Eligible studies required the use of a quantitative method to identify high performing hospitals, and qualitative methods or tools to identify factors associated with high performing hospitals or hospital departments. Practical strategies for achieving high performance were then mapped against the identified themes.

A total of 19 studies from a possible 11,428 were included in the review. A range of process, output, outcome and other indicators were used to identify high performing hospitals. Seven themes representing factors associated with high performance (and 25 sub-themes) emerged from the thematic syntheses: positive organisational culture, senior management support, effective performance monitoring, building and maintaining a proficient workforce, effective leaders across the organisation, expertise-driven practice, and interdisciplinary teamwork. Fifty six practical strategies for achieving high performance were catalogued.

The authors conclude that this review provides insights into methods used to identify high performing hospitals, and yields ideas about the factors important for success. It highlights the need to advance approaches for understanding what constitutes high performance and how to harness factors associated with high performance.

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1186/s12913-015-0879-z

Taylor, N., et al. (2015). High performing hospitals: A qualitative systematic review of associated factors and practical strategies for improvement. BMC Health Services Research, 15:244.

Telehealth is at the forefront of hospital services in Thames. All four types of the technology are been used throughout the hospital to link patients with specialists throughout the Waikato.

When Health Minister Jonathan Coleman and Minister for Coromandel Scott Simpson visited the rural hospital last week Thames clinical director Dr Ruth Large explained how telehealth (or video conferencing) is been used to improve access and equity for patients living remotely.  “Tele-acute support, tele-ambulatory care, tele-ward support and tele-workplace support are been used to allow patients services closer to their home and whanau,” she said.

“Tele-acute support, tele-ambulatory care, tele-ward support and tele-workplace support are been used to allow patients services closer to their home and whanau,” she said.

Dr Large demonstrated how complex trauma cases are now beamed to specialists all over New Zealand when the Emergency Department in Thames needs a more specialist opinion.

“The tool also helps to improve professional collaboration by allowing us to video conference with other specialists in our field – where we used to have to take a day off clinical duties we can now just sit in on the conference for an hour and then get back to see patients,” said Dr Large.

In addition to some outpatients clinic being run via telehealth,  Thames has trialled a mobile cart unit which is hoped to be used increasingly for virtual ward rounds and the development of a virtual stroke unit.

In the future, Telehealth may be able to facilitate the management of acute patients and potentially be used to augment specialist services in the community both by tele-monitoring and increased primary care support.

There is also a videoconference set up for education days and general meetings.

After the demonstration Dr Coleman met with staff and toured other parts of the hospital.

The project was associated with "... a 17% improvement in [National Emergency Access Target (NEAT)] performance with no evidence of an increase in clinical deterioration on inpatient wards and evidence for an improvement in hospital mortality".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/1742-6723.12424 or contact your DHB library, or organisational or local library for assistance.

Dinh, M. M., Green, T. C., Bein, K. J., Lo, S., Jones, A. and Johnson, T. (2015). Emergency department clinical redesign, team-based care and improvements in hospital performance: A time series analysis. Emergency Medicine Australasia, 14 June [Epub before print]

To read the report, go to:  https://www.gov.uk/government/publications/productivity-in-nhs-hospitals

To read a response to this report by the Health Foundation, go to:  http://www.health.org.uk/news-and-events/press/the-health-foundation-s-response-to-lord-carter-s-review-on-nhs-spending/

Topics covered:

• Improving Hospital Food and Beverage Environments
• Improving Hospital Physical Activity Environments 
• Improving Support for Breastfeeding Employees 
• Improving Support for Tobacco-Free Hospital Environments
• Hospitals Partner with Public Health to Improve Food Environments:
• Addressing Community Health in Schools, Early Care and Education, and the Clinic 
• Community Benefit: Encouraging Healthy Habits Early
• Children’s Hospitals Working Together to Improve their Food Environments 

To read the issues in this series, go to:  http://www.cdc.gov/nccdphp/dnpao/hwi/resources/hospital_p2p.htm

Twenty quantitative observational studies were included. The authors conclude from the results that "patient mortality may be improved in large capacity ICUs. However, the association is not consistent across all diagnostic groups. Risk adjusted mortality is increased in low volume ICUs. There appears to be a high volume threshold at which point the risk adjusted mortality benefit is also lost suggesting a window of optimal ICU organisational performance exists between low and high volumes". The authors make recommendations for further research.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.aucc.2014.02.001 or contact your DHB library, or organisational or local library for assistance.

Abbenbroek, B., et al. (2014). The intensive care unit volume–mortality relationship, is bigger better? An integrative literature review. Australian Critical Care, 27(4), 157–164

To read the full story in The Timaru Herald, go to:  http://www.stuff.co.nz/timaru-herald/news/68963359/hitech-medication-distribution-at-timaru-hospital

They conclude that "the introduction of national smoke-free legislation in England was associated with "11 000 fewer hospital admissions per year for RTIs in children".

To read the full abstract, and for information on how to access the full text, go to: http://erj.ersjournals.com/content/early/2015/05/28/09031936.00014615.abstract or contact your DHB library, or organisational or local library for assistance.

Been, J.V., et al. (2015). Smoke-free legislation and childhood hospitalisations for respiratory tract infections. European Respiratory Journal, 28 May [Epub before print]

Experimental studies were included if they assessed the use of Lean or Six Sigma on the ability to improve specified outcomes in surgical patients. Twenty-three studies were included (11 assessed Lean, 6 Six Sigma and 6 Lean Six Sigma).

