Evaluation of quality of surgical care begins with the Donabedian triad focusing on structure, process, and outcomes. Outcomes, which are inherently patient-centered, are most easily and commonly measured, and are indeed fundamental to evaluating the quality of surgical care. Specifically, post-operative adverse events (AEs) remain the most frequently measured and reported outcomes, as they represent harm to the patient; and thus, are often used as a means for comparing institutional, as well as, individual surgeon performance. The importance of rigorous recording of clearly defined AEs, although widely recognized, is poorly performed in practice. In previous work, created in accordance to the Clavien-Dindo classification, we developed and integrated a classification of Thoracic Morbidity & Mortality (TM&M) within The Ottawa Hospital’s Division of Thoracic Surgery allowing objective and standardized assessment of all post-operative AEs following all surgeries. In this thesis, the complementary studies that were conducted surrounding the continued clinical application and critical appraisal of the TM&M classification system as a means toward quality improvement are described. Using standardized reporting of both incidence and severity of post-operative complications, we first provide an overview of the burden and distribution that the two most pervasive post-operative AEs have on the thoracic surgical patient population, including prolonged alveolar air leak and atrial fibrillation (Chapter I and II). Next, we explore the inter-system reliability of reported AEs following thoracic surgery from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP), which is widely considered the most prominent surgical quality improvement effort, and the TM&M classification system in order to better understand to what extent the methods used to collect data may be impacting results (Chapter III). The disparity between the two systems and the duplicate participation indicates distinct value to the two quality reporting systems. An absence of evidence in the literature regarding individual surgeon outcome reporting and its impact on the quality of care prompted us to create risk-adjusted, surgeon-specific outcome reports to enable individualized performance measurement and feedback (Chapter IV). A priority for the division has been to ensure such measurement translates into reproducible improvements in surgical performance. To do so, we implemented complementary continuous quality improvement seminars to provide an additional forum for discussion regarding collective results, utilizing positive deviance, to unmask best performers as a catalyst for discussing practice measures to improve specific AEs. Lastly, an evolutionary understanding of the heterogeneity of TM&M data was considered as a critical next step to following improvements in care (Chapter V). Recognizing that software was necessary to efficiently record and review TM&M data, iterative development led to an evolution of a real-time, web-based, point-of-care Thoracic Surgery Quality monitoring, Information management, and Clinical documentation (TSQIC) software system. The TSQIC system has enabled bedside data recording and storage, and automated dynamic analysis and reporting of surgical volume and quality. We observe that measurement of TM&M data alone, while necessary, is not sufficient for quality improvement. We suggest that in addition to implementing a complementary point-of-care, interactive, web-based quality monitoring system, key factors for improving quality and patient safety include a combination of temporal analyses of AEs, effective surgeon-specific feedback mechanisms, actionable information based on best practice measures, standardization of case reviews, and a unit-based approach conducive of team-work and safety culture, led by open and collegial dialogue.

