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Sinnott C, Alboksmaty A, Moxey JM, Morley KI, Parkinson S, Burt J, Dixon-Woods M. Operational failures in general practice: a consensus-building study on the priorities for improvement. Br J Gen Pract 2024; 74:e339-e346. [PMID: 38621805 PMCID: PMC11044020 DOI: 10.3399/bjgp.2023.0321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/19/2023] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND System problems, known as operational failures, can greatly affect the work of GPs, with negative consequences for patient and professional experience, efficiency, and effectiveness. Many operational failures are tractable to improvement, but which ones should be prioritised is less clear. AIM To build consensus among GPs and patients on the operational failures that should be prioritised to improve NHS general practice. DESIGN AND SETTING Two modified Delphi exercises were conducted online among NHS GPs and patients in several regions across England. METHOD Between February and October 2021, two modified Delphi exercises were conducted online: one with NHS GPs, and a subsequent exercise with patients. Over two rounds, GPs rated the importance of a list of operational failures (n = 45) that had been compiled using existing evidence. The resulting shortlist was presented to patients for rating over two rounds. Data were analysed using median scores and interquartile ranges. Consensus was defined as 80% of responses falling within one value below and above the median. RESULTS Sixty-two GPs responded to the first Delphi exercise, and 53.2% (n = 33) were retained through to round two. This exercise yielded consensus on 14 failures as a priority for improvement, which were presented to patients. Thirty-seven patients responded to the first patient Delphi exercise, and 89.2% (n = 33) were retained through to round two. Patients identified 13 failures as priorities. The highest scoring failures included inaccuracies in patients' medical notes, missing test results, and difficulties referring patients to other providers because of problems with referral forms. CONCLUSION This study identified the highest-priority operational failures in general practice according to GPs and patients, and indicates where improvement efforts relating to operational failures in general practice should be focused.
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Affiliation(s)
- Carol Sinnott
- The Healthcare Improvement Studies (THIS) Institute, Cambridge
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Ledbeter L. Self-efficacy in Quality Improvement Competency of Frontline Acute Care Registered Nurses. J Nurs Care Qual 2024; 39:168-174. [PMID: 37751558 DOI: 10.1097/ncq.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Registered nurses (RNs) are attuned to health care quality and safety concerns but may lack competency in quality improvement (QI) to advance care quality. PURPOSE To describe frontline acute care RNs' self-efficacy in QI competencies, evaluate differences based on educational attainment, and evaluate relationships based on years of RN experience. METHODS The study used a descriptive, quantitative, correlational, comparative cross-sectional survey design to evaluate RNs' self-efficacy in QI competency using the 2021 American Association of Colleges of Nursing The Essentials : Core Competencies for Professional Nursing Education . RESULTS Frontline RNs' overall QI self-efficacy showed variability in knowledge, skills, and attitudes, with no relationship between self-efficacy and years of RN experience, nor difference based on educational attainment. CONCLUSIONS Insufficient self-efficacy signals the need for further QI focus in nursing education, nursing practice, and health care policy to harness RNs' ability to advance care outcomes.
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Affiliation(s)
- Lauri Ledbeter
- Author Affiliations: Providence Health & Services, Spokane, Washington
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Vanbelleghem S, De Regge M, Van Nieuwenhove Y, Gemmel P. Barriers and Enablers of Second-Order Problem-Solving Behavior: How Nurses Can Break Away From the Workaround Culture. Qual Manag Health Care 2022; 31:130-142. [PMID: 35657734 DOI: 10.1097/qmh.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Nurses are challenged by numerous day-to-day unexpected problems due to poorly performing work systems that hinder patient care. These operational failures persist in hospitals, partly because nurses tend to prefer quick fixes or workarounds over real improvements that prevent recurrence. The aim of this review is to shed light on the barriers to and enablers of nurses' second-order problem-solving behavior and their consequences, so that hospitals can learn from failure and improve organizational outcomes. METHODS We conducted a systematic review, with quantitative, qualitative, and mixed-method articles, searching 6 databases (PubMed, Embase, Web of Science, CINAHL, and Google Scholar) following the Preferred Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Quality assessment for inclusion was performed by 2 independent authors using the Mixed Methods Appraisal Tool (MMAT). A descriptive synthesis was used for analysis. RESULTS This study reveals the barriers and enablers for second-order problem-solving behavior, and synthesizes improvement proposals within 3 perspectives, namely the "empowerment" perspective, the "process improvement" perspective, and the "time" perspective. Furthermore, we found that limited attention is given to the patient's perspective, and the existence of a no-action behavior. CONCLUSION Although operational failures have several important consequences for hospital staff and organizations, there has been hardly any research into the barriers and enablers that initiate second-order problem-solving behavior; stemming this nursing behavior has thus rarely appeared as a suggestion for improvement.