The authors found that the "... majority of studies (88%) demonstrate improvement; however high levels of systematic bias and imprecision were evident". They note a need for for high-quality studies.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.surge.2014.08.002 or contact your DHB library, or organisational or local library for assistance.

Mason, S.E., et al. (2015). The use of Lean and Six Sigma methodologies in surgery: A systematic review. The Surgeon, 13(2), 91–100.

"A specialist children's hospital in the National Health Service in England introduced consultant-led ‘satellite’ clinics to two community settings for general paediatric outpatient services. Objectives were to reduce non-attendance at appointments by providing care in more accessible locations and to create new physical clinic capacity. This study evaluated these satellite clinics to inform further development and identify lessons for stakeholders".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1136/bmjqs-2014-003687 or contact your DHB library, or organisational or local library for assistance.

McLeod, H., et al. (2015). Introducing consultant outpatient clinics to community settings to improve access to paediatrics: An observational impact study. BMJ Quality & Safety, 24, 377-384.

In this systematic review, the authors aimed to define the target domains of culture-improvement interventions, assess their impact on surgical culture and whether they led to better patient outcomes and improved healthcare efficiency.

This course introduces the LEAN methodology and a number of associated tools to implement the methodology in your work environment.

To find out more on the LearnOnline website, go to:  http://learnonline.health.nz/course/view.php?id=99

The guide is available to download at:  http://rcni.com/sites/rcn_nspace/files/Economic-Assessment-2015.pdf

HIIRC identified this research via the Ministry of Health Library's Grey Matter newsletter.

Presentations include:

Session one: Learning from international and national high-performers

Sir David Dalton: Salford Royal’s journey to becoming one of England’s highest performing trusts

Brenda Reiss-Brennan: High-performance at Intermountain

Session two: Promoting improvement through networks and national support

David Fillingham: Learning from systems attempting to combine strong organisational leadership with collaborative system-level leadership approaches

Suzie Bailey: Delivering high-quality care underpinned by good financial and operational performance

Session three: Learning from clinical innovators in the NHS

Steve Allder: Can we deliver the same high-quality care with our current resources?

Alexandra Wu: Addressing the hospital capacity problem

To access the presentations, go to:  http://www.kingsfund.org.uk/events/learning-high-performing-health-care-organisations

This volume reports on the first stage of the project, presenting results from a series of country case studies produced by national authors from seven countries in the region, including New Zealand. 

To read the document, go to:  http://www.wpro.who.int/asia_pacific_observatory/country_comparative_studies/ccs_public_hospital_governance/en/

Asia Pacific Observatory on Health Systems and Policies (2015). Public health governance in Asia and Pacific. D. Huntington & K. Hort (Eds.). Comparative Country Studies, 1(1).

"Laparoscopic surgery was associated with reduced complications... and length of stay .... Increasing ERAS compliance was correlated with fewer complications ... and shorter primary hospital admission .... Shorter hospital stay was associated with preoperative carbohydrate and fluid loading .., and totally intravenous anesthesia ...; longer stay was associated with intraoperative epidural analgesia .... Reduced postoperative complications were associated with restrictive perioperative intravenous fluids".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1097/SLA.0000000000001029 or contact your DHB library, or organisational or local library for assistance.

The ERAS Compliance Group (2015). The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: Results from an international registry. Annals of Surgery, 261(6), 1153-1159.

The Efficiency Research Programme aims to address how new approaches can support long-term transformational change in health and social care in the UK.

Research teams will explore some of the most powerful ways that health, or health and social care services can increase value, and provide more for less".

To read the full story on the Health Foundation website, go to:  http://www.health.org.uk/news-and-events/news/the-health-foundation-selects-four-research-projects-to-explore-original-ideas-on-system-efficiency-and-value-for-money/

The NIP initiative, developed by Health Benefits Limited (HBL), will utilise IBM’s cloud-based IT infrastructure services, developed specifically for government. The Platform will increase security, reliability, service levels and reduce the risk of critical outages.

To read the full media release from HBL, go to:  http://www.scoop.co.nz/stories/GE1505/S00060/district-health-board-it-initiative-gathers-momentum.htm

To read the full media release from Canterbury DHB, go to:  http://www.scoop.co.nz/stories/GE1505/S00043/canterbury-dhb-on-track-to-deliver-more-surgery.htm

World Journal of Emergency Surgery is the official publication of the World Society of Emergency Surgery

This involved a multidisciplinary approach to an ER clinical education programme. The programme aimed to develop knowledge of the physiology of post-operative recovery and the evidence underpinning the interventions required. This was considered crucial to secure longer term staff engagement while avoiding unthinking protocol driven compliance. Success of the education programme was measured by improved outcomes in patient LOS and readmission statistics.

During the four months of the clinical education programme there were no significant changes in monthly LOS. At six months post implementation of the programme there was a reduction in LOS of 0.6 days compared to the previous six months. At 12 months there was a reduction in 1.1 days compared with previous 12 months. There was a mean reduction of 28 day readmissions for all elective gynaecology surgery of 1.1 patients per month in the 12 months post programme implementation compared to the 12 months before. Delivering a multidisciplinary participatory education programme improved overall understanding of ER, and achieved sustained improvement in ER for patient benefit.