ABSTRACTStudying patients' reduced autonomy in acute care is complicated. There are few studies describing the patient's perspective in acute intubations. This was a quantitative literature study, where the primary purpose was to examine if there were evidence based plans of action to improve patient safety with intubations at the emergency room. The main question was if an empathetic approach was included. The theoretical framework is based on Jean Watson and her philosophy of care and basic human needs, in this study concentrating on breathing. The method used was literature searches in the database PubMed/Medline and Cinahl, main search words were patient safety, intubation, checklists complications and nursing. Criteria for inclusion in this study: adult patients in need of acute intubation related to respiratory failure caused by various causes. Children under the age of 18 and intubations that were performed pre-hospital were excluded. 14 studies were included, four randomized intervention studies, five intervention studies without randomization and five observational studies. All studies were rated reasonably strong to very strong on the GRADE review template. The main group of results centered around patient safety that generated three subcategories in the form of checklists, preventive measures and structured work methods. No studies described guidelines that included empathetic approach.The literature identified 7 common factors for increasing patient security during intubation: teamwork, communication, simulation training, body position, pre-oxygenating, medication and experience/technique. Secondarily, results showed that checklists were good for patient security, when combined with a structured way of working.Conclusion: Guidelines were available concerning complications in emergency intubations and patient safety may increase if checklist is used. However, the literature study shows that the checklists lacked an empathetic approach in emergency situations with acute intubation. The literature study may be important as a basis for further research but another study design is proposed / SAMMANFATTNING Studera patienters nedsatta autonomi vid akuta omhändertaganden är komplicerat. Det finns få studier som beskriver patientens perspektiv vid akuta intubationer. Forskningsdesignen var en kvantitativ litteraturstudie, där det primära syftet var att undersöka om det fanns evidensbaserade riktlinjer för att förbättra patientsäkerheten vid akuta intubationer på akutrummet. Den viktigaste frågeställningen var om empatiskt förhållningssätt fanns inkluderat i riktlinjer. Det teoretiska ramverket knöts till Jean Watson och hennes filosofi kring omvårdnad och fundamentala mänskliga behov, i detta arbete ligger tyngdpunkten på andningen. Metoden var litteratursökning i databaserna PubMed/Medline och Cinahl, huvudsökorden var patient safety, intubation, checklist, complications och nursing. Inklusionkriterier var vuxna patienter i behov av akut intubation relaterat till respiratorisk svikt av olika orsaker. Barn under 18 år och prehospitala intubationer exkluderades. Totalt inkluderades 14 studier, varav fyra randomiserade interventionsstudier, fem interventionsstudier utan randomisering samt fem observationsstudier. Samtliga studier bedömdes ha måttligt starkt till starkt vetenskapligt underlag enligt GRADE granskningsmall. Resultatet visade en huvudgrupp med patientsäkerhet som genererade tre undergrupper i form av checklista, förebyggande metoder och strukturerat arbetsätt. Inga studier beskrev riktlinjer som inkluderade empatiskt förhållningssätt. I litteraturstudien identifierades sju gemensamma faktorer för att öka patientsäkerheten vid akuta intubationer; teamwork, kommunikation, simuleringsövningar, kroppsposition, preoxygenerering, läkemedel och erfarenhet/teknik. Sekundärt visade resultatet att checklistor var bra för patientsäkerheten, men att dessa bör kombineras med ett strukturerat arbetsätt. Slutsats: Riktlinjer finns gällande komplikationer vid akuta intuberingar och patientsäkerheten verkar kunna öka om checklista används. Litteraturstudien visar dock att checklistorna saknade ett empatiskt förhållningssätt i vårdsituationer med akut intubering. Litteraturstudien kan få betydelse som grund för vidare forskning men en annan studiedesign föreslås.

No description available.

Background: Stress often arises when an individual’s ability to cope with environmental stressors, is exceeded. Nurses are responsible for providing high-quality care in accordancewith laws and regulations. When there is an imbalance between high demands on quality and the nurse's ability, knowledge and competence, this can lead to them suffering from negative work-related stress. Aim: The aim was to describe nurses' experiences of negative work-related stress. Method: A literature-based study was conducted by studying the results of ten qualitative articles from healthcare sciences. Systematic searches, for articles, were performed in the two databases PubMed and Chinal. A major inclusion criterion was that the articles should be empirical studies, peer-reviewed and published from 2010 – 2020. Results: The result showed that the nurses experiences included various difficulties that were related to the relational-, work environment- and personal difficulties. The difficulties were experienced in the form of communication- and cooperation difficulties, lack of support and information, high workload, insufficient resources and difficult working conditions but also insufficient knowledge and suffering from ill-health. Conclusion: Nurses experience stress due to a limited work environment and various factors in the workplace contribute to them developing negative work-related stress. To reduce problems with nurses' negative work-related stress, their workload must be changed. For example, by ensuring that requirements do not exceed resources, developing various forms of support and improving the skills of the organization and management. / Detta examensarbete handlar om sjuksköterskors upplevelser av negativ arbetsrelaterad stress. Resultatet visade att sjuksköterskans upplevelser innefattade olika svårigheter som var relaterade till relationella-, arbetsmiljömässiga- och personliga svårigheter. Svårigheterna upplevdes i form av kommunikation- och samarbetssvårigheter, brist på stöd och information, hög arbetsbelastning, otillräckliga resurser och svåra arbetsvillkor men också otillräckliga kunskaper och att drabbas av ohälsa. Ett viktigt resultat som framkom var den höga arbetsbelastning som innebar att sjuksköterskor var tvungna att utföra flera arbetsuppgifter samtidigt som det förekom konflikter på grund av kommunikation- och samarbetssvårigheter men också brist på stöd. Den negativa arbetsrelaterade stressen fick sjuksköterskor att uppleva dålig psykisk ohälsa och sömnlöshet vilket kunde undergräva kvaliteten på vården men också tankar hos sjuksköterskor att vilja byta yrke då även löneutvecklingen inte överensstämde med det tunga arbetet. Examensarbetet beskriver hur arbetsrelaterad stress leder till fysisk- och psykisk ohälsa och sjukfrånvaro. För att förhindra stressproblem hos sjuksköterskor är en viktig strategi som noterades att erhålla stöd från organisation, arbetsledning och kollegor. Det fanns också ett behov av att skapa en samverkan i team, där sjuksköterskor som upplever problem kan söka hjälp. Det finns också behov av att skapa gemensamma utrymmen, där sjuksköterskor kan vila men också ha en social gemenskap med varandra under pauser. I studien inkluderades tio kvalitativa vårdvetenskapliga artiklar som analyserades med hjälp aven femstegsmodell utifrån syftet att beskriva sjuksköterskors upplevelser av negativ arbetsrelaterad stress. Sjuksköterskor har ansvar att tillhandhålla omvårdnad av hög kvalitet i enlighet med lagar och författningar. När det uppstår en obalans mellan höga krav på kvalitét och sjuksköterskansförmåga, kunskap och kompetens kan detta leda till att de drabbas av arbetsrelaterad stress. Framtida studier bör öka utredningen av hur man strategiskt kan lindra arbetsrelaterad stress bland sjuksköterskor.

