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					On the radar
Issue 35
4 April 2011

Once again, there is quite a lot to cover in this issue. Indeed, some material is already being held
over for the next issue. I hope you find it interesting and useful.

On the Radar is a summary of some of the recent publications in the areas of safety and quality in
health care. Inclusion in this document is not an endorsement or recommendation of any publication
or provider.

Access to particular documents may depend on whether they are Open Access or not, and/or your
individual or institutional access to subscription sites/services.

On the Radar is available via email or as a PDF document from
If you would like to receive On the Radar via email, please contact us at

For information about the Commission and its programs and publications, please visit

This week’s content

Leading Health Indicators for Healthy People 2020
Institute of Medicine
              As part of the US Government’s Healthy People 2020 initiative a set of indicators
              has been developed. This Institute of Medicine (IOM) report reviews the objectives
              and indicators. The Healthy People 2020 initiative is a broad-ranging initiative, and
              includes prioritising 12 health indicators and 24 health objectives among 42 topics
              and nearly 600 objectives. The key 12 health areas are access to care services,
              quality of health-care services, healthy behaviours, physical environment, social
              environment, chronic disease, mental health, injury, maternal and infant health,
              tobacco use, substance abuse, and responsible sexual behaviour.

Engaging the public in delivering health improvement: Research Briefing
South J, Branney P, White J, Gamsu M
Centre for Health Promotion Research, Leeds Metropolitan University, 2010.
              Research briefing summarising the findings of the ‘People in Public Health’ study
              conducted by Leeds Metropolitan University and offering guidance on what
  Notes       services can do to support citizens who take on public health roles. The key
              messages include:
                  • Involving members of the public in delivering health programmes offers a

On the Radar Issue 35                                                                                  1
                      way to utilise the knowledge, skills and resources in communities.
                  • Practical support and system level change are required to maximise the
                      benefits of lay engagement
                  • Valuing what people offer should remain at the heart of strategic planning
                      and development.
                  • Involving people in public health requires an infrastructure that is flexible,
                      supportive and actively addresses barriers to engagement. Service models
                      involving payment can be considered as well as volunteer-only schemes.
                  • Providing training and access to support not only prepares people for
                      delivery and fosters personal development, it also helps services manage
                      any risks.
                  • A broader approach to commissioning, target setting and evaluation is
                      required; one which values the role of active citizens in bridging the gap
                      between communities and services.
              Full report available at http://www.leedsmet.ac.uk/piph

The economic case for improving efficiency and quality in mental health
Department of Health (UK), London: Department of Health, 2011.
             A UK Department of Health document outlining the opportunities to make value
             for money savings in delivering mental health services using the QIPP (quality,
             innovation, productivity and prevention) approach, and by promoting early
             intervention and prevention of mental health problems.
             This is a supporting document to UK Department of Health’s No health without
             mental health: a cross-Government mental health outcomes strategy for people of
             all ages.
             As the Introduction notes, mental health is a large-scale issue:
                 • Mental ill health is the single largest cause of disability in the UK,
                     contributing up to 22.8% of the total burden, compared to 15.9% for cancer
                     and 16.2% for cardiovascular disease
                 • The wider economic costs of mental illness in England have been
                     estimated at £105.2 billion each year. This includes direct costs of services,
  Notes              lost productivity at work and reduced quality of life.
                 • Estimated annual costs for different conditions in England are: depression
                     £7.5 billion, anxiety £8.9 billion, schizophrenia £6.7 billion, and dementia
                     £17 billion. The estimated annual costs of medically unexplained symptoms
                     are £18 billion.
                 • Good mental health and wellbeing, and not simply the absence of mental
                     illness, have been shown to result in health, social and economic benefits
                     for individuals, communities and populations.
             The report goes on to discuss interventions and demonstrate the cost effectiveness
             of taking such steps, leading to conclusions including ‘Evidence-based
             interventions highlight the health and associated economic savings of intervening
             early as soon as mental illness has arisen, preventing mental illness and promoting
             mental health. The resulting savings occur in health and across other areas in the
             short, medium and longer term.’
  URL        http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
  TRIM       46587