This is an open access article and is available to read in free full text at:  http://dx.doi.org/10.1136/bmjquality.u208370.w3387

McDonald, R. (2015). Enhanced recovery clinical education programme improves quality of post-operative care. BMJ Quality Improvement Reports, 4(1).

The 2015 HiNZ Conference is being held on 19-22 October in Christchurch at the Wigram Air Force Museum. 

To find out more, go to:  http://www.hinz.org.nz/?page=HINZConference

In this retrospective cohort study, the authors investigated the impact of RECIPE on acute healthcare utilisation between 2004 and 2011.

Based on the results, the authors suggest that "... an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates".

Now available to read in free full text at: http://dx.doi.org/10.1093/ageing/afu196 

Hutchinson, A.F., et al. (2015). A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation. Age and Ageing, 44 (3): 365-370.

Cost effectiveness analyses were undertaken alongside a single-blinded randomized controlled trial with 12 months follow up inclusive of informal care. Participants were adults admitted to two publicly funded inpatient rehabilitation facilities. The control group received usual care rehabilitation services from Monday to Friday and the intervention group received usual care plus additional Saturday rehabilitation. Incremental cost effectiveness ratios were reported as cost per quality adjusted life year (QALY) gained and for a minimal clinical important difference (MCID) in functional independence.

A total of 996 patients [mean age 74 years (SD 13)] were randomly assigned to the intervention (n = 496) or control group (n = 500). The intervention was associated with improvements in QALY and MCID in function, as well as a non-significant reduction in cost from admission to 12 months (mean difference (MD) AUD$6,325; 95% CI −4,081 to 16,730; t test p = 0.23 and MWU p = 0.06), and a significant reduction in cost from admission to 6 months (MD AUD$6,445; 95% CI 3,368 to 9,522; t test p = 0.04 and MWU p = 0.01).

The authors conclude that there is a high degree of certainty that providing additional rehabilitation services on Saturday is cost effective. 

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1186/s12913-015-0822-3

Brusco, N.K., et al. (2015). Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial. BMC Health Services Research, 15:165.

To read a one-page extract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/ans.13017 or contact your DHB library, or organisational or local library for assistance.

Civil, I. and Shuker, C. (2015). Briefings and debriefings in one surgeon's practice. ANZ Journal of Surgery, 85: 321–323. 

In this study, the authors evaluate the effectiveness of aviation-style teamwork training in improving operating theatre team performance and clinical outcomes in 3 operating theatres in a UK district general hospital (1 control group and 2 intervention groups).

Women waiting to see a breast care specialist at Waikato Hospital are now seen sooner than in the past because of an improvement in ‘did not attend’ rates by the Breast Care Centre.

Waikato DHB Breast Care manager Clare Coles said the service had increased the number of booked appointments and reduced ‘did not attend’ rates in the past two years.

“We have been tracking at less than 3 per cent of our appointments being missed since we introduced phoning women the day prior to their appointment,” she said.

Women are referred to the centre by their GP typically with a new breast symptom that needs investigating and some women may also be asked to return for a follow-up appointment after the initial investigation has occurred, said Coles.

With the demand for each appointment available always being higher than the actual capacity, it is vital that wastage of these appointments is kept to an absolute minimum to keep waiting times as short as possible.

The centre year to date has over delivered on contracted numbers seeing more than 25 new women and 60 returns per week.

It has four breast surgeons and three breast clinicians each working in one to three clinics per week.

In the three months since November last year, only eight women out of 1112 did not attend their appointments.

“The Breast Care Centre team leader started this [phoning women] as part of a several activities aimed to increase efficiency as a result of attending the Lean Thinking training.”

Coles said the team tested how efficient it was to call women by moving from calls to texts.

“Last month our did not attend rate shot up to 7.2 per cent. This is when we stopped phoning and texted women instead,” she said.

As a result the Breast Care Clinic team will be doing some more investigative data analysis to try and reduce the rate further while still best utilising resources.

Coles said while phoning women had not saved the service financially, it has impacted on being able to book appointments for other women sooner if an appointment was no longer needed.

“Women like to be able to re-book there and then if they are unable to attend a planned appointment when we ring and it gives us a chance to offer their appointment to someone who is waiting.”

412 patients were enrolled to the pre-ERAS (existing-practice) phase and compared with 297 patients in the ERAS phase. For ERAS patients, compared with existing-practice patients, hospital stay was reduced and there was a significant improvement in the proportion of patients ready for discharge on day 3 after surgery. The authors also found improved indicators of processes and outcomes of care, including improved patient education, reduced fasting times, less blood loss, better analgesia, earlier ambulation and improved overall quality of recovery.

This article is available to read in free full text at:  http://dx.doi.org/10.5694/mja14.00601

Christelis, N., et al. (2015). An enhanced recovery after surgery program for hip and knee arthroplasty. Medical Journal of Australia, 202(7): 363-368.