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Affiliation(s)
- Sem Vanbelleghem
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium (Mr Vanbelleghem); Departments of Marketing, Innovation and Organization (Drs De Regge and Gemmel) and Public Health and Primary Care (Dr Gemmel), Ghent University, Ghent, Belgium; Departments of Strategic Policy Cell (Dr De Regge) and Gastrointestinal Surgery (Dr Van Nieuwenhove), Ghent University Hospital, Ghent, Belgium; and Faculty of Medicine and Health Sciences, Department of Human Structure and Repair, Ghent University Hospital, Ghent, Belgium (Dr Van Nieuwenhove)
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Jennings BM, Baernholdt M, Hopkinson SG. Exploring the turbulent nature of nurses’ workflow. Nurs Outlook 2022; 70:440-450. [DOI: 10.1016/j.outlook.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/24/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
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Hwang JI, Kim SW, Park HA. Relationships Between Nurses' Work System, Safety-Related Performance, and Outcomes: A Structural Equation Model. J Patient Saf 2021; 17:e1638-e1645. [PMID: 34852419 PMCID: PMC8612905 DOI: 10.1097/pts.0000000000000866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We examined relationships between nurses' work system, safety-related performance, and outcomes based on a modified Systems Engineering Initiative for Patient Safety model. METHODS A cross-sectional survey was conducted with 408 nurses from 2 general hospitals. Data on work system factors (person, organization, environment, tools, and task), processes (safety-related performance), and outcomes (staff and clinical outcomes) were collected. Structural equation modeling was used to determine the relationships between nurses' work system factors, safety-related processes, and outcomes. RESULTS Structural equation modeling yielded a comparative fit index of 0.918, standardized root mean square residual of 0.055, and root mean square error of approximation of 0.054, indicating an acceptable model fit. The person factor had a significant positive direct effect on nurses' safety-related performance, and significant negative direct and indirect effects on the clinical outcome. The organization factor had significant positive direct effects on nurses' safety-related performance and staff outcome, and a negative indirect effect on the clinical outcome. The task factor had a significant positive direct effect on staff outcome. However, the environment and tools factors had no significant effects on safety-related performance or outcomes. CONCLUSIONS The findings demonstrated the usefulness of the Systems Engineering Initiative on Patient Safety model to explain safety-related performance and outcomes, indicating differential effects of work system factors. Although the person factor significantly affected safety performance and clinical outcomes, the organization factor was the most influential component for promoting safety-related performance and staff and clinical outcomes. These results can be used to prioritize activities for patient safety.
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Affiliation(s)
| | - Sung Wan Kim
- Department of ORL-HNS, College of Medicine, Kyung Hee University
| | - Hyeoun-Ae Park
- College of Nursing and Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea
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Lee BY, Wedlock PT, Mitgang EA, Cox SN, Haidari LA, Das MK, Dutta S, Kapuria B, Brown ST. How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India. BMJ Glob Health 2019; 4:e001609. [PMID: 31565408 PMCID: PMC6747917 DOI: 10.1136/bmjgh-2019-001609] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping. Methods We developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping. Results Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08. Conclusion Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.
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Affiliation(s)
- Bruce Y Lee
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Patrick T Wedlock
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Elizabeth A Mitgang
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Sarah N Cox
- Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.,Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
| | - Leila A Haidari
- Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA.,HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA
| | | | | | | | - Shawn T Brown
- HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA.,McGill Center for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada
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