Publications
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Woodcock T, Novov V, Skirrow H, et al., 2023, Health and socio-demographic characteristics associated with uptake of seasonal influenza vaccination amongst pregnant women: retrospective cohort study, British Journal of General Practice, Vol: 73, Pages: e148-e155, ISSN: 0960-1643
Pregnant women are at increased risk from influenza, yet maternal influenza vaccination levels remain suboptimal. This study aimed to estimate associations between socio-demographic and health characteristics and seasonal influenza vaccination uptake among pregnant women and understand trends over time to inform interventions to improve vaccine coverage. A retrospective cohort study using linked electronic health records of women in North West London with at least one pregnancy overlapping with an influenza season between September 2010 and February 2020. We used a multivariable mixed-effects logistic regression model to identify associations between characteristics of interest and primary outcome of influenza vaccination. 451,954 pregnancies, among 260,744 women, were included. In 85,376 (18.9%) pregnancies women were vaccinated against seasonal influenza. Uptake increased from 8.4% in 2010/11 to 26.3% in 2018/19, dropping again to 21.1% in 2019/20. Uptake was lowest among women: aged 15-19 years (12%) or over 40 years (15%; OR 1.17, 95% CI 1.10 to 1.24); of Black ethnicity (14.1%; OR 0.55, 95% CI 0.53 to 0.57), or unknown ethnicity (9.9%; OR 0.42, 95% CI 0.39 to 0.46), lived in more deprived areas (OR least vs most deprived 1.16, 95% CI 1.11 to 1.21), or with no known risk factors for severe influenza. Seasonal influenza vaccine uptake in pregnant women increased in the past decade, prior to the COVID-19 pandemic, but remained suboptimal. We recommend approaches to reducing health inequalities should focus on women of Black ethnicity, younger and older women, and women living in areas of greater socio-economic deprivation.
Marang-van de Mheen PJ, Woodcock T, 2022, Grand rounds in methodology: four critical decision points in statistical process control evaluations of quality improvement initiatives, BMJ QUALITY & SAFETY, Vol: 32, Pages: 47-54, ISSN: 2044-5415
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Woodcock T, Greenfield G, Lalvani A, et al., 2022, Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza: retrospective cohort study, Thorax, ISSN: 0040-6376
Background We examine differences in posthospitalisation outcomes, and health system resource use, for patients hospitalised with COVID-19 during the UK’s first pandemic wave in 2020, and influenza during 2018 and 2019.Methods This retrospective cohort study used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity.Results The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37).Conclusions Patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.
Dewa LH, Pappa S, Greene T, et al., 2022, The Association Between Sleep Disturbance and Suicidality in Psychiatric Inpatients Transitioning to the Community: Protocol for an Ecological Momentary Assessment Study, JMIR RESEARCH PROTOCOLS, Vol: 11, ISSN: 1929-0748
Dewa L, Pappa S, Greene T, et al., 2022, The Association Between Sleep Disturbance and Suicidality inPsychiatric Inpatients Transitioning to the Community: Protocolfor an Ecological Momentary Assessment Study, JMIR Research Protocols, Vol: 11, Pages: 1-12, ISSN: 1929-0748
Background:Patients are at high risk of suicidal behaviour and death by suicide immediately followingdischarge from an inpatient psychiatric hospital. Furthermore, there is a high prevalence ofsleep problems in inpatient settings which is associated with worse outcomes followinghospitalisation. However, it is unknown whether poor sleep is associated with suicidalityfollowing initial hospital discharge.Objective:Our study objective is to describe the ecological momentary assessment (EMA) studyprotocol that aims to examine the relationship between sleep and suicidality in dischargedpatients.Methods:Our study will use EMA design using a wearable device to examine the sleep-suiciderelationship during the transition from acute inpatient care to the community. Prospectivelydischarged inpatients aged 18-35 with a mental disorder (n=50) will be assessed foreligibility and recruited across two sites. Data on suicidal ideation, behaviour and imagery,non-suicidal self-harm and imagery, defeat, entrapment, and hopelessness, affect and sleepwill be collected on the