. There were no significant group differences in global QoL, pain or fatigue up to 26 weeks. The dyspnoea palliation rate was lower in the C3 arm at 18 and 26 weeks (P<0.05), but this finding was inconsistent across different methods of analysis. Median survival in the C3 group was 28 vs 32 weeks in the C6 group (P=0.75, HR 1.04, 95% CI 0.82-1.31). One- and 2-year survival rates were 25 and 9% vs 25 and 5% in the C3 and C6 arm, respectively. Median progression-free survival was 16 and 21 weeks in the C3 and C6 groups, respectively (P=0.21, HR 0.86, 95% CI 0.68-1.08). In conclusion, palliative chemotherapy with carboplatin and vinorelbine beyond three courses conveys no survival or consistent QoL benefits in advanced NSCLC. [ABSTRACT FROM AUTHOR]

Abstract Background Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement. Methods Førde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework. Results Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute. Conclusions The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.

Abstract Background The cancellation of planned surgeries causes prolonged wait times, harm to patients, and is a waste of scarce resources. To reduce high cancellation rates in a Norwegian general hospital, the pathway for elective surgery was redesigned. The changes included earlier clinical assessment of patients, better planning and documentation systems, and increased involvement of patients in the scheduling of surgeries. This study evaluated the outcomes of this new pathway for elective surgery and explored which factors affected the outcomes. Methods We collected the number of planned operations, performed operations, and cancellations per month from the hospital’s patient administrative system. We then used Student's t-test to analyze differences in cancellation rates (CRs) before and after interventions and a u-chart to analyze whether the improvements were sustained. We also conducted semi-structured interviews with employees of the hospital to explore the changes in the surgical pathway and the factors that facilitated these changes. Results The mean CR was reduced from 8.5% to 4.9% (95% CI for mean reduction 2.6-4.5, p p = 0.04). A clear improvement strategy, involvement of frontline clinicians, introduction of an electronic scheduling system, and engagement of middle managers were important factors for the success of the interventions. Conclusion The redesign of the old clinical pathway contributed to a sustained reduction in cancellations and an increased number of performed operations.

Background: Regular screening reduces mortality from colorectal cancer (CRC). The Canton of Vaud, Switzerland, has a regional screening programme offering faecal immunochemical tests (FITs) or colonoscopy. Participation in the screening programme has been low, particularly among complex patients. Patient navigation has strong evidence for increasing the CRC screening rate., Design and Objective: This feasibility study tested patient navigation performed by medical assistants for complex patients at an academic primary care practice., Baseline Measurements: A review of 328 patients' medical charts revealed that 51% were up-to-date with screening (16% within the programme), 24% were ineligible, 5% had a documented refusal and 20% were not up-to-date, of whom 58 (18%) were complex patients. INTERVENTION FEBRUARY 2023 TO MAY 2023: We tried to help complex patients participate in the screening programme using either in-person or telephone patient navigation. Each intervention was piloted by a physician-researcher and then performed by a medical assistant. Based on the reach, effectiveness, adoption, implementation, maintenance framework, we collected: Intervention participation and refusal, screening acceptance and completion and both patients and medical assistant acceptability (ie, qualitative interviews)., Results: Only 4/58 (7%) patients participated in the in-person patient navigation test phase due to scheduling problems. All four patients accepted a prescription and 2/4 (50%) completed their test. We piloted a telephone intervention to bypass scheduling issues but all patients refused a telephone discussion with the medical assistant. At two months after the last intervention, the proportion of patients up-to-date increased from 51% to 56%., Conclusion: Our overall approach was resource-intensive and had little impact on the overall participation rate. It was likely not sustainable. New approaches and reimbursement for a specific patient navigator role are needed to increase CRC screening of complex patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The COVID-19 pandemic magnified the cracks in healthcare performance. Dysfunctionalities and exhaustion appeared, but so did resilience and innovation. Examination of these cracks offers opportunities for learning and potential for new developments just as in the Japanese art of kintsugi, which is about building new objects from pieces of broken ceramic and mending the cracks. Engagement and partnership activities came under strain in Canada, as well - a pioneer in the field. Some were put on hold; others proved resilient and contributed to surmounting the challenges of the pandemic. Applying their Engagement-Capable Environments Framework, Kuluski and colleagues (2024) studied kintsugi in partnership activities in Canada during the pandemic. The resulting case studies exemplify the factors facilitating engagement and partnership during crisis. Through a lens of co-production that we see as a precondition for understanding and improving healthcare during a crisis and beyond, we challenge the results of the study, hoping to open new perspectives and advance engagement and partnership., (Copyright © 2024 Longwoods Publishing.)