From 2002 to 2010, 351 170 803 patients were admitted to U.S. hospitals, with 19% admitted on a weekend. Hospital acquired conditions occurred at an overall frequency of 4.1% (5.7% among weekend admissions versus 3.7% among weekday admissions). Adjusting for patient and hospital cofactors the probability of having one or more hospital acquired conditions was more than 20% higher in weekend admissions compared with weekday admissions (odds ratio 1.25, 95% confidence interval 1.24 to 1.26, P<0.01). Hospital acquired conditions have a negative impact on both hospital charges and length of stay. At least one hospital acquired condition was associated with an 83% (1.83, 1.77 to 1.90, P<0.01) likelihood of increased charges and 38% likelihood of prolonged length of stay (1.38, 1.36 to 1.41, P<0.01).

The authors conclude that weekend admission to hospital is associated with an increased likelihood of hospital acquired condition, cost, and length of stay. They go on to say that future protocols and staffing regulations must be tailored to the requirements of this high risk subgroup.

This is an open access article and is available to read in free full text at:  http://dx.doi.org/10.1136/bmj.h1460

Attenello, F.J., et al. (2015). Incidence of “never events” among weekend admissions versus weekday admissions to US hospitals: National analysis. BMJ, 350:h1460.

The objective of this Australian study was to investigate long-term trends in injury profiles of elderly patients who have fallen, and to identify injuries associated with need for in-patient rehabilitation. Analysis over the past decade found a significant decrease in hip fractures from low-energy falls but this was associated with a rise in severe head injuries. Around 25% of patients were transferred to in-patient rehabilitation.

Now available to read in free full text at: http://onlinelibrary.wiley.com/doi/10.1111/ans.12676/abstract 

Lee, H., et al. (2015). Changing patterns of injury associated with low-energy falls in the elderly: A 10-year analysis at an Australian Major Trauma Centre. ANZ Journal of Surgery, 85(4), 230–234.

A quality improvement project was undertaken to assess this problem and to propose a new patient pathway whereby patients are contacted by ENT nursing staff by telephone three months following surgery. During these telephone conversations only 9.5% of patients requested outpatient follow-up and all of these patients were discharged upon their follow-up. The project demonstrates that nurse-led follow up is an efficient, effective and safe way of managing patient care post-nasal surgery.

This article is available to read in free full text at:  http://dx.doi.org/10.1136/bmjquality.u208386.w3311

Sooby, P. & Kirkland, P. (2015). Use of nurse-led telephone follow-up as a sole method of assessing patients after nasal surgery. BMJ Quality Improvement Reports, 4.

Eighteen studies were included (3 randomised controlled trials, 5 case-controlled studies and 10 case series) - 7 on gastric and 11 on oesophageal resection. 

Based on their analysis, the authors conclude that "the evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1308/003588414X14055925061630 or contact your DHB library, or organisational or local library for assistance.

Gemmill, E.H., et al. (2015). Systematic review of enhanced recovery after gastro-oesophageal cancer surgery. Annals of The Royal College of Surgeons of England, 97(3), 173-179.

Whanganui District Health Board (WDHB) staff attracted strong interest at last week’s national Productive Ward forum in Wellington when presenting the board’s successful implementation of the Releasing Time to Care programme to Whanganui Hospital’s Surgical Ward and acute mental health unit Te Awhina.

One of six of the country’s 20 DHBs invited to present to the forum, the WDHB is recognised for its commitment to establishing a work environment that supports nurses to analyse and change the way they work so they can spend more time with patients and deliver safer care.

WDHB nurse manager Katheryn Butters says Releasing Time to Care (RTTC) is all about enabling staff to focus on the internationally recognised programme’s four principles and improving ward processes around:

• patient safety and reliability of care
• the patient’s experience
• staff wellbeing
• ward efficiency.

Ms Butters says during the past year, Whanganui Hospital’s Surgical Ward has focused on using both theReleasing Time to Care and the Care Capacity Demand Management (CCDM) programmes to better meet patients’ needs by having the right people, in the right place, at the right time with the right tools to deliver safe effective care.

During a visit to the WDHB last week, Safe Staffing Healthy Workplace Unit director Lisa Skeet said she was very impressed with the work and results achieved by the Surgical Ward team.

Ms Skeet said by combining the two programmes (RTTC and CCDM) had enabled ward staff to diagnose process and system issues, and plan and implement improvements.

Ms Butters says it is no coincidence that the Surgical Ward had seen a 33 percent decrease in patients who fell while in their care between 2013 and 2014 due to the effort staff have put into falls prevention and spending more time with their patients.

Results from the national patient survey showed 100 percent of patients who received care in the Surgical Ward were treated with respect and dignity. And, that a recent survey had shown staff satisfaction has increased significantly with staff feeling they contribute to a successful team.

Ms Butters is a strong supporter of Releasing Time to Care having introduced it to Te Awhina where seclusion and restraint has reduced by 53 percent since 2010.

“We are proud that Te Awhina nurses have more than doubled the time they spend with the people they care for thanks to the improvements implemented with Releasing Time to Care,” Ms Butters says.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1080/09540962.2015.1007714 or contact your DHB library, or organisational or local library for assistance.

Leggat, S.G., et al. (2015). Have process redesign methods, such as Lean, been successful in changing care delivery in hospitals? A systematic review. Public Money & Management, 35(2), 161-168.

The key themes are: equity of access to care; timeliness, person-centredness and safety; efficiency of care; effectiveness of care.