Pro-Diary V wrist-worn electronic watch for up to 14 days. Objectivesleep and daytime activity will be measured using the inbuilt MotionWare software.Questionnaires will be administered face-to-face at baseline and follow-up while data willalso be collected on the acceptability and feasibility of using the Pro-Diary V watch tomonitor the transition following discharge. The study has been, and will continue to be, coproduced with young people with experience of being in an inpatient setting and suicidality.Results:South Birmingham Research Ethics Committee (Ref: 21/WM/0128) approved the study onJune 28th 2021. We expect to see a relationship between poor sleep and post-dischargesuicidality. Results will be available in 2022.DiscussionThis protocol describes the first co-produced EMA study to examine the relationshipbetween sleep and suicidality, and to apply the IMV model in young patients transitioningfrom psychiatric
Nakubulwa MA, Greenfield G, Pizzo E, et al., 2022, To what extent do callers follow the advice given by a non-emergency medical helpline (NHS 111): A retrospective cohort study, PLoS One, Vol: 17, ISSN: 1932-6203
National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. We examine patient and call-related characteristics associated with compliance with advice given in NHS 111 calls. The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics. Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls. Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service. This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote heal
Cribb A, Woodcock T, 2022, Measuring with quality: the example of person-centred care, Journal of Health Services Research and Policy, Vol: 27, ISSN: 1355-8196
Qualitative data analysis should be embedded in routine health service measurement, management and organizational practices. The rigorous use of such analyses should become an institutional norm, comparable to the routine use of quantitative data. Our case is intended to have general relevance, but we develop it by reference to person-centred care and patient-centred outcome measures (PCOMs). The increased use of qualitative data analysis of individualized PCOMs is a crucial complementary counterweight to steps towards the standardization of PCOMs. More broadly, our argument is that health care organizations cannot make confident judgements about whether they are offering appropriate care without collecting qualitative data on what matters to individual patients. Introducing properly supported and conducted qualitative data analyses is important in its own right, and also helps underpin the validity and usefulness of quantitative measurement.
Nakubulwa M, Junghans C, Novov V, et al., 2022, Factors associated with accessing long-term adult social care in people aged 75 and over: a retrospective cohort study., Age and Ageing, Vol: 51, Pages: 1-9, ISSN: 0002-0729
BACKGROUND: An ageing population and limited resources have put strain on state provision of adult social care (ASC) in England. With social care needs predicted to double over the next 20 years, there is a need for new approaches to inform service planning and development, including through predictive models of demand. OBJECTIVE: Describe risk factors for long-term ASC in two inner London boroughs and develop a risk prediction model for long-term ASC. METHODS: Pseudonymised person-level data from an integrated care dataset were analysed. We used multivariable logistic regression to model associations of demographic factors, and baseline aspects of health status and health service use, with accessing long-term ASC over 12 months. RESULTS: The cohort comprised 13,394 residents, aged ≥75 years with no prior history of ASC at baseline. Of these, 1.7% became ASC clients over 12 months. Residents were more likely to access ASC if they were older or living in areas with high socioeconomic deprivation. Those with preexisting mental health or neurological conditions, or more intense prior health service use during the baseline period, were also more likely to access ASC. A prognostic model derived from risk factors had limited predictive power. CONCLUSIONS: Our findings reinforce evidence on known risk factors for residents aged 75 or over, yet even with linked routinely collected health and social care data, it was not possible to make accurate predictions of long-term ASC use for individuals. We propose that a paradigm shift towards more relational, personalised approaches, is needed.