The timing of taking antihypertensive medication does not have an impact on the cardiovascular plan. Geniculate block is an alternative to oral analgesic treatment for knee osteoarthritis. Feedback and audits are ineffective in reducing the inappropriate prescription of antibiotics in Switzerland. The intervention of community health professionals in collaboration with general practitioners allows for the control of arterial hypertension. In the case of peripheral facial paralysis, it is relevant to systematically consider performing magnetic resonance imaging. Aspirin is an alternative to enoxaparin in thromboembolic prophylaxis after surgery for a traumatic fracture. Walking 8,000 steps a few days a week reduces mortality. Opioids are not effective for acute neck and lower back pain., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Objectives: The clinical and social burden of the COVID-19 pandemic were high among asylum seekers (ASs). We aimed to understand better ASs' experiences of the pandemic and their sources of worries. Methods: Participants ( n = 203) completed a survey about their worries, sleep disorders, and fear of dying. We also conducted semi-structured interviews with ASs living in a community center ( n = 15), focusing on how social and living conditions affected their experiences and worries. Results: ASs in community centers experienced more sleep disorders related to the COVID-19 pandemic than those living in private apartments (aOR 2.01, p = 0.045). Similarly, those with lower education had greater fear for their life due to the COVID-19 pandemic (aOR 2.31, p = 0.015). Qualitative findings showed that sharing living spaces was an important source of worries for ASs and that protective measures were perceived to increase social isolation. Conclusion: Our study highlighted the impact of the COVID-19 pandemic for ASs and the importance of tailoring public health measures to their needs and living conditions., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2023 Morisod, Martin, Rawlinson, Grazioli, von Plessen, Durand, Selby, Le Pogam, Bühler and Bodenmann.)

Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Asylum seekers face multiple language, cultural and administrative barriers that could result in the inappropriate implementation of COVID-19 measures. This study aimed to explore their knowledge and attitudes to recommendations about COVID-19. We conducted a cross-sectional survey among asylum seekers living in the canton of Vaud, Switzerland. We used logistic regressions to analyze associations between knowledge about health recommendations, the experience of the pandemic and belief to rumors, and participant sociodemographic characteristics. In total, 242 people participated in the survey, with 63% of men (n = 150) and a median age of 30 years old (IQR 23-40). Low knowledge was associated with linguistic barriers (aOR 0.36, 95% CI 0.14-0.94, p = 0.028) and living in a community center (aOR 0.43, 95% CI 0.22-0.85, p = 0.014). Rejected asylum seekers were more likely to believe COVID-19 rumors (aOR 2.81, 95% CI 1.24-6.36, p = 0.013). This survey underlines the importance of tailoring health recommendations and interventions to reach asylum seekers, particularly those living in community centers or facing language barriers., (© 2022. The Author(s).)

Models of shared decision making recommend the use of patient decision aids. Hundreds of such aids exist worldwide but scaling up of their use in French-speaking Switzerland requires their translation to French and their adaptation to the clinical context. We review seven sources of tools that we assume relevant for French-speaking Switzerland. A short survey on a selection of three decision aids of general practitioners in the canton of Vaud confirmed their general interest in using such tools. They preferred a limited amount and a simple presentation of information in the decision aids to facilitate integration in clinical practice. Given the complexity of the required translations and adaptations, the medical community should develop a collaborative approach to lift this important task., Competing Interests: Anik Giguère (AG) est autrice de la Boîte à décision et de PADA, et l’Université Laval est la propriétaire des droits d’auteur et la titulaire des droits de gestion sur ces innovations. En outre, AG est la chercheuse responsable des programmes de recherche sur la Boîte à décision, Vieillir en santé et PADA. Thomas Agoritsas est directeur général adjoint de MAGIC. Marie-Anne Durand a développé l’outil d’aide à la décision « Option Grid », qui est sous licence auprès de la compagnie EBSCO Health. Elle est consultante pour EBSCO Health. Les autres auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

