Teaching Physicians to Care Amid Chaos

Detsky, Allan S.; Berwick, Donald M.

doi:10.1001/jama.2013.620

Cited by 30 publications

(16 citation statements)

References 10 publications

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“…Changes in hospital practice have altered the educational experience for junior doctors 2 . The welcome reduction in working hours has lowered their volume of clinical experience 3 and their experience of continuity of care 4 . Technological advances have shortened patients' admissions, and efficiency pressures exacerbate this trend.…”

Section: Hospital Practicementioning

confidence: 99%

Preparation for general practice vocational training: time for a rethink

Wearne

Magin

Spike

2018

Medical Journal of Australia

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Section: Hospital Practicementioning

confidence: 99%

Preparation for general practice vocational training: time for a rethink

Wearne

Magin

Spike

2018

Medical Journal of Australia

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“…30,36,117 The detrimental impact on patient safety of a weak board and senior management team, marred by professional disengagement, poor governance and a lack of focus on the standards of care, has been illustrated in the Francis Inquiry. 81 However, at the point of care, professional leadership, especially medical, remains paramount [118][119][120][121] and may function as catalyst for, or barrier to, patient safety improvement. 28,90,[122][123][124][125] …”

Section: Limited Patient and Public Engagementmentioning

confidence: 99%

“…5 These include (i) the use of checklists; (ii) care bundles (checklists and associated directive guidelines) for high-risk drugs 197 and invasive practices; 192,198,199 (iii) multicomponent interventions, such as those advocated for the prevention and management of pressure ulcers, falls and hospital-acquired infections; [200][201][202][203] and (iv) various other forms of intervention, including staff training, 118,[204][205][206] adverse event simulation, 207,208 computer-assisted care management, 62,209 national and/or local alert systems and trigger tools. 28,53,210,211 Hospital patient safety: a realist analysis…”

Section: Design Implementation and Evaluationmentioning

confidence: 99%

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Herepath

Kitchener

Waring

2015

Health Serv Deliv Res

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BackgroundHospital patient safety is a major social problem. In the UK, policy responses focus on the introduction of improvement programmes that seek to implement evidence-based clinical practices using the Model for Improvement, Plan-Do-Study-Act cycle. Empirical evidence that the outcomes of such programmes vary across hospitals demonstrates that the context of their implementation matters. However, the relationships between features of context and the implementation of safety programmes are both undertheorised and poorly understood in empirical terms.ObjectivesThis study is designed to address gaps in conceptual, methodological and empirical knowledge about the influence of context on the local implementation of patient safety programmes.DesignWe used concepts from critical realism and institutional analysis to conduct a qualitative comparative-intensive case study involving 21 hospitals across all seven Welsh health boards. We focused on the local implementation of three focal interventions from the 1000 Lives+patient safety programme: Improving Leadership for Quality Improvement, Reducing Surgical Complications and Reducing Health-care Associated Infection. Our main sources of data were 160 semistructured interviews, observation and 1700 health policy and organisational documents. These data were analysed using the realist approaches of abstraction, abduction and retroduction.SettingWelsh Government and NHS Wales.ParticipantsInterviews were conducted with 160 participants including government policy leads, health managers and professionals, partner agencies with strategic oversight of patient safety, advocacy groups and academics with expertise in patient safety.Main outcome measuresIdentification of the contextual factors pertinent to the local implementation of the 1000 Lives+patient safety programme in Welsh NHS hospitals.ResultsAn innovative conceptual framework harnessing realist social theory and institutional theory was produced to address challenges identified within previous applications of realist inquiry in patient safety research. This involved the development and use of an explanatory intervention–context–mechanism–agency–outcome (I-CMAO) configuration to illustrate the processes behind implementation of a change programme. Our findings, illustrated by multiple nested I-CMAO configurations, show how local implementation of patient safety interventions are impacted and modified by particular aspects of context: specifically, isomorphism, by which an intervention becomes adapted to the environment in which it is implemented; institutional logics, the beliefs and values underpinning the intervention and its source, and their perceived legitimacy among different groups of health-care professionals; and the relational structure and power dynamics of the functional group, that is, those tasked with implementing the initiative. This dynamic interplay shapes and guides actions leading to the normalisation or the rejection of the patient safety programme.ConclusionsHeightened awareness of the influence of context on the local implementation of patient safety programmes is required to inform the design of such interventions and to ensure their effective implementation and operationalisation in the day-to-day practice of health-care teams. Future work is required to elaborate our conceptual model and findings in similar settings where different interventions are introduced, and in different settings where similar innovations are implemented.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Pediatric patients admitted to academic medical centers have become increasingly complex . Additionally, with rapid expansion in the medical knowledge a resident must master, increasing documentation demands, and duty‐hour restrictions, there is more to do and less time to do it—a matter that places increasing strain on resident physicians . This concept, also known as “work compression,” can lead to consequences including decreased resident satisfaction, impaired resident learning, and higher rates of resident burnout …”

Section: Introductionmentioning

confidence: 99%

Divide and conquer: Evaluation of a redesign of a pediatric teaching service

Winn

Gross

Silverman

et al. 2019

Pediatric Blood & Cancer

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Background Increasing census and work compression on the pediatric inpatient hematologic malignancy (IHM) service yielded resident dissatisfaction, impaired learning, and decreased perceived quality of patient care. This study aimed to evaluate the impact of a service redesign on resident perceptions of (a) the educational value of the rotation and (b) the safety of patient care. As a secondary objective, we evaluated the impact on the time of day of patient discharge. Procedure A bundled intervention on the IHM service was instituted, including decreased patient volumes, intentional patient assignment, intentional faculty selection, and increased weekend staffing. We distributed an annual survey to end‐of‐the‐year junior residents. We compared responses from residents who experienced the redesign (2017) with residents whose experience predated the redesign (2016). We compared the time of day of patient discharge before and after the redesign. Results Survey completion rates were 70% (28/40) in 2016 and 57% (29/51) in 2017. Redesign residents rated their educational experience and perceived ability to care for patients on the nights and weekends significantly higher than previous residents. Redesign residents reported that their clinical education was compromised by excessive service less frequently than previous residents (24% vs 82%, P < 0.001). The time of day of patient discharge after the redesign was 35 minutes earlier than before the redesign (4:06 pm vs 4:41 pm, P = 0.01, 95% CI = −63, −6). Conclusions A redesign initiative of an oncology service led to improved resident perceptions of the educational value of the rotation and ability to provide safe care to patients, along with earlier discharge times.

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Teaching Physicians to Care Amid Chaos

Cited by 30 publications

References 10 publications

Preparation for general practice vocational training: time for a rethink

Preparation for general practice vocational training: time for a rethink

A realist analysis of hospital patient safety in Wales: applied learning for alternative contexts from a multisite case study

Divide and conquer: Evaluation of a redesign of a pediatric teaching service

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