The overview is available to read in free full text at:  http://www.health.org.uk/publications/how-does-the-nhs-compare-with-health-systems-in-other-countries/

Two hundred and twenty-five patients were analysed, of which 155 (69%) were in the group (Monday to Wednesday) and 70 (31%) in the group (Thursday to Friday). No significant differences were observed amongst the groups for age, sex, tumour location, operation performed, type of surgery (laparoscopy or open), complications. However, a significant shorter length of stay was present in the first group six days (interquartile range: 4–10) versus eight days (interquartile range: 5–11) (p = 0.045).

Based on their analysis of the results, the authors conclude that "operating on colorectal patients early in the week is associated with a significant decreased hospital stay. This should be put into consideration by units practising enhanced recovery programme if the maximal benefit of this is to be attained".

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1177/2054270414562983

Ihedioha, U., et al. (2015). Enhanced recovery programmes in colorectal surgery are less enhanced later in the week: An observational study. JRSM Open February, 6(2).

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/ans.13043 or contact your DHB library, or organisational or local library for assistance.

Mir, M. C., Zargar, H., Bolton, D. M., Murphy, D. G. and Lawrentschuk, N. (2015), Enhanced Recovery After Surgery protocols for radical cystectomy surgery: review of current evidence and local protocols. ANZ Journal of Surgery, 17 March [Epub before print]

Interviews with 13 strategic stakeholders were undertaken as well as three individual case studies for the relevant clinical areas: medicine, surgery and orthopaedics.

The authors found that the "... ANPs had a positive impact on patient experience, outcomes and safety. They improved staff knowledge, skills and competence and enhanced quality of working life, distribution of workload and team-working. ANPs contributed to the achievement of organizational priorities and targets and development of policy".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/jan.12558 or contact your DHB library, or organisational or local library for assistance.

McDonnell A., Goodwin E., Kennedy F., Hawley K., Gerrish K. & Smith C. (2015) An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting. Journal of Advanced Nursing 71(4), 789–799. 

Semi-structured individual and group interviews with 45 participants (representing clinical team members, administrative team members, service managers/team leaders, senior managers and software support team members). 

"The analysis found that communication was not always effective, and there was a lack of awareness, knowledge and understanding of the programme. Many staff did not find the Productive Community Services work relevant, and although certain improvements were sustained, suboptimal practices crept back. Although negative outcomes were reported, such as the programme taking time away from patients initially, many benefits were described including improved stock control and work environments, and better use of the Electronic Patient Record system".

The authors discuss the implications of these findings.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.ijnurstu.2015.02.005 or contact your DHB library, or organisational or local library for assistance.

Bradley, D. & Griffin, M. (2015). Staff perceptions of a Productive Community Services implementation. International Journal of Nursing Studies, 52(6), 1052–1063

This study examined the current practices of senior emergency physicians’ at 2 large Australian hospitals in regards to test result notification, along with their attitudes to direct patient notification of clinically significant abnormal and normal test results. Results showed that more than half of the emergency physicians surveyed (54%) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%) was comfortable with direct notification of normal test results. The authors conclude that, although patients’ direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians’ concerns need further exploration.

To access a free full text version of the article, go to: http://www.jmir.org/2015/3/e60/

Callen J., et al. (2015). Emergency physicians’ views of direct notification of laboratory and radiology results to patients using the internet: A multisite survey. Journal of Medical Internet Research, 17 (3), e60, doi: 10.2196/jmir.3721

A simple solution to a costly problem has seen a Hauraki health provider reduce the number of people missing specialist hospital appointments by about 49 per cent – saving the public hundreds of thousands of dollars.

Te Korowai Hauora o Hauraki has reduced its patient ‘did not attend’ (DNA) rates from 25.6 per cent in 2005 to 11.82 per cent last year.

Te Korowai kaiawhaina services co-ordinator Heather Makiri-Wi spends up to two hours a day phoning and texting up to 30 patients in an effort to ensure they make appointments.

She said patients do not turn up for several reasons such as lack of transport, fear or sometimes they just forget.

Makiri-Wi said a common problem is that many patients cannot afford to use their phones to cancel an appointment.

“If there was an 0800 number it would help,” she said.

The DNA phone and text monitoring programme was initiated by the hospital in 2005 with the DNA rate dropping from 25.6 per cent to 16 per cent the following year.

The programme ceased after a new computer system was installed at Thames Hospital but it was reactivated in 2011.

The efforts since then have led to the lowest recorded DNA rate.

Te Korowai general manger of operations Gwendol Welburn said the results show how important it is to follow up with patients.

“There is definitely a need for someone like Heather to do this,” she said.

Welburn said many people do not realise it costs the hospital about $375 per patient, $600,000 per year when they miss a scheduled appointment but more so it also delays treatment for someone else.

Outpatients manager Rodger Clark said the Ministry of Health expects everyone will receive a first specialist appointment within four months of being placed on the waiting list.

“It is frustrating when people do not attend appoints because that appointment could have been offered to someone else.”

He said paediatrics was one of the worst for DNAs with 45 per cent of December bookings unattended.

Thames Hospital and community service manager Jacquie Mitchell said people don’t realise the implications their actions have.

“We wait for a person to show up, someone we have invested a whole lot of time in and [then when they don’t] other people get frustrated because they miss out on an appointment or surgery.

“It could be your family or neighbour who misses out on an appointment,” she said.

However Mitchell is delighted at the success of Te Korowai’s monitoring programme and thanked all the staff for their efforts.