In patients aged 65 or older, the risk of dementia decreases with cataract surgery. Mental stress doubles the risk of a cardiac event in patients with stable coronary artery disease. The one-legged stance performance estimates total mortality in patients 50 years or older. Patients with chronic pain benefit from treatment with dronabinol or nabiximols. Salt substitutes are an alternative to regular salt in hypertensive patients aged 60 years or more. The promotion of physical activity in the office is effective in reducing sedentary behavior. Music has a favorable impact on the mental dimensions of quality of life. Colonoscopies performed on patients aged 75 years or more have a higher risk of non-gastrointestinal complications than gastrointestinal complications., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Objective: Interest in the coproduction concept in healthcare is increasing. According to coproduction, services are, unlike goods, always coproduced by a user and a service provider. This study explored how immigrants and refugees perceive the coproduction of their healthcare service in clinical encounters., Methods: We conducted semi-structured interviews with thirteen patients with varied backgrounds and health problems. Participants were purposefully recruited in an interdisciplinary clinic for immigrants and refugees at a Danish University Hospital. Interviews were transcribed, anonymized, and analyzed using meaning condensation., Results: Patients emphasized the importance of a safe space where they could be themselves and feel supported. This encouraged them to be open and assume an active role in the coproduction of their health. A stable therapeutic alliance based on kindness and kinship helped them find strength and take responsibility for their own health., Conclusions: This study improves our understanding of how immigrants and refugees experience the coproduction of healthcare services. Further studies, evaluating long-term outcomes of coproduction efforts, are required., Practice Implications: Providing a safe space in which health professionals have time to listen and empathically validate immigrant and refugee patients' lived realities, can enable patients to open up and become agents of their own health., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

The Swiss healthcare system is highly decentralized, making implementation of shared decision making (SDM) and patient and public involvement (PPI) quite slow; nonetheless, change is happening. SDM is now a core communication competency for medical school graduates, as reflected by a dedicated station on the federal exam, and is endorsed by several national societies. Multiple local initiatives are contributing to international best practices, local implementation, and increased capacity. PPI is also gaining momentum, most notably in research, with the development of a national platform for clinical research and inclusion of patients in the evaluation committees for funding. The challenge now is going from example projects by motivated early adopters in academia to making SDM and PPI standard practice., (Copyright © 2022. Published by Elsevier GmbH.)

Background: The aim of accreditation is to improve quality of care and patient safety. However, studies on the effectiveness of accreditation on clinical outcomes are limited and inconsistent. Comparative studies have contrasted accredited with non-accredited hospitals or hospitals without a benchmark, but assessments of clinical outcomes of patients treated at hospitals undergoing accreditation are sparse. The Faroe Islands hospitals were accredited for the first time in 2017, making them an ideal place to study the impact of accreditation., Objective: We aimed to investigate the association between first-time hospital accreditation and length of stay (LOS), acute readmission (AR) and 30-day mortality in the unique situation of the Faroe Islands., Methods: We conducted a before and after study based on medical record reviews in relation to first-time accreditation. All three Faroese hospitals were voluntarily accredited using a modified second version of the Danish Healthcare Quality Programme encompassing 76 standards. We included inpatients 18 years or older treated at a Faroese hospital with one of six clinical conditions (stroke/transient ischemic attack (TIA), bleeding gastic ulcer, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture) in 2012-2013 designated 'before accreditation'or 2017-2018' after accreditation'. The main outcome measures were LOS, all-cause AR and all-cause 30-day mortality. We computed adjusted cause-specific hazard rate (HR) ratios using Cox Proportional Hazard regression with before accreditation as reference. The analyses were controlled for age, sex, cohabitant status, in-hospital rehabilitation, type of admission, diagnosis and cluster effect at patient and hospital levels., Results: The mean LOS was 13.4 days [95% confidence interval (95% CI): 10.8, 15.9] before accreditation and 7.5 days (95% CI: 6.10, 8.89) after accreditation. LOS of patients hospitalized after accreditation was significantly shorter [overall, adjusted HR = 1.23 (95% CI: 1.04, 1.46)]. By medical condition, only women in childbirth had a significantly shorter LOS [adjusted HR = 1.30 (95% CI: 1.04, 1.62)]. In total, 12.3% of inpatients before and 9.5% after accreditation were readmitted acutely within 30 days of discharge, and 30-day mortality was 3.3% among inpatients before and 2.8% after accreditation, respectively. No associations were found overall or by medical condition for AR [overall, adjusted HR = 1.34 (95% CI: 0.82, 2.18)] or 30-day mortality [overall, adjusted HR = 1.33 (95% CI: 0.55, 3.21)]) after adjustment for potential confounding factors., Conclusion: First-time hospital accreditation in the Faroe Islands was associated with a significant reduction in LOS, especially of women in childbirth. Notably, shorter LOS was not followed by increased AR. There was no evidence that first-time accreditation lowered the risk of AR or 30-day mortality., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The concept of coproduction shows great promise for meaningful partnerships between patients and health professionals. This is particularly relevant for immigrant patients who are less inclined to take an active role in consultations. The present study described health professionals' practices and experiences of coproducing healthcare service with immigrant and refugee patients in clinical encounters., Methods: We conducted a three-phase qualitative study with immigrant and refugee patients and health professionals at an interdisciplinary outpatient clinic for immigrants and refugees with complex long-standing health problems at a Danish university hospital. First, we conducted 25 observations of consultations between seven professionals (three doctors, three nurses, one social worker) and 24 patients with varied backgrounds and health problems. Findings were discussed in a focus group and individual interviews with the migrant clinic's staff. Finally, the themes were discussed with co-researchers and revised in a member check with experienced clinicians. Data were analyzed through meaning condensation, supported by the NVivo software., Results: We identified four themes characterizing the work of health professionals in creating coproduced healthcare service: a team effort of sense-making, disentangling the chaos first, when everything fails - listen to the patient, and continuity - becoming part of the patient's story., Conclusion: Interdisciplinary work fostering values of doing what makes sense to form a positive partnership with the patient allows health professionals to act autonomously, flexibly, and creatively. Using communication tools designed around patient needs, create optimal conditions for coproduction as health professionals empathically validate and integrate patient experiences. Professionals need advanced listening and relational skills and tolerance of ambiguity and insecurity. Relational continuity facilitates long-term coproduction but also bears risks of emotional dependency., Competing Interests: The following statement is also included in the manuscript in Section 4.2 and the attached declaration of interest: One co-author (DSN) participated in the focus group discussion and the member check. Another co-author (MSO) participated in the member check. As both also work in the clinic, they were able to add valuable critical observations and further exemplifications due to their extensive experience on working with immigrant patients. Researching in their own organization, they were aware of their dual roles of researcher and study participant and needed to align their own subjectivity with their attention and understanding of the data, the situation, their judgments, and their responsible actions, (© 2022 The Authors. Published by Elsevier Ltd.)

