Ethical considerations in quality improvement: key questions and a practical guide

Improving Safety, Efficiency, Cost, and Satisfaction Across a Musculoskeletal Pathway Using the Digital Assessment Routing Tool for Triage: Quality Improvement Study

BACKGROUND

Musculoskeletal (MSK) conditions are prevalent and increasing in Western-style economies, associated with an aging population and reduced physical activity levels. Prevention, early detection, and treatment can enable people to live in good health, remain independent and socially connected, and have economic advantages for society, such as reducing pressure on health and social care services. Triaging patients safely and effectively to the right care, for the first time improves outcomes and reduces costs, with digital solutions offering potential advantages over traditional methods.

OBJECTIVE

We evaluated the impact of introducing a digital assessment routing tool (DART) on safety, efficiency, cost, and satisfaction across a National Health Service (NHS) England MSK service.

METHODS

We designed a quality improvement study using a Plan-Do-Study-Act design and Integrated Knowledge Translation model, with DART as the first point of contact for self-referring patients with MSK conditions. Patients completed a web-based DART assessment independently, or with administrative telephone support. The primary safety outcome was measured by agreement between clinician judgment and safety incident surveillance. Quantitative and qualitative methods were used to measure secondary outcomes of efficiency, cost, and satisfaction. Analysis was completed collaboratively between researchers and the NHS service team with reference to 4 months of prestudy data. Three consecutive study cycles were completed over a 4-month period between February and May 2024 with 4076 self-referring patients between the ages of 16-104 (mean 59) years.

RESULTS

Ninety-three percent of patients self-assessed using DART with the remainder assisted by an administrator. All predefined outcome targets were met for all measures. Agreement between clinicians and DART was 96%, no safety incidents occurred, there was immediate stratification of 401 (9.8%) urgent cases, and 203 fewer cases requiring clinical escalation following initial clinician contact. Administrative time to process self-referrals was reduced by 51% with a cost saving of £80.16 (US $101.30) per 100 referrals. Introduction of a new route to self-management for less complex conditions showed a cost reduction per patient of 73%, giving a saving of £1272.90 (US $1605.56) for 100 referrals. Routing to a new osteoarthritis knee program would reduce costs for these patients by 63%, equating to £220.35 (US $278.46), if implemented. Further potential savings of £28,476 (US $37,320)/annum could be realized using DART to screen for service eligibility criteria. Patient satisfaction was consistent throughout the study, with a mean of 90%. Service administrators and clinicians rated the new process as a positive service improvement.

CONCLUSIONS

The introduction of DART demonstrated positive outcomes in all measures and presented opportunities to improve safety and efficiency, reduce cost, and improve patient and clinician satisfaction across an NHS MSK pathway. In addition, the successful delivery of an Integrated Knowledge Translation Approach showed the benefits of collaborative working between researchers, clinicians, and other service staff.

Quality improvement in palliative care: A review of the ethics

INTRODUCTION

Quality improvement is the systematic seeking of improvements in care and experience. This discussion paper will explore how the principles of good clinical care and the established ethical frameworks for research can help guide its practice, using examples from palliative care.

QUALITY IMPROVEMENT IN PALLIATIVE CARE

Palliative care is well positioned to be at the vanguard of quality improvement in healthcare. But it holds ethical particularities which require specific considerations, that are helpful for other specialities. The experiences of two improvement activities in palliative care, the Liverpool Care Pathway and Do Not Attempt Resuscitation status reviews, illustrate potential dangers of QI.

IMPLICATIONS FOR ETHICAL PRACTICE

Recommendations for ethically sound quality improvement projects in palliative care include paying attention to the burden of time, viewing informed consent as a tool, monitoring for vulnerability and coercion and transparency in the use of data. The ethics and practices in clinical encounters provide a framework for approaching consent and protecting those with palliative care needs who are deemed as vulnerable. It is explicit in palliative care that time and energy are precious and finite resources. These must be valued and respected in any quality improvement projects. Respect for beneficence and autonomy is essential to avoid coercion and for any project to be ethically sound.

CONCLUSION

Quality improvement processes are an integral part of good healthcare practices. High ethical standards, a supportive culture, transparency and candour are needed for the promotion and sustainability of quality improvement in palliative care.

Workplace factors impacting the wellbeing of diagnostic radiographers in clinical practice: A literature review

INTRODUCTION

The Coronavirus (COVID-19) pandemic resulted in an emphasis on external factors affecting the wellbeing of staff within the National Health Service. There is a national shortage of diagnostic radiographers in the United Kingdom, so maintaining the health and satisfaction of the current radiographic workforce is important. The aim of this literature review is to determine workplace-related factors affecting the wellbeing of diagnostic radiographers in their clinical practice.