On the Radar Issue 35                                                                                 2
Improving the Quality of Care in General Practice: Report of an independent inquiry commissioned
by The King’s Fund.
Goodwin N, Dixon A, Poole T, Raleigh V.
London: The King's Fund, 2011.
             Report of an independent panel enquiry commissioned by the King’s Fund into the
             quality of general practice in England. The inquiry’s aim was to help to support the
             work of general practice and to provide a guide to ensure that quality is at the heart
             of the service that it offers to patients.
             The report represents the most extensive review of quality across general practice
             (in England) carried out in recent years. Its work was informed by specially
             commissioned research and analysis of routinely available data across a range of
   Notes     aspects of general practice.
             The report found that, in terms of the current quality of care, the majority of care
             provided by general practice is good. However, there are wide variations in
             performance and gaps in the quality of care that suggest there is significant
             opportunity for improvement. Practices need a lot of support to encourage them to
             seek out and address variable performance, including: appropriate data and
             information; skills development; ‘protected’ time; and appropriate rewards for
             excellence (as well as consequences for poor performance).
   URL       http://www.kingsfund.org.uk/publications/gp_inquiry_report.html
   TRIM      46594

Journal articles

Launching Accountable Care Organizations — The Proposed Rule for the Medicare Shared
Savings Program
Berwick DM.
New England Journal of Medicine 2011 [epub].
             In this NEJM piece, Don Berwick outlines the rules for the accountable care
             organisations (ACO). An ACO is a group of providers and suppliers of healthcare
             services who work together to coordinate care for patients. Under the rule, the US
             government will pay individual healthcare providers and suppliers as it does under
             Medicare, and also develop a benchmark for each ACO against which its
             performance is measured to determine if the ACO qualifies to receive shared
             savings or be held accountable for losses.
  Notes      The rule states that an ACO shall enter into a three-year agreement to participate in
             the program; have a formal structure that would allow the organization to receive
             and distribute payments for shared savings to participating providers; have at least
             5,000 beneficiaries assigned to it; and include primary-care professionals.
             The rule will measure quality in an ACO in five essential areas: patient/caregiver
             experience of care, care coordination, patient safety, preventive health, and at-risk
             population/frail elderly health. There are 65 measures proposed for those five
             domains. They are listed in the NEJM piece.
  DOI        http://dx.doi.org/10.1056/NEJMp1103602
  URL        http://www.ofr.gov/OFRUpload/OFRData/2011-07880_PI.pdf (For the proposed

On the Radar Issue 35                                                                                3
BMJ Quality and Safety, April 2011, Volume 20, Issue 4
             The April issue of BMJ Quality and Safety has been published. The majority of its
             contents have been discussed in previous issues of On the Radar (as the articles
             were published online), but a number are discussed elsewhere in this issue. The
             content of the April issue of BMJ Quality and Safety includes:
                 • Editorial – New opportunities for better, safer healthcare
                 • Commentary – Can we save money by improving quality?
                 • Pressure ulcers: effectiveness of risk-assessment tools. A randomised
                     controlled trial (the ULCER trial)
                 • Measuring the learning capacity of organisations: development and factor
                     analysis of the Questionnaire for Learning Organizations
                 • Quality of patient record keeping: an indicator of the quality of care?
                 • Can teaching medical students to investigate medication errors change their
                     attitudes towards patient safety?
                 • Structure, process or outcome: which contributes most to patients' overall
  Notes              assessment of healthcare quality?
                 • Factors that shape the development of interprofessional improvement
                     initiatives in health organisations
                 • Safety culture in healthcare: a review of concepts, dimensions,
                     measures and progress
                 • Creating effective quality-improvement collaboratives: a multiple case
                 • Organisational strategies to cultivate professional values and
                 • An assessment of the quality and impact of NPSA medication safety outputs
                     issued to the NHS in England and Wales
                 • Implementation of the process of ethical review of improvement activities
                     at the Children's Hospital at Westmead
                 • Utilising improvement science methods to optimise medication
  URL        http://qualitysafety.bmj.com/content/20/4.toc