Background: Root Cause Analysis (RCA) is a method of investigating adverse events (AEs). The purpose of RCA is to improve quality of care and patient safety through a retrospective, structured investigative process of an incident, resulting in recommendations to prevent the recurrence of medical errors. Aim: The aim of the study was to develop and validate a prototype questionnaire to establish whether the RCA model and processes employed at the research setting were perceived by the users to be acceptable, thorough and credible in terms of internationally established criteria. Methods: This is a validation study comprising four phases to meet the study objectives: 1) the development of a prototype questionnaire guided by a literature review; 2) assessing the validity of the content of the questionnaire by and numerical evaluation of the face validity thereof; 3) assessing the qualitative face validity cognitive interviews; and 4) reliability by test-retest. Results: Content validity assessment in Phase 2 resulted in removal of 1/36 (2.77%) question items and amendment of 7/36 (19.44%), resulting in 35 for the revised questionnaire. Analysis of data from the cognitive interviews resulted in amendment of 20/35 (57.14%) question items but no removal. Reliability of the final questionnaire achieved the predetermined ≥0.7 level of agreement. Conclusion: The questionnaire achieved a high content validity index and face validity was enhanced by cognitive interviews by providing qualitative data. The inter-rater coefficient indicated a high level of reliability. The tool was designed for a local private healthcare sector and this may limit its use.

No description available.

Teamwork in healthcare is recognized as a significant factor in achieving patient safety and impacting patient outcomes. Despite the general focus on teamwork in healthcare, there has been little research on teamwork among nurses and nursing assistants working on patient care units. The purpose of this doctoral project was to identify, compare, and analyze perceptions of teamwork in a group of nurses and nursing assistants in a community hospital setting where the TeamSTEPPS program has been implemented. The framework of this project was the concept of shared mental model and Imogene King's conceptual system and middle-range theory of goal attainment. Teamwork perceptions were measured using the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ), which is composed of five constructs: (a) team structure, (b) leadership, (c) situation monitoring, (d) mutual support, and (e) communication. Sixty-three nurses and 42 nursing assistants participated in the study. There was a significant difference between nursing assistants and staff nurses with respect to the Total T-TPQ mean score (4.03 and 4.26, respectively; p < 0.03), leadership (4.11 and 4.44, respectively; p < 0.01), and communication (4.13 and 4.35, respectively; p < 0.04). Nurses had a higher level of agreement than nursing assistants for Total T-TPQ, leadership, and communication. The results underscore the need to close the gap between nursing assistants' and nurses' perceptions of teamwork. Hospital and nursing leaders should make significant efforts to improve teamwork to build cohesive and highly functional nursing teams that can improve patient safety and thus create lasting social change.

No description available.