Beaney T, Clarke J, Woodcock T, et al., 2021, Patterns of healthcare utilisation in children and young people: a retrospective cohort study using routinely collected healthcare data in Northwest London, BMJ Open, Vol: 11, Pages: 1-14, ISSN: 2044-6055
ObjectivesWith a growing role for health services in managing population health, there is a need for early identification of populations with high need. Segmentation approaches partition the population based on demographics, long-term conditions (LTCs) or healthcare utilisation but have mostly been applied to adults. Our study uses segmentation methods to distinguish patterns of healthcare utilisation in children and young people (CYP) and to explore predictors of segment membership.DesignRetrospective cohort study.SettingRoutinely collected primary and secondary healthcare data in Northwest London from the Discover database.Participants378,309 CYP aged 0-15 years registered to a general practice in Northwest London with one full year of follow-up.Primary and secondary outcome measuresAssignment of each participant to a segment defined by seven healthcare variables representing primary and secondary care attendances, and description of utilisation patterns by segment. Predictors of segment membership described by age, sex, ethnicity, deprivation and LTCs.ResultsParticipants were grouped into six segments based on healthcare utilisation. Three segments predominantly used primary care; two moderate utilisation segments differed in use of emergency or elective care, and a high utilisation segment, representing 16,632 (4.4%) children accounted for the highest mean presentations across all service types. The two smallest segments, representing 13.3% of the population, accounted for 62.5% of total costs. Younger age, residence in areas of higher deprivation, and presence of one or more LTCs were associated with membership of higher utilisation segments, but 75.0% of those in the highest utilisation segment had no LTC.ConclusionsThis article identifies six segments of healthcare utilisation in CYP and predictors of segment membership. Demographics and LTCs may not explain utilisation patterns as strongly as in adults which may limit the use of routine data in predicting ut
Dewa L, Pappa S, Greene T, et al., 2021, SWAY: Sleep disturbance as an early warning sign of suicidality in psychiatric inpatients transitioning to the community: an ecological momentary assessment study protocol
Dewa LH, Pappa S, Greene T, et al., 2021, The Association Between Sleep Disturbance and Suicidality in Psychiatric Inpatients Transitioning to the Community: Protocol for an Ecological Momentary Assessment Study (Preprint)
<sec> <title>BACKGROUND</title> <p>Patients are at high risk of suicidal behavior and death by suicide immediately following discharge from inpatient psychiatric hospitals. Furthermore, there is a high prevalence of sleep problems in inpatient settings, which is associated with worse outcomes following hospitalization. However, it is unknown whether poor sleep is associated with suicidality following initial hospital discharge.</p> </sec> <sec> <title>OBJECTIVE</title> <p>Our study objective is to describe a protocol for an ecological momentary assessment (EMA) study that aims to examine the relationship between sleep and suicidality in discharged patients.</p> </sec> <sec> <title>METHODS</title> <p>Our study will use an EMA design based on a wearable device to examine the sleep-suicide relationship during the transition from acute inpatient care to the community. Prospectively discharged inpatients 18 to 35 years old with mental disorders (N=50) will be assessed for eligibility and recruited across 2 sites. Data on suicidal ideation, behavior, and imagery; nonsuicidal self-harm and imagery; defeat, entrapment, and hopelessness; affect; and sleep will be collected on the Pro-Diary V wrist-worn electronic watch for up to 14 days. Objective sleep and daytime activity will be measured using the inbuilt MotionWare software. Questionnaires will be administered face-to-face at baseline and follow up, and data will also be collected on the acceptability and feasibility of using the Pro-Diary V watch to monitor the transition following discharge. The study has been, and will continue to be, coproduced with young people with experience of being in an inpatient settin
Wong KY, Davies B, Adeleke Y, et al., 2021, Hospital admissions for stroke and bleeding in Hounslow following a quality improvement initiative, Open Heart, Vol: 8, ISSN: 2053-3624
Objective Atrial fibrillation (AF) is the most common arrhythmia. Undiagnosed and poorly managed AF increases risk of stroke. The Hounslow AF quality improvement (QI) initiative was associated with improved quality of care for patients with AF through increased detection of AF and appropriate anticoagulation. This study aimed to evaluate whether there has been a change in stroke and bleeding rates in the Hounslow population following the QI initiative.Methods Using hospital admissions data from January 2011 to August 2018, interrupted time series analysis was performed to investigate the changes in standardised rates of admission with stroke and bleeding, following the start of the QI initiative in October 2014.Results There was a 17% decrease in the rate of admission with stroke as primary diagnosis (incidence rate ratio (IRR) 0.83; 95% CI 0.712 to 0.963; p<0.014). There was an even larger yet not statistically significant decrease in admission with stroke as primary diagnosis and AF as secondary diagnosis (IRR 0.75; 95% CI 0.550 to 1.025; p<0.071). No significant changes were observed in bleeding admissions. For each outcome, an additional regression model including both the level change and an interaction term for slope change was created. In all cases, the slope change was small and not statistically significant.Conclusion Reduction in stroke admissions may be associated with the AF QI initiative. However, the immediate level change and non-significant slope change suggests a lack of effect of the intervention over time and that the decrease observed may be attributable to other events.