Quality of patient record keeping: an indicator of the quality of care?
Zegers M, de Bruijne MC, Spreeuwenberg P, Wagner C, Groenewegen PP, van der Wal G
BMJ Quality & Safety 2011;20(4):314-318.
               Paper regarding a Dutch study of the relationship between the quality of patient
               records and the occurrence of adverse events (AEs). The project examined 7,926
               hospital admissions at 21 Dutch hospitals using a structured record review method.
               The occurrence of AEs, the presence of patient information and the quality of the
               present information (completeness, readability and adequacy) were assessed.
               The absence of record components was associated with lower rates of AEs,
               suggesting that missing record components lead to an under-assessment of AEs in
               record-review studies. In contrast, poor quality of the information present in patient
               records was associated with higher rates of AEs, implying that the quality of the
               present patient information is a predictor of the quality of care.
               The authors conclude that ‘Evidence-based standards and a (electronic) format for
               record keeping are necessary for standardisation of recording patient information.
               This will improve the completeness, readability, accessibility, accuracy and
               exchange of patient information between healthcare providers and institutions.

On the Radar Issue 35                                                                                   4
              Better registration of patient information will benefit the quality of the healthcare
              process and will reduce the risk of AEs’.
   DOI        http://dx.doi.org/10.1136/bmjqs.2009.038976

Pressure ulcers: effectiveness of risk-assessment tools. A randomised controlled trial
Webster J, Coleman K, Mudge A, Marquart L, Gardner G, Stankiewicz M, et al.
BMJ Quality & Safety 2011;20(4):297-306.
              Report on the results of a trial of two pressure ulcer risk assessment methods
              compared with ‘clinical judgement’. This reports on a randomised controlled trial
              undertaken at a large metropolitan tertiary hospital in Australia that involved 1,231
              patients admitted to internal medicine or oncology wards with expected stays of
              more than 2 days. Participants were allocated to either a Waterlow (n=410) or
              Ramstadius (n=411) screening tool group or to a clinical judgement group (n=410)
              where no formal risk screening instrument was used with the main outcome
              measure being the incidence of hospital acquired pressure ulcers ascertained by
  Notes       regular direct observation.
              On admission, 71 (5.8%) patients had an existing pressure ulcer. The incidence of
              hospital-acquired pressure ulcers was similar between groups (clinical judgement
              28/410 (6.8%); Waterlow 31/411 (7.5%); Ramstadius 22/410 (5.4%).
              The authors assert that they ‘found no evidence to show that two common pressure-
              ulcer risk-assessment tools are superior to clinical judgement to prevent pressure
              injury’ and suggest that resources associated with use of such screening tools might
              be better spent on careful daily skin inspection and improving management of
              specific risks.
  DOI         http://dx.doi.org/10.1136/bmjqs.2010.043109

Creating effective quality-improvement collaboratives: a multiple case study
Strating MMH, Nieboer AP, Zuiderent-Jerak T, Bal RA
BMJ Quality & Safety 2011;20(4):344-350.
              Paper reporting on the results of surveying 75 team leaders of 182 teams from long-
              term healthcare organisation developed improvement initiatives in seven quality-
              improvement collaboratives (QICs) focusing on patient safety and autonomy. The
              authors sought to examine how differences between collaboratives in regards of
              type of topic, type of targets, measures were reflected in the degree of
              As you might expect, the degree of effectiveness and percentage of teams realising
              targets varied between collaboratives. The authors argue that the effectiveness of a
   Notes      QIC ‘is associated with the efforts of programme managers to create conditions that
              provide insight into which changes in processes of care and in client outcomes have
              been made. Measurability is not an inherent property of the improvement topic.
              Rather, creating measurability and formulating challenging and achievable targets
              is one of the crucial tasks for programme managers of QICs.’ The combination of
              challenging but achievable can be difficult to determine at times, but is important
              as unachievable ‘aspirational’ targets can undermine projects, while the opposite
              issue, of targets that are not a ‘stretch’ can be insufficient as a goal for project
   DOI        http://dx.doi.org/10.1136/bmjqs.2010.047159