Indiana University-Purdue University Indianapolis (IUPUI) / The ability to improve the safety of patient care delivery is dependent on the safety culture, or the norms surrounding reactions following an error, the learning that takes place, and the proactive strategies in place to prevent future errors. While measurement of patient safety culture is now common in the United States (US) using instrument specifically developed for US healthcare organizations, no measurements of safety culture had been conducted at Hamad Medical Corporation in the State of Qatar, a Middle Eastern country; nor were valid or reliable instruments available. The purpose of this study was to assess registered nurses’ perceptions of the safety culture in the units where they provide nursing care at Hamad Medical Corporation using a modified version of the Agency for Healthcare Research and Quality (AHRQ) patient safety culture an instrument (Hospital Survey of Patient Safety Culture). Eight hundred surveys were distributed to all randomly-selected nurses from eight targeted clinical services with a response rate of 57%. Survey results were compared with those from US hospitals using the original AHRQ survey. Ranking of subscales for this study in terms of strengths and areas needing improvement were almost identical to the ordering of US hospital results, with teamwork within units ranked highest and indicating a strength; and the subscale non-punitive response to error the lowest and indicating an area for improvement. Positive response rates in terms of safety culture for this study were generally lower on most subscales compared to the US results and may reflect the intensity of patient safety improvement activity in the US over the last eight years in response to the Institute of Medicine’s report on medical errors in 1999. Results from this study provide a baseline measurement for safety culture at Hamad Medical Corporation and beginning adaptation of an instrument that can be used in other Middle Eastern healthcare organizations in the future.

Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams to adapt to rapidly changing patient conditions while facing intense time pressure and conditional stress. Realities such as these emphasize the need for teamwork skills in the ICU. The measurement of teamwork serves a number of different purposes, including routine assessment, directing feedback, and evaluating the impact of improvement initiatives. Yet no behavioral marker system exists in critical care for quantifying teamwork across multiple task types. This study contributes to the state of science and practice in critical care by taking a (1) theory-driven, (2) context-driven, and (3) psychometrically-driven approach to the development of a teamwork measure. The development of the marker system for the current study considered the state of science and practice surrounding teamwork in critical care, the application of behavioral marker systems across the healthcare community, and interviews with front line clinicians. The ICU behavioral marker system covers four core teamwork dimensions especially relevant to critical care teams: Communication, Leadership, Backup and Supportive Behavior, and Team Decision Making, with each dimension subsuming other relevant subdimensions. This study provided an initial assessment of the reliability and validity of the marker system by focusing on a subset of teamwork competencies relevant to subset of team tasks. Two raters scored the performance of 50 teams along six subdimensions during rounds (n=25) and handoffs (n=25). In addition to calculating traditional forms of reliability evidence [intraclass correlations (ICCs) and percent agreement], this study modeled the systematic variance in ratings associated with raters, instances of teamwork, subdimensions, and tasks by applying generalizability (G) theory. G theory was also employed to provide evidence that the marker system adequately distinguishes teamwork competencies targeted for measurement. The marker system differentiated teamwork subdimensions when the data for rounds and handoffs were combined and when the data were examined separately by task (G coefficient greater than 0.80). Additionally, variance associated with instances of teamwork, subdimensions, and their interaction constituted the greatest proportion of variance in scores while variance associated with rater and task effects were minimal. That said, there remained a large percentage of residual error across analyses. Single measures ICCs were fair to good when the data for rounds and handoffs were combined depending on the competency assessed (0.52 to 0.74). The ICCs ranged from fair to good when only examining handoffs (0.47 to 0.69) and fair to excellent when only considering rounds (0.53 to 0.79). Average measures ICCs were always greater than single measures for each analysis, ranging from good to excellent (overall: 0.69 to 0.85, handoffs: 0.64 to 0.81, rounds: 0.70 to 0.89). In general, the percent of overall agreement was substandard, ranging from 0.44 to 0.80 across each task analysis. The percentage of scores within a single point, however, was nearly perfect, ranging from 0.80 to 1.00 for rounds and handoffs, handoffs, and rounds. The confluence of evidence supported the expectation that the marker system differentiates among teamwork subdmensions. Yet different reliability indices suggested varying levels of confidence in rater consistency depending on the teamwork competency that was measured. Because this study applied a psychometric approach, areas for future development and testing to redress these issues were identified. There also is a need to assess the viability of this tool in other research contexts to evaluate its generalizability in places with different norms and organizational policies as well as for different tasks that emphasize different teamwork skills. Further, it is important to increase the number of users able to make assessments through low-cost, easily accessible rater training and guidance materials. Particular emphasis should be given to areas where rater reliability was less than ideal. This would allow future researchers to evaluate team performance, provide developmental feedback, and determine the impact of future teamwork improvement initiatives.