Persons with SARS-CoV2 can be contagious with few or no symptoms. They can infect others in private, during education or work without knowing it. Few so-called super-propagators can thus initiate clusters of infections and chains of transmission. Isolation of new cases and quarantine of their contacts (forward contact tracing) often does not uncover such situations. Adding detailed backward investigations of events and places with elevated risk of transmission can increase the identification of potentially infected persons. These can then be quarantined, and chains of transmission be interrupted. We describe the principles and challenges of cluster investigation, epidemiological methods and IT tools that we deve loped at the Centre for contact tracing, Vaud. Knowledge of this method is useful in general clinical practice during a pandemic., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Service users, professionals, and civil society all contribute to public health. Inclusion of all relevant actors in a network community coproduction approach can improve public health crisis responses. Using the Swiss canton of Vaud's COVID-19 response as an example, we describe ways in which a network approach can add value to public health services., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The rapid evolution of the SARS-CoV-2 epidemic required the implementation of contact tracing at an unprecedented scale in the Swiss cantons. Hundreds of contact tracers with different professions, most without medical background, had to be recruited and educated for tasks that usually are carried out by small teams of experts in communicable diseases. Teaching materials and courses about contact tracing, especially in French, were scarce. Thus, the learning team at the contact tracing centre of the canton of Vaud supported by clinicians and epidemiologists developed a method to dynamically create and apply a series of teaching modules. We describe this process and its results. The teaching materials are freely available upon contact with the authors., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: The impact of hospital accreditation on the experiences of patients remains a weak point in quality improvement research. This is surprising given the time and cost of accreditation and the fact that patient experiences influence outcomes. We investigated the impact of first-time hospital accreditation on patients' experience of support from health-care professionals, information and involvement in decisions., Objective: We aimed to examine the association between first-time hospital accreditation and patient experiences., Methods: We conducted a longitudinal study in the three Faroese hospitals that, unlike hospitals on the Danish mainland and elsewhere internationally, had no prior exposure to systematic quality improvement. The hospitals were accredited in 2017 according to a modified second version of the Danish Healthcare Quality program. Study participants were 18 years or older and hospitalized for at least 24 h in 2016 before or 2018 after accreditation. We administered the National Danish Survey of Patient Experiences for acute and scheduled hospitalization. Patients rated their experiences of support, information and involvement in decision-making on a 5-point Likert scale. We calculated individual and grouped mean item scores, the percentages of scores ≥4, the mean score difference, the relative risk (RR) for high/very high scores (≥4) using Poisson regression and the risk difference. Patient experience ratings were compared using mixed effects linear regression., Results: In total, 400 patients before and 400 after accreditation completed the survey. After accreditation patients reported increased support from health professionals; adjusted mean score difference (adj. mean diff.) = 1.99 (95% confidence interval (CI): 1.89, 2.10), feeling better informed before and during the hospitalization; adj. mean diff. = 1.14 (95% CI: 1.07; 1.20) and more involved in decision-making; adj. mean diff. = 1.79 (95% CI: 1.76; 1.82). Additionally, the RR for a high/very high score (≥4) was significantly greater on 15 of the 16 questionnaire items. The greatest RR for a high/very high score (≥4) after accreditation, was found for the item 'Have you had a dialogue with the staff about the advantages and disadvantages of the examination/treatment options available?'; RR= 5.73 (95% CI: 4.51, 7.27)., Conclusion: Hospitalized patients experienced significantly more support from health professionals, information and involvement in decision-making after accreditation. Future research on accreditation should include the patients' perspective., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: During a comprehensive patient safety program at a 550-bed regional hospital in the Capital Region of Denmark, we observed an unexpected and unexplained doubling of the median patient harm rate from 56 to 109 harms per 1000 patient days measured by the Institute for Healthcare Improvement Global Trigger Tool (GTT). Meanwhile, other measures of patient safety, including hospital standardized mortality ratio, were stable or improving. Moreover, the review team was very experienced and stable during this period. Thus, we hypothesized that the increase in harm rate was not a true reflection of increased risk of patient harm but the result of the team getting better at identifying harms during GTT reviews., Methods: We examined the ability of the GTT review team to reproduce the rate of harm of two separate periods in the same hospital: period 1 (January-June 2010) and period 2 (October 2011-March 2012). For each period, we examined two samples: the original sample that was drawn and used for the ongoing monitoring of harm at the hospital during the safety campaign and a second that we drew and analyzed for this study., Results: We found increased harm rates both between review 1 and review 2 and between period 1 and period 2. The increase was solely in category E, minor temporary harm., Conclusions: The very experienced GTT team could not reproduce harm rates found in earlier reviews. We conclude that GTT in its present form is not a reliable measure of harm rate over time., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Significant resources are spent on hospital accreditation worldwide. However, documentation of the effects of accreditation on processes, quality of care and outcomes in healthcare remain scarce. This study aimed to examine changes in the delivery of patient care in accordance with clinical guidelines (recommended care) after first-time accreditation in a care setting not previously exposed to systematic quality improvement initiatives., Methods: We conducted a before and after study based on medical record reviews in connection with introducing first-time accreditation. We included patients with stroke/transient ischemic attack, bleeding gastric ulcer, diabetes, chronic obstructive pulmonary disease (COPD), childbirth, heart failure and hip fracture treated at public, non-psychiatric Faroese hospitals during 2012-2013 (before accreditation) or 2017-2018 (after accreditation). The intervention was the implementation of a modified second version of The Danish Healthcare Quality Program (DDKM) from 2014 to 2016 including an on-site accreditation survey in the Faroese hospitals. Recommended care was assessed using 63 disease specific patient level process performance measures in seven clinical conditions. We calculated the fulfillment and changes in the opportunity-based composite score and the all-or-none score., Results: We included 867 patient pathways (536 before and 331 after). After accreditation, the total opportunity-based composite score was marginally higher though the change did not reach statistical significance (adjusted percentage point difference (%): 4.4%; 95% CI: - 0.7 to 9.6). At disease level, patients with stroke/transient ischemic attack, bleeding gastric ulcer, COPD and childbirth received a higher proportion of recommended care after accreditation. No difference was found for heart failure and diabetes. Hip fracture received less recommended care after accreditation. The total all-or-none score, which is the probability of a patient receiving all recommended care, was significantly higher after accreditation (adjusted relative risk (RR): 2.32; 95% CI: 2.03 to 2.67). The improvement was particularly strong for patients with COPD (RR: 16.22; 95% CI: 14.54 to 18.10)., Conclusion: Hospitals were in general more likely to provide recommended care after first-time accreditation., (© 2021. The Author(s).)