Woodcock T, Liberati E, Dixon-Woods M, 2021, A mixed-methods study of challenges experienced by clinical teams in measuring improvement, BMJ Quality and Safety, Vol: 30, Pages: 106-115, ISSN: 2044-5415
Objective: Measurement is an indispensable element of most quality improvement (QI) projects, but it is undertaken to variable standards. We aimed to characterise challenges faced by clinical teams in undertaking measurement in the context of a safety QI programme that encouraged local selection of measures. Methods: Drawing on an independent evaluation of a multi-site improvement programme (Safer Clinical Systems), we combined a qualitative study of participating teams’ experiences and perceptions of measurement with expert review of measurement plans and analysis of data collected for the programme. Multidisciplinary teams of frontline clinicians at nine UK NHS sites took part across the two phases of the programme between 2011 and 2016. Results: Developing and implementing a measurement plan against which to assess their improvement goals was an arduous task for participating sites. The operational definitions of the measures that they selected were often imprecise or missed important details. Some measures used by the teams were not logically linked to the improvement actions they implemented. Regardless of the specific type of data used (routinely collected or selected ex-novo), the burdensome nature of data collection was underestimated. Problems also emerged in identifying and using suitable analytical approaches. Conclusion: Measurement is a highly technical task requiring a degree of expertise. Simply leveraging individual clinicians’ motivation is unlikely to defeat the persistent difficulties experienced by clinical teams when attempting to measure their improvement efforts. We suggest that more structural initiatives and broader capability-building programmes should be pursued by the professional community. Improving access to, and ability to use repositories of validated measures, and increasing transparency in reporting measurement attempts, is likely to be helpful.
Woodcock T, Adeleke Y, Goeschel C, et al., 2020, A modified Delphi study to identify the features of high quality measurement plans for healthcare improvement projects, BMC Medical Research Methodology, Vol: 20, ISSN: 1471-2288
BackgroundThe design and execution of measurement in quality improvement (QI) initiatives is often poor. Better guidance on “what good looks like” might help to mitigate some of the problems. We report a consensus-building process that sought to identify which features are important to include in QI measurement plans. MethodsWe conducted a three-stage consensus-building approach: (1) identifying the list of features of measurement plans that were potential candidates for inclusion based on literature review and the study team’s experience; (2) a two-round modified Delphi exercise with a panel of experts to establish consensus on the importance of these features; and (3) a small in-person consensus group meeting to finalise the list of features. ResultsA list of 104 candidate questions was generated. A panel of 19 experts in the Delphi reviewed these questions and produced consensus on retaining 46 questions in the first round and on a further 22 in the second round. Thematic analysis of open text responses from the panellists suggested a number of areas of debate that were explicitly considered by the consensus group. The exercise yielded 74 questions (71% of 104) on which there was consensus in five categories of measurement relating to: design, data collection and management, analysis, action, and embedding. ConclusionsThis study offers a consensus-based view on the features of a good measurement plan for a QI project in healthcare. The results may be of use to QI teams, funders and evaluators, but are likely to require further development and testing to ensure feasibility and usefulness. Key words: Measurement; Quality improvement; Quality measurement; Delphi technique.
