BMJ Open Quality

The ability to measure the extent to which an organisation is highly reliable, or the extent to which reliability may change over time, has not kept up with the development of theory. The paper examines aspects of workplace culture, employee motivation and leadership behaviours that support continuous learning and improvement in an effort to measure the transition to high reliability.
To evaluate the effectiveness of its high reliability initiative, one children’s hospital sought to build measures that would provide an assessment of progressive movement towards a ‘culture of safety’, and track the success over time. This paper reports on the development of two scales (trust in team members and trust in leadership) that are intended to measure two cultural conditions fostered by the five high reliability principles and a composite measure on local learning activities. The two scales are strongly associated with local learning activities in employees’ work areas and with employees’ willingness to participate in extra role activities. We suggest that they are foundational to creating a psychologically safe environment and thus to becoming a high reliability organisation.

Jenifer Cartland

Michaeleen Green

Desty Kamm

Diana Halfer

Mary Alida Brisk

Derek Wheeler

BMJ Open Qual

Measuring psychological safety and local learning to enable high reliability organisational change

测量心理安全与局部学习以实现高可靠性组织变革

Paediatric surgery is a stressful experience for patients and caregivers. While standardised protocols are the norm, patient-centred approaches are needed to empower patients/caregivers for an optimal perioperative pain experience. To address this gap, we employed a patient-centred approach using design thinking (DT) methodology to develop insights, map processes, identify opportunities and design solutions for individualised empowerment tools.In consultation with DT experts, a multidisciplinary team of stakeholders (healthcare providers, patients who underwent pectus excavatum/scoliosis surgery and their caregivers), were invited to participate in surveys, interviews and focus groups. The project was conducted in two sequential stages each over 24 weeks-involving 7 families in stage 1 and 16 patients/17 caregivers in stage 2. Each stage consisted of three phases: design research (focus groups with key stakeholders to review and apply collective learnings, map processes, stressors, identify influencing factors and opportunities), concept ideation (benchmarking and co-creation of new solutions) and concept refinement.In stage 1, mapping of stress/anxiety peaks identified target intervention times. We identified positive and negative influencers as well as the need for consistent messaging from the healthcare team in our design research. Current educational tools were benchmarked, parent-child engagement dyads determined and healthcare-based technology-based solutions conceived. The 'hero's journey' concept which has been applied to other illness paradigms for motivation successfully the was adapted to describe surgery as a transformative experience. In stage 2, patient and caregiver expectations, distinct personas and responses to perioperative experience were categorised. Educational tools and an empowerment tool kit based on sensorial, thinking, relaxation and activity themes, tailored to parent/child categories were conceptualised.DT methodology provided novel family centred insights, enabling design of tailored empowerment toolkits to optimise perioperative experience. Adapting the hero's journey call to adventure may motivate and build resilience among children undergoing surgery.

Vidya Chidambaran

Blair Simpson

Laura Brower

Rachel Hanke

Marc Mecoli

Blake Lane

Sara Williams

Emily McKenna

Christina Bates

Aimee Kraemer

Peter Sturm

Rebeccah Brown

Linda Dunseath

Craig Vogel

Victor Garcia

Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery

Medication errors continue to pose a significant risk to patient safety, accounting for half of the avoidable harm in healthcare systems around the world. In emergency departments (EDs), factors such as high patient loads and emergent nature of care increase the likelihood of such errors. An audit conducted at the ED of Changi General Hospital Singapore from January 2019 to July 2022 revealed that the duplicate therapy error comprised 31% of all reported medication errors. Therapeutic duplication occurs when the same or pharmacologically equivalent agents are prescribed concurrently to a patient. These errors not only jeopardise patient safety but also place additional strain on healthcare resources and lead to stress among the staff involved.This quality improvement (QI) project aims to reduce duplicate therapy error by 50% 3 months post-intervention at the ED. Beginning in August 2022 and continuing through December 2023, the project followed a structured approach comprising four phases: problem identification, identifying root causes, developing of targeted interventions and ensuring sustainability. Phase 1 involved an audit from January 2019 to July 2022 to determine the extent and types of medication errors in the ED. In phase 2, a root cause analysis (RCA) of the medication error identified key issues such as system knowledge deficits, inadequate IT processes, environment, policies and procedures and gaps in care coordination. Based on these findings, targeted interventions were developed and implemented in phase 3. Phase 4 focused on sustaining improvements through ongoing audits.The QI project successfully met its goal of reducing duplicate therapy error rates by 50% post-intervention. Additionally, it completely eliminated duplicate therapy errors in certain medication categories.In conclusion, through targeted interventions, active engagement of relevant stakeholders and ongoing efforts to sustain and enhance improvement, a safer healthcare environment can be achieved for patients.