The average rate for DNAs in Thames is 9 per cent, about 1600 people, compared to 8 per cent across the Waikato DHB area.

Further work is being done to reduce those figures, including a weekend monitoring system.

A new patient orientated approach to bookings by the hospital’s dietetic clinic has seen a dramatic drop in appointment non-attendance, from 50 per cent of patients to zero in the last 6 months.

Dietitian Nicole Walker found that with one call both she and her patients are getting more out of appointments.

“The high level of non-attendance meant clinician’s time was being wasted and the waiting list of people who weren’t being seen was growing.

“By calling the patient directly, confirming their appointment time, and what they wanted to achieve, the patient felt more in control, better cared for, and also came more prepared to their appointments.

“I can tell them exactly what they need to do, whether to create a food diary or bring in any extra information.

“I went from having 30 to 40 patients on my waitlist down to zero and patients only waiting two to ten working days for an appointment.”

“By creating this relationship the patients feel more obligated to show up and feel like they already know me. Just through one phone call the appointment became far more personalised.”

Nicole says that it takes her about 30 minutes to call her patients per week, but she estimates that she’s saving two to three hours a week through the reduction of non-attendances.

“If they have any simple enquiries that can be attended to over the phone I can help them on the spot, rather than having them come all the way into the clinic.

“It also allows me to discover who physically cannot attend appointments and refer the community dietetic service.”

Nicole will present her findings at the national meeting of the New Zealand Society for the Study of Diabetes on the first week of May.

In the February 2015 issue of Nursing Review, Fiona Cassie talks to a sleep physiologist and nurse leaders to find out how to minimise the risks and maximise the lifestyle benefits of shiftwork.

The Health Quality & Safety Commission is encouraging people to join the growing number of patients helping district health boards (DHBs) assess the quality of care in public hospitals.

For the Commission’s third patient experience survey, 6000 people who were inpatients between 2–15 February have been asked to rate their care out of 10, based on communication, partnership, coordination of the care, and having their physical and emotional needs met.

They have also been asked a range of 20 more detailed questions, including ‘Were you involved as much as you wanted to be in decisions about your care and treatment?, ‘Overall, did you feel staff treated you with respect and dignity while you were in the hospital?’ and ‘Was your condition explained to you in a way that you could understand?’

Response rates have risen from 24 percent in the first survey last year to 27 percent in the second, the results of which were released in February.

Although Commission director of health quality evaluation Richard Hamblin says that rate is similar to surveys in other countries, the Commission is aiming for 40 percent, which Mr Hamblin describes as a very achievable target.

‘Already, with the two surveys published, we have been able to provide DHBs with valuable insights into the care they are providing.

‘I urge anyone invited to fill in the survey to do so. It’s easy, doesn’t take long, and you remain anonymous unless you choose to supply contact details.

‘You can reply online or post your response. However you do it, your feedback on your stay in hospital will let DHBs know what they’re doing right and where improvements are needed.’

Participants have until Tuesday 17 March to return the survey.

Click here to see how the meeting uses the components of the Management Operating System and how the team use it to focus their actions.  You will also hear from team members as to how this approach has made things better for their Patients, their team and the wider organisation.

For more information, please contact Tim Winstone, Programme Director Performance Improvement. 

Click here to find out what a Management Operating System is and how Auckland DHB have developed this to assist teams to align strategy and improve performance.

For more information, please contact Tim Winstone, Programme Director Performance Improvement. 

Health Minister Jonathan Coleman says patients in mental health wards are the latest to benefit from an innovative programme that frees up staff to spend more time looking after patients.

“The success of the Productive Ward programme in hospitals is being extended to some of our largest mental health units,” says Dr Coleman.

“The Productive Series programmes guide staff to streamline systems so they can spend more time in direct contact with patients.

“Staff in a Waikato DHB mental health ward improved time spent on direct patient care as a result of a range of changes, including ensuring equipment is conveniently located and patient information is easily accessible.”

17 DHBs are implementing one or more of the Productive Series programmes including the Productive Ward, the Productive Mental Health Ward, the Productive Community Services, and the Productive Operating Theatre.

“These programmes guide staff to review and change the way they work, and help to deliver cost and time savings, improved quality of care, and improved staff morale,” says Dr Coleman.

“The Productive Series is making a quantifiable difference. For example, in a Hawke’s Bay specialist surgery unit, a new more focused user-friendly nursing admission form is expected to save 267 hours of nursing time a year.”

The Ministry of Health is supporting uptake of the Productive Series, including providing financial support to DHBs to access training materials. A national workshop will be held in Wellington in March to share learnings and encourage expansion of the programmes.

Data included 21 stakeholder interviews; 250 hours of observation, 24 staff interviews, 32 patient interviews, a staff survey (n=55) and staff pedometer data (n=56) in the four case study wards; routinely collected data at ward level in the control hospitals (e.g. infection rates) and costs associated with hospital design (e.g. cleaning and staffing) in the new hospital. 

(1) There was no significant change to the proportion of time spent by nursing staff on different activities. Staff perceived improvements (patient comfort and confidentiality), but thought the new accommodation worse for visibility and surveillance, teamwork, monitoring, safeguarding and remaining close to patients. Giving sufficient time and attention to each patient, locating other staff and discussing care with colleagues proved difficult. Two-thirds of patients expressed a clear preference for single rooms, with the benefits of comfort and control outweighing any disadvantages. Some patients experienced care as task-driven and functional, and interaction with other patients was absent, leading to a sense of isolation. Staff walking distances increased significantly after the move.