Adeleke Y, Matthew D, Porter B, et al., 2019, Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices, Open Heart, Vol: 6, ISSN: 2053-3624
Objective Atrial fibrillation (AF) is a growing problem internationally and a recognised cause of cardiovascular morbidity and mortality. The London borough of Hounslow has a lower than expected prevalence of AF, suggesting poor detection and associated undertreatment. To improve AF diagnosis and management, a quality improvement (QI) initiative was set up in 48 general practices in Hounslow. We aimed to study whether there was evidence of a change in AF diagnosis and management in Hounslow following implementation of interventions in this QI initiative.Methods Using the general practice information system (SystmOne), data were retrospectively collected for 415 626 patients, who were actively registered at a Hounslow practice between 1 January 2011 and 31 August 2018. Process, outcome and balancing measures were analysed using statistical process control and interrupted time series regression methods. The baseline period was from 1 January 2011 to 30 September 2014 and the intervention period was from 1 October 2014 to 31 August 2018.Results When comparing the baseline to the intervention period, (1) the rate of new AF diagnoses increased by 27% (relative risk 1.27; 95% CI 1.05 to 1.52; p<0.01); (2) ECG tests done for patients aged 60 and above increased; (3) CHA2DS2-VASc and HAS-BLED risk assessments within 30 days of AF diagnosis increased from 1.7% to 19% and 0.2% to 8.1%, respectively; (4) among those at higher risk of stroke, anticoagulation prescription within 30 days of AF diagnosis increased from 31% to 63% while prescription of antiplatelet monotherapy within the same time period decreased from 17% to 7.1%; and (5) average CHA2DS2-VASc and HAS-BLED risk scores did not change.Conclusion Implementation of interventions in the Hounslow QI initiative coincided with improved AF diagnosis and management. Areas with perceived underdetection of AF should consider similar interventions and methodology.
Sommerville P, Lang A, Archer S, et al., 2019, FORWARD (Feeding via the Oral Route With Acknowledged Risk of Deterioration): evaluation of a novel tool to support patients eating and drinking at risk of aspiration, AGE AND AGEING, Vol: 48, Pages: 553-558, ISSN: 0002-0729
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Sakonidou S, Andrzejewska I, Kotzamanis S, et al., 2019, Better use of data to improve parent satisfaction (BUDS): protocol for a prospective before-and-after pilot study employing mixed methods to improve parent experience of neonatal care, BMJ Paediatrics Open, Vol: 3, ISSN: 2399-9772
Introduction Having a baby that requires neonatal care is stressful and traumatic. Parents often report dissatisfaction with communication of clinical information. In the UK neonatal care data are recorded daily using electronic patient record systems (EPR), from which deidentified data form the National Neonatal Research Database (NNRD). We aim to evaluate the impact of sharing neonatal EPR data with parents, on parent-reported satisfaction, parent–staff interactions, staff workload and data completeness.Methods A prospective, before-and-after, mixed-method study. Participants are parents of inpatient babies (maximum 90) and staff in a tertiary neonatal intensive care unit, London, UK. The intervention was developed by former neonatal parents, neonatologists and neonatal nurses: a communication tool for parents comprising individualised, written, daily infant updates for parents, derived from EPR data. The intervention will be provided to parents over 6 weeks. Plan-Do-Study-Act cycles will inform the tool’s iterative development and improvement. The tool’s impact will be measured using a validated parent survey, staff survey, data completeness measures and interviews.Analysis Primary outcome: parent satisfaction ‘with communication of clinical information and involvement in care’. Secondary outcomes: parent–staff interactions, staff workload, data completeness. Baseline survey data will be obtained from clinical service evaluation preceding the intervention. Baseline data completeness will be derived from the NNRD. During the intervention, surveys will be administered biweekly and data completeness assessed daily. We will analyse outcomes using run charts and partially paired statistical tests. Parent and staff interviews will explore information exchange and the communication tool’s impact.Discussion This study will evaluate the impact of a parent co-designed intervention on communication with parents in neonatal care and
McNicholas C, Lennox L, Woodcock T, et al., 2019, Evolving quality improvement support strategies to improve Plan-Do-Study-Act cycle fidelity: a retrospective mixed methods study, BMJ Quality and Safety, Vol: 28, Pages: 356-365, ISSN: 2044-5415
BackgroundThough widely recommended as an effective approach to quality improvement (QI), the Plan-Do-Study-Act (PDSA) cycle method can be challenging to use and low fidelity of published accounts of the method has been reported. There is little evidence of the fidelity of PDSA cycles used by frontline teams, nor how to support and improve the method’s use. Data collected from 39 frontline improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this overtime.MethodsThe fidelity of 421 PDSA cycles was reviewed using a pre-defined framework, and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews.ResultsAlthough modest, statistically significant improvements in PDSA fidelity occurred, however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use, and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.ConclusionsThis study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.