On the Radar Issue 35                                                                                 5
BMJ Quality and Safety, Supplement
             In addition to the April issue of BMJ Quality and Safety (discussed above) they
             have published a supplement stemming from the Vin McLoughlin Colloquium on
             the Epistemology of Improving Quality convened on 12–16 April 2010 at
             Cliveden, England. The entire supplement is available as Open Access.
             The content of the supplement to the current BMJ Quality and Safety includes:
                 • Commentary: Planning and leading a multidisciplinary colloquium to
                     explore the epistemology of improvement
                 • Systems of service: reflections on the moral foundations of improvement
                 • Heterogeneity: we can't live with it, and we can't live without it
                 • Can evidence-based medicine and clinical quality improvement learn
                     from each other?
                 • Understanding the conditions for improvement: research to discover
                     which context influences affect improvement success
                 • The epistemology of quality improvement: it's all Greek
                 • Reconciling complexity and classification in quality improvement research
                 • The contribution of case study research to knowledge of how to
                     improve quality of care
                 • The meaning of variation to healthcare managers, clinical and health-
                     services researchers, and individual patients
                 • Five main processes in healthcare: a citizen perspective
                 • Beyond evidence: the micropolitics of improvement
  Notes          • Problems and promises of innovation: why healthcare needs to rethink
                     its love/hate relationship with the new
                 • Clarity and strength of implications for practice in medical journal articles:
                     an exploratory analysis
                 • Building an integrated methodology of learning that can optimally support
                     improvements in healthcare
                 • Intergroup relationships and quality improvement in healthcare
                 • Expert patients: learning from HIV
                 • Ten tips for incorporating scientific quality improvement into everyday
                 • Multidisciplinary centres for safety and quality improvement: learning from
                     climate change science
                 • Mainstreaming quality and safety: a reformulation of quality and
                     safety education for health professions students
                 • Creating safety by strengthening clinicians' capacity for reflexivity
                 • Increasing the generalisability of improvement research with an
                     improvement replication programme
                 • Analytical studies: a framework for quality improvement design and
                 • Confessions of a chagrined trialist
                 • Commentary: So what? Now what? Exploring, understanding and
                     using the epistemologies that inform the improvement of healthcare
  URL        http://qualitysafety.bmj.com/content/vol20/Suppl_1/

On the Radar Issue 35                                                                               6
Introduction of a new observation chart and education programme is associated with higher rates
of vital-sign ascertainment in hospital wards
Cahill H, Jones A, Herkes R, Cook K, Stirling A, Halbert T, et al.
BMJ Quality & Safety 2011 [epub].
               Report on a project in a Sydney hospital to re-design observation charts so as to
               improve the recognition of, and response to, clinical deterioration.
               Having developed a new chart and undertaken an education program, three study
               periods, each lasting 14 days (at pre-intervention, 2 weeks post-intervention, and 3
               months post-intervention), were carried out in three wards.
               The authors report that documentation of respiratory rate increased from 47.8% to
               97.8% and was sustained at 3 months post intervention (98.5%). Collection of a
               full set of vital signs also improved by a similar magnitude. Basic neurological
               observation for all patients was introduced in the new chart; the uptake of this was
               very good (93.1%). Ascertainment rates of blood pressure and oxygen saturation
               also increased by small, but significant amounts, from good baseline rates of 97%
               or higher.
               These led the authors to conclude that the introduction of a new observation chart
               (with education on its use and importance) was associated with a major
               improvement in the recording of respiratory rate and other vital signs. Such
               recording is a vital step in the recognition and response to deterioration.
   DOI         http://dx.doi.org/10.1136/bmjqs.2010.045096

For information on the Commission’s Recognising and Responding to Clinical Deterioration
program, including work on observation charts, see

The Benefits Of Health Information Technology: A Review Of The Recent Literature Shows
Predominantly Positive Results
Buntin MB, Burke MF, Hoaglin MC, Blumenthal D
Health Affairs 2011;30(3):464-471.
              A systematic review of health information technology (HIT) studies that concludes
              that most published studies have reported positive effects of HIT on a variety of
              outcomes, ranging from patient safety to provider satisfaction and the effectiveness
  Notes       of care. This review extends the findings from a previous (2006).
              While there are the benefits of HIT the implementation of such solutions as
              electronic health records has been tardy. This review does also include studies that
              reported less positive results and these can offer insights into difficulties.