Huiling Huang

Srivatsava Sunku

Hui Shan Ong

Jonathan Kim Yang Chan

Guek Gwee Sim

Multifaceted approach to reduce duplicate therapy errors in the emergency department

多管齐下减少急诊科重复治疗错误

Background The use of quality indicators in healthcare systems is one of the factors that improve the quality of health services. However, indicators for assessing HIV clinical care in the context of low- and middle-income countries are not fully explored. Some existing indicators were established within the context of developed countries and are primarily defined for community care, with limited emphasis on the hospital setting. Additionally, these indicators often do not account for the local practicality and relevance of quality measures in the context of low- and middle-income countries. Aim To assess the clinical significance and practical applicability of these indicators from the perspective of healthcare professionals specialising in HIV care in South Africa and Democratic Republic of Congo. Methods After performing a systematic review of quality indicators employed in the evaluation of clinical care for individuals with HIV, we conducted an observational, cross-sectional study. In this research, 30 physicians filled out two questionnaires with a core set of indicators, to establish the most pertinent and practically indicators for evaluation of the HIV clinical care. A Likert scale was used to rank the indicators. Kendall’s tau-B rank correlation analysis was also performed. Results From the initial list of 88 quality indicators, 43 were identified as the most relevant and practical in HIV clinical care. Healthcare professionals deemed the monitoring and therapy domain to be the most pertinent and useful indicators out of the seven different clinical domains, followed by the functional organisational structure domain. Conclusion This instrument may be a tool for healthcare professionals and hospital administrators to improve the quality of HIV clinical care.

Tambwe Willy Muzumbukilwa

Riziki Gyslain Manimani

Rajesh Vikram Vagiri

Manimbulu Zephy Nlooto

Masemo Dieudonne Bihehe

Aganze Gloire Aime Mushebenge

Developing HIV indicators for clinical care quality assessment: relevance and practicality evaluated by healthcare practitioners in South Africa and Democratic Republic of Congo

开发用于临床护理质量评估的HIV指标：南非和刚果民主共和国医疗从业者的相关性和实用性评估

Introduction High-frequency recurring orders placed through the electronic medical record (EMR) may contribute to unnecessary care in hospitalised patients. This quality initiative sought to develop and pilot test a hospital order set for bundled review and de-implementation of common recurring orders. Methods A voluntary-use EMR order set was developed to display low-frequency order alternatives for common hospital care components. The order set was introduced to hospitalists at a large academic hospital from February to June 2023. Orders for overnight vital signs, tubes/tethers (a composite of telemetry, continuous pulse oximetry and Foley catheter) and daily labs (a composite of complete blood counts and metabolic panels) were monitored twice weekly in hospitalised patients at low risk for clinical decompensation from December 2022 through June 2023. Paired t-test was used to assess for differences in order frequency before and after order set introduction. Results The order set was used in 48 unique encounters to place 80 de-implementation orders, most commonly for discontinuation of overnight vital signs (n=37). Two or more de-implementation orders were placed during 44% of order set encounters. Mean (SD) total high-frequency orders decreased by 0.22 per patient day (95% CI −0.39 to −0.06; p=0.010) after order set introduction, driven by a reduction in overnight vital sign orders of 0.17 per patient day (95% CI −0.23 to −0.12; p&lt;0.001). There was no statistically significant difference in orders for tubes/tethers or daily labs before and after order set introduction. Discussion Introduction of a novel order set for bundled review and de-implementation of recurring orders was associated with reduced high-frequency recurring orders in hospitalised patients, driven by a reduction in overnight vital signs. Nearly half of order set use was for two or more de-implementation orders, suggesting that bundling de-implementation orders may be an efficient way to reduce unnecessary orders.