Mummery V, Rogers E, Padmanaban V, et al., 2019, Transcutaneous CO2 measurement is not a reliable alternative to arterial blood gas sampling in the acute medical setting, European Respiratory Journal, Vol: 53, ISSN: 0903-1936
Mummery V, Adeleke Y, Lin F, et al., 2018, NON-INVASIVE VENTILATION: MAKING CHANGES AND DEMONSTRATING IMPROVEMENT USING QUALITY IMPROVEMENT METHODOLOGY, Winter Meeting of the British-Thoracic-Society, Publisher: BMJ PUBLISHING GROUP, Pages: A205-A205, ISSN: 0040-6376
Mummery V, Rodgers E, Padmanaban V, et al., 2018, TRANSCUTANEOUS CO2 MEASUREMENT IS NOT A RELIABLE ALTERNATIVE TO ARTERIAL BLOOD GAS SAMPLING IN THE ACUTE MEDICAL SETTING, Winter Meeting of the British-Thoracic-Society, Publisher: BMJ PUBLISHING GROUP, Pages: A228-A228, ISSN: 0040-6376
Issen L, Woodcock T, McNicholas C, et al., 2018, Criteria for evaluating programme theory diagrams in quality improvement initiatives: a structured method for appraisal, International Journal for Quality in Health Care, Vol: 30, Pages: 508-513, ISSN: 1353-4505
Background: Despite criticisms that many Quality Improvement (QI) initiatives fail due to incomplete programme theory, there is no defined way to evaluate how programme theory has been articulated. The objective of this research was to develop, and assess the usability and reliability of, scoring criteria to evaluate programme theory diagrams. Methods: Criteria development was informed by published literature and QI experts. Inter-rater reliability was tested between two evaluators. 63 programme theory diagrams (42 driver diagrams and 21 action effect diagrams) were reviewed to establish whether the criteria could support comparative analysis of different approaches to constructing diagrams.Results: Components of the scoring criteria include: assessment of overall aim, logical overview, clarity of components, cause/effect relationships, evidence, and measurement. Independent reviewers had 78% inter-rater reliability. Scoring enabled direct comparison of different approaches to developing programme theory; Action-Effect diagrams were found to have had a statistically significant but moderate improvement in programme theory quality over Driver Diagrams; no significant differences were observed based on the setting in which Driver Diagrams were developed.Conclusions: The scoring criteria summarise the necessary components of programme theory that are thought to contribute to successful QI projects. The viability of the scoring criteria for practical application was demonstrated. Future uses include assessment of individual programme theory diagrams, and comparison of different approaches (e.g. methodological, teaching or other QI support) to produce programme theory. The criteria can be used as a tool to guide the production of better programme theory diagrams, and also highlights where additional support for QI teams could be needed.