(2) A temporary increase in falls and medication errors within the AAU was likely to be associated with the need to adjust work patterns rather than associated with single rooms, although staff perceived the loss of panoptic surveillance as the key to increases in falls. Because of the fall in infection rates nationally and the low incidence at our study site and comparator hospitals, it is difficult to conclude from our data that it is the ‘single room’ factor that prevents infection.

(3) Building an all single room hospital can cost 5% more but the difference is marginal over time. Housekeeping and cleaning costs are higher.

The authors discuss the implications of these findings.

This is an open access report that is available to read in free full text at:  http://www.journalslibrary.nihr.ac.uk/hsdr/volume-3/issue-3#hometab0

Maben J, Griffiths P, Penfold C, Simon M, Pizzo E, Anderson J, et al. (2015). Evaluating a major innovation in hospital design: workforce implications and impact on patient and staff experiences of all single room hospital accommodation. Health Services and Delivery Research, 3(3).

Lean is an organizational redesign approach focused on elimination of waste, which is defined as any activity that consumes resources (e.g., staff, time, money, space) without adding value to those being served by the process.

In addition to background information and the results of a literature review, the report presents six case studies from five organizations that implemented Lean principles in different types of health care settings. Recommendations are provided for similar organizations wishing to implement Lean in their facilities.

http://www.ahrq.gov/professionals/systems/system/systemdesign/leancasestudies/index.html

The authors concluded that the Triage Rule-out Using high-Sensitivity Troponin (TRUST) ADP, which incorporates structured risk-assessment and a single presentation hs-cTnT blood draw, has potential to allow early discharge in 40% of patients with suspected ACS and has greater clinical utility than undetectable hs-cTnT strategies.

This is an open access article and is available to read in free full text at: http://dx.doi.org/10.1136/heartjnl-2014-307288

Carlton, E., et al. (2015). A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin. Heart, 101(13), 1041-1046

The improvement comes on the back of wait times that exceeded six months for 359 patients in January 2014. Significant work has been undertaken to ensure that scans are performed in a more timely manner.

To read the full story from MidCentral DHB, go to:  http://www.midcentraldhb.govt.nz/News/Pages/Ultrasound-waiting-times-reduce.aspx

Pills and potions are much more than products; they are an integral part of patient care and patient safety.

For several years Waikato Hospital Pharmacy has overseen a programme to improve the quality, safety and efficiency of medication services at all Waikato DHB hospitals.

On Tuesday 10 February one of the last pieces in a complex puzzle slid into place when Pharmacy started taking responsibility for the supply of medications to all wards and departments.

Back in 2000 the “supply chain” of ordering, packing and distributing medications from the wholesaler to hospital departments was transferred from in-house to a private company to try to streamline the system and make it cost effective and timely.

While it achieved those aims, the supply chain approach has treated medications more as a product rather than an area of specific expertise.

And that’s where the pharmacy programme comes in.

The programme identified opportunities along the supply chain for adding expert pharmacist input, especially at the points where medications are stored, selected and distributed to the ward.

Pharmacy manager Jan Goddard says the end result maintains efficiency but brings in a quality control and patient safety focus, and stronger Pharmacy support for clinicians.

“What we have done is mainly behind the scenes but it is extremely valuable in improving patient care,” she says. “We have increased the profile of Pharmacy within all Waikato DHB hospitals and promoted the availability of Pharmacy staff to support clinical staff and see patients.

“The DHB has recognised and supported this development,” she adds.

The project aims were better clinical service, medication safety, improved response times, medication security, legislative compliance, and working closely with Pharmac to implement the national Medicines List.

Supporting the project were senior clinician John Barnard and group manager clinical support services Melinda Ch’ng.

Beefing up the role of Pharmacy in medication management has seen the team of experts grow from around 18 fulltime roles in 2005 to 55 today. These include pharmacists, pharmacist assistants and pharmacy technicians.

“This increase means we can be involved in a lot more activity now that directly supports patient care,” Jan Goddard says. A cytotoxic compounding and dispensing service means the Pharmacy orders and prepares drugs for chemotherapy infusion. Another initiative is the development of a chronic care pharmacy team who provide expert advice on medications for patients with chronic conditions.

The Pharmacy is now involved in more clinical trials and provides a wider range of services on the wards and in liaison with community pharmacists. It is also part of a wider Midland health region e-pharmacy project for a shared inpatient pharmacy IT system.

Automated medication dispense cabinets on some wards is yet another way Pharmacy has reshaped its service. Cabinets are now in place in high use areas – Intensive Care, CathLab, three of the four acute medical wards, Older Persons and Rehabilitation wards, and Emergency Department. The system is linked to the hospital’s i.PM patient management system. An authorised nurse logs in, selects the correct patient, searches for the medication type and identifies the dose and formulation required. Once entered on the PC, the system automatically opens the cabinet drawer containing the correct medication.

Looking back over the Pharmacy’s service development Jan Goddard says: “It has been a lot of hard work, involving a huge effort from dedicated Pharmacy staff, but well worth it to know a patient’s medication requirements and clinical safety are much improved.

“This isn’t the end of the journey,” she adds. “There is a lot we can learn from other hospitals here and overseas that will add even more to our services.”