Caleb J Murphy

Vanshika Narala

Aishwarya Katiki

Maylyn S Martinez

Matthew T Cerasale

Khanh T Nguyen

Bundled de-implementation of recurring hospital orders with a novel electronic medical record order set

通过新型电子病历订单集捆绑式取消重复医院医嘱

Background Urinary tract infections (UTIs) are among the most common bacterial infections, and appropriate antimicrobial therapy with agents that minimise resistance is crucial. Despite international concern, adherence to guidelines is still suboptimal. This study aims to determine the effect of the absence of national guidelines and the rate of conformity to international guidelines among physicians in antibiotic (ATB) prescriptions for the treatment of UTIs in adults and detect the factors that are associated with a higher rate of non-compliance. Methods Patient-related characteristics and the prescribed ATBs were gathered from patients' medical files, and a questionnaire was directed to physicians to elicit the factors involved in decision-making. Four criteria were evaluated: molecule conformity, daily dose conformity, duration conformity and global conformity. Results 37 Lebanese physicians and 185 prescriptions were included. The most prevalent class of ATBs was fluoroquinolones (30.3%). Global conformity to guidelines was 31.4%, while conformity on drug choice, daily dose and duration of treatment was 83.2%, 74.7% and 41.6%, respectively. There were no differences in conformity rates according to the physician’s specialty (p=0.135). Physicians who studied in an American-system university had an increased risk of non-conformity (adjusted OR (aOR=2.107, p=0.018). Patients with higher education levels, or presenting with fever or chills, were more likely to get a non-compliant prescription (aOR=2.140, p=0.032 and aOR=4.947, p=0.033, respectively). Conclusion In a country with no local guidelines, non-conformity to international guidelines is high. Larger national studies are needed with immediate interventions to enhance physicians’ prescribing practices. After local guidelines were established, it would be interesting to compare the rate of adherence to these guidelines.

Joe El Khoury

Nadine Saleh

Nathalie Lahoud

Patrick Maison

Mira Hleyhel

Compliance to international guidelines and rational use of antibiotics in urinary tract infections in a country without national guidance: a cross-sectional study

在没有国家指南的国家中，遵循国际指南和合理使用抗生素治疗尿路感染的横断面研究

Ventilator-associated pneumonia (VAP) is a prevalent nosocomial infection in the intensive care unit (ICU), significantly increasing patient morbidity, mortality, and healthcare costs. Effective management is essential, particularly in the context of antimicrobial resistance and the frequent use of antibiotics in ICUs.

Vijay Kumar

Ratnadeep Biswas

Vishnu Shankar Ojha

Sanjeev Kumar

Asim Sarfraz

Efficacy of quality improvement interventions on antibiotic prescription practices for ventilator-associated pneumonia at a tertiary care centre: a prospective pre–post interventional study

三级医疗中心质量改进干预对呼吸机相关性肺炎抗生素处方实践的效果：一项前瞻性前后干预研究

Abbreviation	BMJ Open Qual.
Journal Impact	1.21
Quartiles(Global)	MEDICINE, GENERAL & INTERNAL(Q2)

ISSN	2399-6641
h-index	22

Publication Information	Publisher: BMJ Publishing Group，Publishing cycle: ，Journal Type: journal，Open Access Journals: Yes
Basic data	Year of publication: 2018，Proportion of original research papers: 97.66%，Self Citation Rate:7.70%， Gold OA Rate: 98.91%
Journal Fees	$Details
Average review cycle	20 weeks

BMJ Open Quality

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Measuring psychological safety and local learning to enable high reliability organisational change

Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery

Multifaceted approach to reduce duplicate therapy errors in the emergency department

Developing HIV indicators for clinical care quality assessment: relevance and practicality evaluated by healthcare practitioners in South Africa and Democratic Republic of Congo

Bundled de-implementation of recurring hospital orders with a novel electronic medical record order set

Multifaceted approach to reduce duplicate therapy errors in the emergency department

Developing HIV indicators for clinical care quality assessment: relevance and practicality evaluated by healthcare practitioners in South Africa and Democratic Republic of Congo

Bundled de-implementation of recurring hospital orders with a novel electronic medical record order set

Compliance to international guidelines and rational use of antibiotics in urinary tract infections in a country without national guidance: a cross-sectional study

Efficacy of quality improvement interventions on antibiotic prescription practices for ventilator-associated pneumonia at a tertiary care centre: a prospective pre–post interventional study