Etchells E, Woodcock T, 2017, Value of small sample sizes in rapid-cycle quality improvement projects (Part II): Assessing Fidelity of Implementation for Improvement Interventions, BMJ Quality and Safety, Vol: 27, Pages: 61-65, ISSN: 2044-5415
Reed JE, Stillman N, Lennox L, et al., 2017, Applying the concept of 'hard core' and 'soft periphery' of interventions to share learning from quality improvement efforts, ISQua 34th International Conference, Publisher: Oxford University Press (OUP), Pages: 47-48, ISSN: 1353-4505
Poots A, Reed J, Woodcock T, et al., 2017, How to attribute causality in quality improvement: lessons from epidemiology, BMJ Quality & Safety, Vol: 26, Pages: 933-937, ISSN: 2044-5423
Quality improvement and implementation (QI&I) initiatives face critical challenges in an era of evidence-based, value-driven patient care. Whether front-line staff, large organisations or government bodies design and run QI&I, there is increasing need to demonstrate impact to justify investment of time and resources in implementing and scaling up an intervention.Decisions about sustaining, scaling up and spreading an initiative can be informed by evidence of causation and the estimated attributable effect of an intervention on observed outcomes. Achieving this in healthcare can be challenging, where interventions often are multimodal and applied in complex systems.1 Where there is weak evidence of causation, credibility in the effectiveness of the intervention is reduced with a resultant reduced desire to replicate. The greater confidence of a causal relationship between QI&I interventions and observed results, the greater our confidence that improvement will result when the intervention occurs in different settings.Guidance exists for design, conduct, evaluation and reporting of QI&I initiatives;2–4; the Standards for QUality Improvement Reporting Excellence (SQUIRE) and the Standards for Reporting Implementation Studies (STARI) guidelines were developed specifically for reporting QI&I initiatives.5 6 However, much of this guidance is targeted at larger formal evaluations, and may require levels of resource or expertise not available to all QI&I initiatives. This paper proposes QI&I initiatives, regardless of scope and resources, can be enhanced by applying epidemiological principles, adapted from those promulgated by Austin Bradford Hill.7
Reed JE, Davey N, Woodcock T, 2016, The foundations of quality improvement science, Future Hospital Journal, Vol: 3, Pages: 199-202, ISSN: 2055-3331
As an alternative to ‘Big Bang’ initiatives, Plan-Do-Study-Act (PDSA) cycles are an increasingly popular approach to conduct tests of change to support quality improvement in healthcare. Using PDSA can help clinicians deliver improvements in patient care through a structured experimental approach to learning and tests of change. Its facilitation of individual, team and organisational learning makes this an essential tool for the future hospital. This paper provides an example of the benefits of using PDSA in practice to test and develop a change idea to ensure it is fit for purpose. As with any new skill or competency, learning to use PDSA cycles takes time and practice and is necessary to ensure that the method is being used to its full effect. This paper explores some of the challenges encountered by clinicians in learning to use PDSA cycles well, and provides advice on how they can be overcome to help practitioners to get more out of using the method.
Marvin V, Kuo S, Poots A, et al., 2016, Applying Quality Improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital, BMJ Open, Vol: 6, ISSN: 2044-6055
Objectives: Reliable reconciliation of medicines at admission and dischargefrom hospital is key to reducing unintentional prescribing discrepancies attransitions of health care. We introduced a team approach to the reconciliationprocess at an acute hospital with the aim of improving the provision ofinformation and documentation of reliable medication lists to enable clear,timely communications on discharge.Setting: An acute 400 bedded teaching hospital in London UK.Participants: The effects of change were measured in a simple randomsample of ten adult patients a week on the Acute Admissions Unit over 18months.Interventions: Quality Improvement methods were used throughout.Interventions included education and training of staff involved at ward leveland in the pharmacy department, introduction of medication documentationtemplates for electronic prescribing and for communicating information onmedicines in discharge summaries co-designed with patient representatives.Results: Statistical Process Control analysis showed reliable documentation(complete, verified and intentional changes clarified) of current medication on49.2% of patients’ discharge summaries. This appears to have improved (to85.2%) according to a post-study audit the year after the project end.Pharmacist involvement in discharge reconciliation significantly increased,and improvements in the numbers of medicines prescribed in error or omittedfrom the discharge prescription are demonstrated. Variation in weeklymeasures is seen throughout but particularly at periods of changeover of newdoctors and introduction of new systems.Conclusion: New processes led to a sustained increase in reconciledmedications and thereby an improvement in the number of patientsdischarged from hospital with unintentional discrepancies (errors oromissions) on their discharge prescription.The initiatives were pharmacist-led but involved close working and sharedunderstanding about roles and responsibilities between doctors, nurses