The advent of the electronic health record (EHR) raises many questions regarding its adoption and its added value for patients, clinicians and the entire healthcare system. Based on the results of a participatory project that brought together citizens and experts, we show that the EHR should be understood as a collective and evolving project serving public health objectives, and that both patients and healthcare professionals should contribute to its development. Therefore, this common project represents a significant opportunity to strengthen the patient-professionals partnership., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: Several countries have launched health information technology (HIT) systems for shared electronic medication plans. These systems enable patients and health care professionals to use and manage a common list of current medications across sectors and settings. Shared electronic medication plans have great potential to improve medication management and patient safety, but their integration into complex medication-related processes has proven difficult, and there is little scientific evidence to guide their implementation., Objective: The objective of this paper is to summarize lessons learned from primary care professionals involved in a pioneering pilot project in Switzerland for the systemwide implementation of shared electronic medication plans. We collected experiences, assessed the influences of the local context, and analyzed underlying mechanisms influencing the implementation., Methods: In this formative action research study, we followed 5 clusters of health care professionals during 6 months. The clusters represented rural and urban primary care settings. A total of 18 health care professionals (primary care physicians, pharmacists, and nurses) used the pilot version of a shared electronic medication plan on a secure web platform, the precursor of Switzerland's electronic patient record infrastructure. We undertook 3 group interviews with each of the 5 clusters, analyzed the content longitudinally and across clusters, and summarized it into lessons learned., Results: Participants considered medication plan management, digitalized or not, a core element of good clinical practice. Requirements for the successful implementation of a shared electronic medication plan were the integration into and simplification of clinical routines. Participants underlined the importance of an enabling setting with designated reference professionals and regular high-quality interactions with patients. Such a setting should foster trusting relationships and nurture a culture of safety and data privacy. For participants, the HIT was a necessary but insufficient building block toward better interprofessional communication, especially in transitions. Despite oral and written information, the availability of shared electronic medication plans did not generate spontaneous demand from patients or foster more engagement in their medication management. The variable settings illustrated the diversity of medication management and the need for local adaptations., Conclusions: The results of our study present a unique and comprehensive description of the sociotechnical challenges of implementing shared electronic medication plans in primary care. The shared ownership among multiple stakeholders is a core challenge for implementers. No single stakeholder can build and maintain a safe, usable HIT system with up-to-date medication information. Buy-in from all involved health care professionals is necessary for consistent medication reconciliation along the entire care pathway. Implementers must balance the need to change clinical processes to achieve improvements with the need to integrate the shared electronic medication plan into existing routines to facilitate adoption. The lack of patient involvement warrants further study., (©Benjamin Bugnon, Antoine Geissbuhler, Thomas Bischoff, Pascal Bonnabry, Christian von Plessen. Originally published in JMIR Formative Research (http://formative.jmir.org), 07.01.2021.)