METHODS

An interpretive phenomenological approach was selected to gain an insight of wellbeing from the perspective of radiographers and radiology managers. A systematic literature search was conducted, resulting in 10 core articles which were then thematically analysed.

RESULTS

Five themes were identified: Initial waves of COVID-19, Workload and Working Patterns, Mental Health, Sources of Support, and Recognition and Development.

DISCUSSION

COVID-19 has had a short and long-term impact on the working practices of radiographers, leading to a risk of burnout. Radiographers appreciated different forms of recognition from managers and support within their team but felt a lack of professional recognition outside the radiology department. Radiographers displayed resilience during the pandemic, using various strategies to cope with emotional challenges. A variety of external support was available to radiographers, but this was often self-directed, with in-person support difficult to access due to working patterns.

CONCLUSION

This review highlights the lack of tailored support addressing radiographers' unique experiences. As imaging modalities have different workloads and varying emotional involvement with patients, further research to provide evidence-based interventions to improve radiographers' mental health is advised.

A Systematic Review of Cervical Cancer Mobile Applications and a Future Directions for Developers

OBJECTIVE

The objective of this study is to evaluate the quality of mobile health (mHealth) applications that promote cervical cancer awareness and provide screening assistance, with an emphasis on apps available on the Google Play Store and iOS.

METHODS

From December 2023 to February 2024, we assessed mobile applications focused on cervical cancer screening that are available on Google Play and Apple iTunes. The "Cervical Cancer," "Mobile Application," "Pap Test," "Cervical Cancer Guide," "Human Papillomavirus," plus "Cervical Screening are the keywords used to search the applications." Data collection includes features such as application name, pricing, download metrics, invention date, last update, affiliation, online access, login requirements, and notification functionality, which were gathered in Excel. Interrater reliability based on four reviewers' independent judgments, varied from 0.75 to 0.83.

RESULT

In our research, we found 25 apps (16 on the Google Play Store and 9 on iOS). After a thorough review, only 14 relevant apps were included. According to the MARS rating, Rise Against Cancer received the highest score (3.9), followed by FightHPV and Cervical Cancer Forum (3.8). Rise Against Cancer (29), HPV Vaccine (28), and CDC STI Tx Guidelines (28) scored highest in the APPLICATIONS rating system. Hope 4 All and OCI Cervibreast closely matched the statements, meeting seven of the thirteen requirements each.

CONCLUSION

Future app developers should produce user-friendly, often updated mHealth applications that include high-quality cervical cancer awareness and screening content. These apps should provide validated information and pleasant graphic effects.

Simulated learning for staff at a children's hospice: a quality improvement project

Simulated learning has well known positive effects but its use in palliative care education is limited. A quality improvement project was undertaken at a children's hospice to develop and evaluate simulation workshops. The aim was to increase the knowledge, skills and confidence of nurses and healthcare assistants in managing challenging situations commonly experienced when caring for children with life-limiting conditions and their families. The Plan, Do, Study, Act (PDSA) model for improvement was used to test simulation workshops on a small scale using a post-workshop questionnaire and reflective diaries. Despite some initial anxiety, participants felt that the workshop had enhanced their confidence, knowledge and skills, particularly in relation to conducting challenging conversations. The project has provided insight and evidence to develop simulated learning at the children's hospice and further afield.

Navigating the Therapeutic Landscape: A Comprehensive Review of Platelet-Rich Plasma and Bone Marrow Aspirate Concentrate in Knee Osteoarthritis

This comprehensive review provides an in-depth analysis of platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) as potential treatments for knee osteoarthritis. It explores their mechanisms of action, clinical efficacy, safety considerations, and the importance of personalised treatment approaches. The review highlights promising findings regarding the ability of PRP and BMAC to alleviate symptoms, improve joint function, and potentially slow disease progression. It emphasises the need for further research into long-term outcomes, direct comparative studies, protocol standardisation, biomarker identification, and cost-effectiveness assessments to enhance clinical practice. While the review does not directly compare PRP and BMAC, it provides valuable insights into their respective roles in knee osteoarthritis management. The review aims to contribute to evidence-based advancements in regenerative therapies for knee osteoarthritis by addressing critical research priorities and refining treatment strategies.

