Quality Lines

Guidelines for promoting good clinical practice are often developed using formal consensus methods. These methods seek to identify whether there is consensus or whether individual views diverge to such an extent that recommendations cannot be made. This article examines how differences in the design of the consensus method and various clinical and social cues affect the extent of disagreement within 16 groups rating the appropriateness of mental health interventions for various conditions. The provision of a literature review, differences in group composition, and assumptions about resources did not significantly affect the extent of disagreement. The extent of disagreement did vary with the interventions and conditions being considered, and some patient characteristics. These findings are encouraging because the extent of disagreement appears to be sensitive to the scenarios considered but robust to variations in the design of the consensus process.
See p 240

The purpose of this study was to develop and test an intervention to increase prescriptions of lipid modifying therapy by primary care physicians for patients with ischemic heart disease and low levels of high density lipoprotein (HDL) cholesterol. The secondary purpose was to determine whether there was any difference between three kinds of prompts (progress notes, patient letters, or computer chart reminders) on provider prescribing behaviour. The intervention, consisting of an educational workshop, opinion leader influence, and prompts, resulted in a significant 32% increase in prescription rates. None of the different prompt types appeared to have any clear-cut advantage over the others.
See p 258

Hospital acquired infections are a major cause of adverse events and an associated increased cost of healthcare provision. There is widespread variation in rates of hospital acquired infection measured as probable nosocomial bacteraemia in UK neonatal intensive care units (NICUs). In a study of 13 334 infants admitted to a random sample of 54 UK NICUs the investigators found widespread variation in rates of nosocomial bacteraemia. They investigated whether these rates were related to organisational and structural factors of the NIUCs. The authors found that probable nosocomial bacteraemia is reduced in units with a dedicated infection control nurse and with the presence of more hand washbasins.
See p 264

In this study the effects on outcome of temporarily moving a 10-bed general intensive care unit because of rebuilding was investigated. There were no other major changes in the ICU service in the period of investigation. Using variable life-adjusted display an increase in hospital mortality of intensive care patients was observed during the 8 month rebuilding period, compared with the two 12 months periods immediately before and after rebuilding. The increased mortality was also found using Kaplan-Meier estimates of survival, and the standardised mortality ratio.
See p 270

How do frontline health care professionals perceive patient safety in their institutions? Many measurement tools are available to assess safety climate; however, few have been formally tested with respect to their reliability. Reliability assessment ensures 1) all survey items tap into the same construct (internal consistency) and 2) survey responses are stable in the absence of change (test–retest reliability). The Safety Climate Survey is a publicly available instrument endorsed by the Institute for Healthcare Improvement. In this article, learn about the reliability characteristics of the SCSu, and two other tools, the Safety Climate Scale, and the Safety Climate Mean from a survey using all three tools in four Canadian intensive care units. There were no differences in responses between hospitals; however, managers perceived a significantly more positive safety climate than other staff.
See p 273

As healthcare organisations increasingly measure their key clinical processes, they must also determine how to best use this information for improvement efforts. In many cases, frontline workers receive this information several months after it is collected. This delay limits the data’s usefulness and can stifle improvement activities. In this issue, Wall and colleagues describe the development of a novel system for measuring central venous catheter (CVC) insertions in real time. By auditing the insertion process in real time, the authors were able to continuously feed back data to frontline staff and optimise an intervention aimed at reducing CVC-related bloodstream infections. The use of these real time process measures allowed their organisation to prospectively monitor the system and overcome barriers to change. Two years after the project’s initiation, their hospital’s bloodstream infection rate remained at a historic low, and real time process measurement was ongoing. The project highlights several key concepts for sustaining any improvement effort, including embedding measurement into daily work, transparency and avoidance of blame, use of interdisciplinary teams, and leadership support.
See p 295

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Relevant Articles

An experimental study of determinants of the extent of disagreement within clinical guideline development groups

A Hutchings, R Raine, C Sanderson, and N Black
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