Towards saving a million bed days: reducing length of stay through an acute oncology model of
care for inpatients diagnosed as having cancer
King J, Ingham-Clark C, Parker C, Jennings R, Leonard P
BMJ Quality & Safety 2011 epub].
               Report on a relatively small-scale, but apparently successful, change at a London
               hospital to a patient pathway for emergency admissions who have a previously
               undiagnosed cancer.
               A new patient pathway was developed, and a new online referral process was
               implemented (after auditing and process mapping the existing pathway).
               The new system was piloted for 6 months. 12/18 patients were referred via the new

On the Radar Issue 35                                                                                 7
              pathway. 15/18 patients were referred via the a online system.
              Length of stay, endoscopies, biopsies and blood tests were all statistically
              significantly reduced during the study period compared with the original audit.
              The authors found that the ‘challenge was to convince the referring general
              physicians to use the new patient pathway and referral method. Incorporating their
              ideas for improvement and implementation made it more likely that they would
              take up the new ideas’ and that having ‘the Lead Cancer Clinician and Acute
              Medicine Consultant engage directly with consultant colleagues, as well as strong
              support from the Medical Director’ were crucial.
   DOI        http://dx.doi.org/10.1136/bmjqs.2010.044313

The role of theory in research to develop and evaluate the implementation of patient safety
Foy R, Ovretveit J, Shekelle PG, Pronovost PJ, Taylor SL, Dy S, et al
BMJ Quality & Safety 2011 [epub].
               A call for the greater use of theory to help improve the successful implementation
               and greater applicability of patient safety strategies.
               From the AHRQ PS net email:
               ‘The first decade of the patient safety movement has seen notable successes, but
               many highly publicized practices have been less impactful than anticipated. This
               AHRQ-funded expert panel calls for patient safety researchers to explicitly
               incorporate theories of individual behavior change and organizational improvement
               into the planning, implementation, and evaluation of patient safety research. Using
               established theoretical models has the potential to improve the odds of successful
               implementation of safety practices and increase the generalizability of successful
               strategies for other institutions.’
               The paper’s abstract:
   Notes       ‘Theories provide a way of understanding and predicting the effects of patient
               safety practices (PSPs), interventions intended to prevent or mitigate harm caused
               by healthcare or risks of such harm. Yet most published evaluations make little or
               no explicit reference to theory, thereby hindering efforts to generalise findings from
               one context to another. Theories from a wide range of disciplines are potentially
               relevant to research on PSPs. Theory can be used in research to explain clinical and
               organisational behaviour, to guide the development and selection of PSPs, and in
               evaluating their implementation and mechanisms of action. One key
               recommendation from an expert consensus process is that researchers should
               describe the theoretical basis for chosen intervention components or provide an
               explicit logic model for ‘why this PSP should work.’ Future theory-driven
               evaluations would enhance generalisability and help build a cumulative
               understanding of the nature of change.’
   DOI         http://dx.doi.org/10.1136/bmjqs.2010.047993
   TRIM        46449

How can we improve guideline use? A conceptual framework of implementability
Gagliardi AR, Brouwers MC, Palda VA, Lemieux-Charles L, Grimshaw JM.
Implementation Science 2011;6(1):26 [epub].
             The authors of this paper suggest that guidelines are underutilized and strategies to
             improve their use have been suboptimal. They sought to identify and define
             features that facilitate guideline use, and examine whether and how they are
             included in current guidelines.