Orthopaedic Out of Bed Project (OOBP): improving early mobilisation following femoral fracture using a therapy-led education programme

Delayed mobilisation following hip fracture surgery is detrimental to patients and health systems. Prolonged hospital stay additionally results in decreased function and increased mortality. Our hospital was underperforming against the national metric for mobilisation by the day after surgery and physiotherapists were the primary healthcare professionals expected to do this. The therapy team therefore undertook a service improvement to increase the number of patients mobilised by the day after their femoral fracture surgery. This was through a ward-based education programme aimed at increasing confidence and competence of the trauma ward healthcare assistants (HCAs) to complete this task when appropriate instead of physiotherapists.The model for improvement was used, with two Plan-Do-See-Act cycles completed between 2020 and 2022. On completion of the therapy-led intervention, the percentage of patients mobilised by the day after surgery was shown to have increased from a mean average of 60% in 2019 to 79% in 2022. The number of patients mobilised by HCAs prior to physiotherapy assessment increased from 2% prior to and 30% following the intervention.The programme improved HCA confidence and competence using a rehabilitation ethos to mobilise patients following hip fracture surgery. It also showed a clinically significant improvement in the percentage of patients with hip fracture mobilising by the day after surgery and a large increase in the number of patients mobilised by our trauma ward HCAs prior to an initial physiotherapy assessment. This work has demonstrated implications for orthopaedic trauma services and the patients who receive them. It reduces the single point of failure of relying on a physiotherapist to mobilise a patient through increasing multidisciplinary confidence and capability on the ward to perform the task. In turn, this increases physiotherapy capacity to provide acute rehabilitation, which is another important part of femoral fracture recovery.

Improving personalised care and support planning for people living with treatable-but-not-curable cancer

People living with treatable-but-not-curable (TbnC) cancer encounter cancer-related needs. While the NHS long-term plan commits to offering a Holistic Needs Assessment (HNA) and care plan to all people diagnosed with cancer, the content, delivery and timing of this intervention differs across practice. Understanding how people make sense of their cancer experience can support personalised care. A conceptual framework based on personal narratives of living with and beyond cancer (across different cancer types and all stages of the disease trajectory), identified three interlinked themes: Adversity, Restoration and Compatibility, resulting in the ARC framework.Our aim was to use the ARC framework to underpin the HNA to improve the experience of personalised care and support planning for people living with TbnC cancer. We used clinical work experience to operationalise the ARC framework and develop the intervention, called the ARC HNA, and service-level structure, called the ARC clinic. We sought expert input on the proposed content and structure from patients and clinicians through involvement and engagement activities. Delivered alongside standard care, the ARC HNA was piloted with patients on the TbnC cancer (myeloma and metastatic breast, prostate or lung) pathway, who were 6-24 months into their treatment. Iterations were made to the content, delivery and timing of the intervention based on user feedback.Fifty-one patients received the intervention. An average of 12 new concerns were identified per patient, and 96% of patients achieved at least one of their goals. Patients valued the space for reflection and follow-up, and clinicians valued the collaborative approach to meeting patients' supportive care needs. Compared with routine initial HNA and care plan completion rates of 13%, ARC clinic achieved 90% with all care plans shared with general practitioners. The ARC clinic adopts a novel and proactive approach to delivering HNAs and care plans in a meaningful and personalised way.

Evaluation of the Impact of an Education Program on Self-Reported Leadership and Management Competence Among Nurse Managers

Background

Developing leadership and management competencies for nursing managers is critical to the effective leadership of others and driving team and organizational performance. This paper aimed to evaluate the impact of a system-wide nursing leadership quality improvement initiative in a network of four public hospitals and one specialized outpatient center in the United Arab Emirates (UAE). The initiative was designed to enhance nursing middle managers’ leadership and managerial competencies.

Methods

This is a quantitative evaluation following the Standards for Quality Improvement Reporting Excellence (SQUIRES) guidelines. Secondary Data analysis of a pre- and post-course self-assessment for 105 middle nursing managers who attended a nursing leadership quality improvement training program between December 2017 and April 2019.

Results

Following participation in this quality improvement initiative, the paired sample t-test analysis demonstrated a statistically significant difference between the pre- and post-assessments total and individual leadership domains mean scores.

Conclusion

Attending well-structured nursing leadership quality improvement programs positively enhances nurse managers’ professional abilities and perception of their management and leadership competencies. Leadership development programs should equip managers with the skills and tools to achieve their professional goals effectively and support their transition to becoming expert nurse leaders. Healthcare institutions’ ethical obligation is to provide them with the necessary resources and training to achieve this goal.