Background: The success of government-recommended mitigation measures during the COVID-19 pandemic depends largely on information uptake and implementation by individual citizens., Objective: Our aim was to assess citizens' knowledge and perceptions about COVID-19 recommendations in the Canton of Vaud, Switzerland., Methods: A cross-sectional electronic survey with open and closed questions was disseminated by community-based partners prior to the relaxation of government restrictions. Outcomes included citizen knowledge (9-question measure) and worry about the virus, perception of government measures, and recommendations for improvements. Comparisons used linear regression, controlling for age, sex, education, and health literacy. Free-text answers were analyzed thematically., Results: Of 807 people who accessed the survey, 684 (85%) completed all questions and 479 (60%) gave free-text recommendations. Overall, 75% were female, the mean age was 48 years, and 93% had high health literacy. Knowledge scores were high, with a median score of 8 out of 9. Mean levels of worry about the COVID-19 pandemic were higher in women than men (55/100 versus 44/100, P<.001), and in respondents with lower health literacy (57/100 versus 52/100, P=.03). Self-reported adherence to recommendations was high (85%) and increased with age and worry (both P<.001). Respondents rated their own adherence higher than others (85% versus 61%, P<.001). Moreover, 34% of respondents reported having self-quarantined; this rose to 52% for those aged ≥75 years. Those who had self-quarantined reported higher levels of fear. Nearly half (49%) of respondents felt the government response had been adequate, though younger age and higher levels of worry were associated with considering the response to be insufficient (both P<.001). Analysis of open-text answers revealed 4 major themes: access to and use of masks, gloves, and hand sanitizer; government messaging; lockdown and lockdown exit plan communication; and testing for COVID-19., Conclusions: Knowledge, adherence, and satisfaction regarding government recommendations and response were high in this sample, but many desired greater access to personal protective equipment. Those with lower health literacy and those who have been in self-isolation reported greater concerns about the pandemic., (©Kevin Selby, Marie-Anne Durand, Alexandre Gouveia, Francesca Bosisio, Gaia Barazzetti, Maxime Hostettler, Valérie D'Acremont, Alain Kaufmann, Christian von Plessen. Originally published in JMIR Formative Research (http://formative.jmir.org), 03.12.2020.)