Dunn S, Jones M, Woodcock T, et al., 2016, Consistent services throughout the week for acute medical care., Journal of the Royal College of Physicians of Edinburgh, Vol: 46, Pages: 77-80, ISSN: 1478-2715
Blair M, Watson M, klaber R, et al., 2016, G311 How exactly does integrated paediatric care work? A theoretical research framework, Archives of Disease in Childhood, Vol: 101, Pages: A178-A179, ISSN: 1468-2044
Background Many areas in the UK are experimenting with different models of care delivery to improve integration of services and experiences of children young people and their carers. One such initiative “Connecting Care for Children” (CC4C) is based on three key components:- specialist outreach to a number of GP “hubs”, open access for advice and referrals and public and patient engagement. Robust evaluation of such health system change is desirable but often complex to conceptualise and achieve.Aim To develop an agreed conceptual framework to facilitate measurement of the quality of health system delivery in a defined population and to support research on proposed mediating factors.Methods A number of methods were used including stakeholder mapping, experiential “word cloud” capture, and “Action Effect Diagram” (AED) development.1 Engagement of staff, patients and young people at a number of collaborative events over a two year period. A joint workshop with academics from a number of institutions helped to refine specific measures and identify gaps in current knowledge. Over 100 individuals have been involved in drawing up the final model.Results Word cloud highlighted clinical and organisational issues (See Figure 1). There was considerable consistency across populations. An AED was developed over a series of iterations which elucidated the possible theoretical mechanisms for cause and effect of the three key components of the CC4C model. This was subsequently redrawn in a standardised logic model format to aid understanding (Figure 2). We have highlighted those elements which we believe are common to all such developments in integrated care and those which are for local determination and adaptation. Potential metrics for each of these segments are highlighted in Table 1.Conclusions We found a high degree of agreement for a conceptual framework which explains how integrated care processes might be mediated. Local aca
Soong JTY, Poots AJ, Scott S, et al., 2015, Quantifying the prevalence of frailty in English hospitals, BMJ Open, Vol: 5, ISSN: 2044-6055
Objectives Population ageing has been associated with an increase in comorbid chronic disease, functional dependence, disability and associated higher health care costs. Frailty Syndromes have been proposed as a way to define this group within older persons. We explore whether frailty syndromes are a reliable methodology to quantify clinically significant frailty within hospital settings, and measure trends and geospatial variation using English secondary care data set Hospital Episode Statistics (HES).Setting National English Secondary Care Administrative Data HES.Participants All 50 540 141 patient spells for patients over 65 years admitted to acute provider hospitals in England (January 2005—March 2013) within HES.Primary and secondary outcome measures We explore the prevalence of Frailty Syndromes as coded by International Statistical Classification of Diseases, Injuries and Causes of Death (ICD-10) over time, and their geographic distribution across England. We examine national trends for admission spells, inpatient mortality and 30-day readmission.Results A rising trend of admission spells was noted from January 2005 to March 2013(daily average admissions for month rising from over 2000 to over 4000). The overall prevalence of coded frailty is increasing (64 559 spells in January 2005 to 150 085 spells by Jan 2013). The majority of patients had a single frailty syndrome coded (10.2% vs total burden of 13.9%). Cognitive impairment and falls (including significant fracture) are the most common frailty syndromes coded within HES. Geographic variation in frailty burden was in keeping with known distribution of prevalence of the English elderly population and location of National Health Service (NHS) acute provider sites. Overtime, in-hospital mortality has decreased (>65 years) whereas readmission rates have increased (esp.>85 years).Conclusions This study provides a novel methodology to reliably quantify clinically significant frailty. Applications in
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