On the Radar Issue 35                                                                                   8
             They developed a guideline implementability framework after reviewing the
             implementation science literature and then examined whether guidelines included
             these, or additional implementability elements.
             Their implementability framework included 22 elements arranged in the domains
             of adaptability, usability, validity, applicability, communicability, accommodation,
             implementation and evaluation.
             Examining 20 guidelines on the management of diabetes, hypertension, leg ulcer
             and heart failure they found that most contained a large volume of graded, narrative
             evidence, and tables featuring complementary clinical information. However, few
             contained features that could improve guideline use, such as alternate versions for
             different users and purposes, summaries of evidence and recommendations,
             information to facilitate interaction with and involvement of patients, details of
             resource implications, and instructions on how to locally promote and monitor
             guideline use.
  URL        http://www.implementationscience.com/content/6/1/26/abstract

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel
Grunebaum A, Chervenak F, Skupski D.
American Journal of Obstetrics and Gynecology 2011;204(2):97-105.
               Paper reporting on the implementation of a comprehensive obstetrics safety
               program, including teamwork training, additional staffing and reduction of work
               hours, electronic medical records, and a dedicated patient safety nurse.
               The paper describes the program and its effect on reducing compensation payments
               and sentinel adverse events in a US academic hospital setting.
   Notes       The program was initiated in 2003 and this papers reports on findings from then to
               2009. Average yearly compensation payments decreased from $27,591,610
               between 2003-2006 to $2,550,136 between 2007-2009, sentinel events decreased
               from 5 in 2000 to none in 2008 and 2009. They conclude that the comprehensive
               obstetric patient safety program ‘decreased compensation payments and sentinel
               events resulting in immediate and significant savings’.
   DOI         http://dx.doi.org/10.1016/j.ajog.2010.11.009

Online Resources

Australian Safety and Quality Framework for Health Care – Tools and resources
Australian Commission on Safety and Quality in Health Care
Getting started
To support the use of the Framework, the Commission has prepared a series of “Getting Started”
documents. These have been specially prepared for four groups who are particularly important for
embedding the Framework in the Australian healthcare system. Getting Started documents have
been prepared for:
    • the healthcare team
    • managers
    • health service executives and board members, and
    • policy makers.

On the Radar Issue 35                                                                               9
Each Getting Started document focuses on a number of the actions in the Framework that
particularly apply to that group and describes activities that they can do or put in place to improve
safety and quality.
Tools and resources
A selection of tools and resources that can be used to support the use of the Framework has been
assembled. These may be of relevance depending on the context of your own setting.

Speak Up: Prevent errors in your care
Joint Commission (USA)
The Joint Commission has added to their multimedia with the first in a series of new animated
Speak Up™ videos that encourage patients to speak up and be active participants in their health
care. Like the other Speak Up materials, the videos are free and can be used by accredited
organizations and other interested stakeholders that want to promote the Speak Up message.

Why Is There A Problem With Health Care Quality?
Health Affairs Blog
This edition of the Health Affairs Blog is a piece by John Goodman, Gerald Musgrave and Devon
Herrick in which they discuss the role of quality in the competition and marketing of care. They
argue it is notable that the quality of care is not more commonly used to attract clients/patients. One
of the issues is the balance between cost, time and quality and how they are perceived by clients,
particularly where the price signal is not directly affecting the patient. They also note the
asymmetry of information about quality – that patients tend to be only able to get information about
quality from the (potential) providers.
[Thanks to Shaun Larkin for alerting me to this]

New Ways to Communicate with Patients
ARHQ Innovations Exchange Chat on Change:
2 – 3 pm (ET) Tuesday, 5 April 2011, Note: This is 4am AEST, 2am WST, etc. Australian time.
How are roles different in innovative compared to traditional patient-provider communications? Do
these innovative communication strategies improve care delivery and/or improve health status for
vulnerable populations in particular? How does funding of innovative health communications
influence their effectiveness?
This event will be a live Twitter chat that will offer the opportunity for rich exchange among
participants on this important topic.
A transcript of the Chat will be available soon on the Innovations Exchange Web Site, on the
Events & Podcasts page.

On the radar is an information resource of the Australian Commission on Safety and Quality in
Health Care. The Commission is not responsible for the content of, nor does it endorse, any articles
or sites listed. The Commission accepts no liability for the information or advice provided by these
external links. Links are provided on the basis that users make their own decisions about the
accuracy, currency and reliability of the information contained therein. Any opinions expressed are
not necessarily those of the Australian Commission on Safety and Quality in Health Care.

On the Radar Issue 35                                                                               10