Purpose: Immigrant patients run a risk of receiving lower quality of care. Co-production, as the concept of how to collaboratively create valuable healthcare service for the patient, offers a new perspective that might help. The scoping review aimed at identifying and analysing factors facilitating co-production between immigrant patients and healthcare professionals., Methods: We searched seven scientific databases for peer-reviewed publications of all study designs. Two reviewers independently screened the publications for eligibility and performed data extraction. Data were analysed by applying an inductive, interpretive approach for data synthesis., Results: Fifteen publications were included for analysis. We identified six factors hat facilitate co-production: 1) prioritizing co-production in the organization, 2) providing a safe environment that promotes trust and patience, 3) using a language the patient understands, 4) respecting the patient's knowledge and priorities, 5) improvising with knowledge and courage, and 6) engaging in self-reflection., Conclusions: The scoping review illustrated that co-production with immigrant patients can be successful if the system and professionals are interested and prepared. Immigrant patients could be a valuable source of information and powerful co-producers of their own health. The study contributed to a growing body of research on patient-professional co-production in healthcare and might also prove relevant for other disadvantaged patient groups.

Background: To investigate the use of do-not-resuscitate (DNR) orders in patients hospitalized with community-acquired pneumonia (CAP) and the association with mortality., Methods: We assembled a cohort of 1317 adults hospitalized with radiographically confirmed CAP in three Danish hospitals. Patients were grouped into no DNR order, early DNR order (≤48 h after admission), and late DNR order (> 48 h after admission). We tested for associations between a DNR order and mortality using a cox proportional hazard model adjusted for patient and disease related factors., Results: Among 1317 patients 177 (13%) patients received a DNR order: 107 (8%) early and 70 (5%) late, during admission. Patients with a DNR order were older (82 years vs. 70 years, p < 0.001), more frequently nursing home residents (41% vs. 6%, p < 0.001) and had more comorbidities (one or more comorbidities: 73% vs. 59%, p < 0.001). The 30-day mortality was 62% and 4% in patients with and without a DNR order, respectively. DNR orders were associated with increased risk of 30-day mortality after adjustment for age, nursing home residency and comorbidities. The association was modified by the CURB-65 score Hazard ratio (HR) 39.3 (95% CI 13.9-110.6), HR 24.0 (95% CI 11.9-48,3) and HR 9.4 (95% CI: 4.7-18.6) for CURB-65 score 0-1, 2 and 3-5, respectively., Conclusion: In this representative Danish cohort, 13% of patients hospitalized with CAP received a DNR order. DNR orders were associated with higher mortality after adjustment for clinical risk factors. Thus, we encourage researcher to take DNR orders into account as potential confounder when reporting CAP associated mortality.

Background: Community-acquired pneumonia (CAP) is one of the leading causes of healthcare utilisation and death worldwide. Treatment according to evidence-based clinical guidelines can reduce mortality, antibiotic exposure and length of hospital stay related to CAP., Local Problem: Several studies, including a pilot study from one of our sites, indicate that physicians show a low grade of guideline adherence when managing patients with CAP., Methods: To improve the guideline-based treatment of patients with CAP admitted to hospital, we designed a quality improvement study. Four process indicators were combined in a CAP care bundle: chest X-ray, CURB-65 severity score, lower respiratory tract samples and antibiotics within 8 hours from admission. After a 4-month baseline period, we applied multiple interventions at three hospitals during 8 months. Progression in our process indicators was measured continuously and compared with a control site without interventions. After the 8-month intervention period, we continued with a 4-month follow-up period to assess the sustainability of the improvements., Results: The care bundle utilisation rate within 8 hours increased from 11% at baseline to 41% in the follow-up period at the intervention sites, whereas it remained below 3% at the control site. The most considerable improvements have been observed regarding documentation of CURB-65 (34% at baseline, 68% at follow-up) and the collection of lower respiratory tract samples (43% at baseline, 63% at follow-up)., Conclusion: Our study has demonstrated poor adherence to CAP guidelines at all sites at baseline. After implementing multiple tailored interventions, guideline adherence increased substantially. In conclusion, we recommend that CAP guidelines should be actively adapted in order to be followed in a daily routine., Competing Interests: The authors have declared that no competing interests exist.

Background: Anticancer treatment exposes patients to negative consequences such as increased toxicity and decreased quality of life, and there are clear guidelines recommending limiting use of aggressive anticancer treatments for patients near end of life. The aim of this study is to investigate the association between anticancer treatment given during the last 30 days of life and adverse events contributing to death and elucidate how adverse events can be used as a measure of quality and safety in end-of-life cancer care., Methods: Retrospective cohort study of 247 deceased hospitalised cancer patients at three hospitals in Norway in 2012 and 2013. The Global Trigger Tool method were used to identify adverse events. We used Poisson regression and binary logistic regression to compare adverse events and association with use of anticancer treatment given during the last 30 days of life., Results: 30% of deceased hospitalised cancer patients received some kind of anticancer treatment during the last 30 days of life, mainly systemic anticancer treatment. These patients had 62% more adverse events compared to patients not being treated last 30 days, 39 vs. 24 adverse events per 1000 patient days (p < 0.001, OR 1.62 (1.23-2.15). They also had twice the odds of an adverse event contributing to death compared to patients without such treatment, 33 vs. 18% (p = 0.045, OR 1.85 (1.01-3.36)). Receiving follow up by specialist palliative care reduced the rate of AEs per 1000 patient days in both groups by 29% (p = 0.02, IRR 0.71, CI 95% 0.53-0.96)., Conclusions: Anticancer treatment given during the last 30 days of life is associated with a significantly increased rate of adverse events and related mortality. Patients receiving specialist palliative care had significantly fewer adverse events, supporting recommendations of early integration of palliative care in a patient safety perspective.

Background: This study aimed to examine managers' attitudes towards and use of a mandatory accreditation program in Denmark, the Danish Healthcare Quality Program (Den Danske Kvalitetsmodel [DDKM]) after it was terminated in 2015., Methods: We designed a nationwide cross-sectional online survey of all senior and middle managers in the 31 somatic and psychiatric public hospitals in Denmark. We elicited managers' attitudes towards and use of DDKM as a management using 5-point Likert scales. Regression analysis examined differences in responses by age, years in current position, and management level., Results: The response rate was 49% with 533 of 1095 managers participating. Overall, managers' perceptions of accreditation were favorable, highlighting key findings about some of the strengths of accreditation. DDKM was found most useful for standardizing processes, improving patient safety, and clarifying responsibility in the organization. Managers were most negative about DDKM's ability to improve their hospitals' financial performance, reshape the work environment, and support the function of clinical teams. Results were generally consistent across age and management level; however, managers with greater years of experience in their position had more favorable attitudes, and there was some variation in attitudes towards and use of DDKM between regions., Conclusion: Future attention should be paid to attitudes towards accreditation. Positive attitudes and the effective use of accreditation as a management tool can support the implementation of accreditation, the development of standards, overcoming disagreements and boundaries and improving future quality programs.

Purpose: The purpose of this paper is to understand how the hospital staff (nurses and physicians) at two hospital wards have coped with everyday work having leaders in conflict or longer periods without one or the other leader and whether the way the staff handled the challenges was resilient., Design/methodology/approach: Through semi-structured interviews with the staff at the two wards, the authors analysed how the staff were working, if they had cooperation and interdisciplinary cooperation, how they would handle uncertainties and how they coped with the absence of their leaders., Findings: The staff at both wards were handling the everyday work in a resilient way. The authors argue that to increase the resilience in an organisation, leaders should acknowledge the need to establish strong emotional ties among staff and at the same time ensure role structures that make sense in the everyday work., Originality/value: This study reports on original work and shows what decision makers could do to increase resilience in an organisation. This paper shows that the organisational context is important for the staff to act resiliently. As leaders come and go, it can be important for the stability of the organisation to promote the staff in acting resiliently independent of the leader situation.