A new vision to see modern nutritious foods sold at Taumarunui and Tokoroa hospitals has led to an overhaul of the hospitals’ cafes.

Food and environment services manager Sarah Turpitt has led the change with an idea to make the space and food more attractive.

“I really wanted to make it a bit more exciting and attract both staff and the public into a neat space with great food,” she said.

The plan is by improving some of the food, snacks and coffee the cafes will begin to become contributors back to the hospitals’ bottom line.

“We have external businesses on site –in the way of the pharmacy and medical centres – and their staff and patients aren’t utilising the café as much as they could, so this a great opportunity to change that,” she said

One of the biggest changes will be frozen Take Home Meals which the cooks will prepare on site.

“We have noticed a big demand from people wanting meals to take home, especially from our shift workers. We have built up a stock of specially prepared meals that can just be heated and eaten on site or taken home,” said Turpitt.

Over the Christmas period both cafes closed down to prepare for the changes and learn the new production side.

Turpitt’s background as a lecturer at Wintec helped her upskill the teams and embed a new culture among the staff.

“I have really enjoyed the challenge of seeing this vision through. We have had some battles but I have a very strong will,” she said.

Turpitt said this is only the beginning and has more plans for both sites.

“My motivation is to get everyone eating better but also to make the cafes pay their own way.”

Health Minister Jonathan Coleman says patients recovering from hip or knee replacement surgery are spending less time in hospital as a result of a new national quality improvement programme.

Dr Coleman was today launching new Orthopaedic Enhanced Recovery After Surgery (ERAS) patient education videos at Waitemata DHB Electives Surgical Centre.

“The national Orthopaedic ERAS programme is a patient centred approach designed to prepare patients for surgery,” says Dr Coleman.

“A key part of ERAS is involving patients in the preparation for surgery. If people know what to expect, they are better prepared, recover faster, have fewer complications, and can get out of hospital quicker.

“ERAS also makes better use of staff time, contributes to fewer cancelled operations, and increases the capacity for more operations to be done.

“Coordinated by the Ministry of Health, ERAS has involved orthopaedic teams from 18 DHBs. It is a good example of collaboration across DHBs.

“The Ministry of Health is looking at other specialties where ERAS can be applied. Efforts are also underway to increase primary care involvement.”

The number of patients receiving hip, knee and other elective surgery each year has increased from 118,000 in 2007/08 to 162,000 in 2013/14. The Government committed in Budget 2014 a further $110 million into elective surgery over four years to continue to meet increased demand.

The videos ‘Your Guide to Hip Replacement Surgery’ and ‘Your Guide to Knee Replacement Surgery’ can be found at www.health.govt.nz.

The College develops strategic consumer alliances with the aim of creating 100% access and zero disparities in NZ health care, while providing a leading voice for the nursing profession and professional commentary on issues which affect nurses, and also the health of the whole community.

Pre- and post-operative surveys were completed by patients who underwent major hepatic, colorectal, or oesophagogastric surgery and surveys were also sent to surgeons, anesthetists, and nurses experienced in delivering enhanced recovery protocols. 

"Overall, both patients and care providers rated the majority of items as important and supported ERAS principles. Freedom from nausea ... and pain at rest ... were the care components rated the highest by both patients and care providers. Early return of bowel function ... and avoiding preanesthetic sedation... were scored the lowest by care providers". The authors conclude that ERAS principles are supported by both patients and care providers, althoough controversies still remain regarding the relative importance of individual ERAS components.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.jss.2014.06.032 or contact your DHB library, or organisational or local library for assistance.

Hughes, M., et al. (2015). Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery. Journal of Surgical Research, 193(1), 102–110.

"Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential". The authors discuss the implications of these findings.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1097/SLA.0000000000000604 or contact your DHB library, or organisational or local library for assistance.

Pearsall, E.A., et al. (2015). A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Annals of Surgery, 261(1), 92–96.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.healthpol.2015.02.002 or contact your DHB library, or organisational or local library for assistance.

D’Andreamatteo, A., et al. (2015). Lean in healthcare: A comprehensive review. Health Policy, 11 February [Epub bfore print]

Discharged patients give our hospitals a big thumbs-up for meeting their physical and emotional needs while they were inpatients.

The latest Health Quality and Safety Commission national patient experience survey gives Waikato DHB a 9 out of 10 score in that category, up from 8.4 a few months ago.

The patient survey results also show better ratings for Waikato District Health Board (DHB) in some key areas it has targeted for improvement. This includes how well informed patients feel about managing their condition and their medication after they are discharged from hospital. The number of patients who ticked the “yes completely” box for that question improved from 39 to 53 per cent for condition and from 55 to 64 percent for medication. Waikato DHB is determined to raise this even further in future surveys through its discharge planning project.

Overall, patients rated their experience in Waikato DHB hospitals as 8.3 out of 10 for communication, 8.6 for partnership (involvement of themselves and family in decisions about care), 8.3 for coordination, and 9 out of 10 on physical and emotional needs.

The national equivalent for all district health boards was 8.3 for communication, 8.5 for partnership, 8.4 for coordination, and 8.6 for meeting physical and emotional needs.

The quarterly survey is offered to over 6000 randomly selected people who were inpatients in New Zealand public hospitals between 3 and 16 November and are now discharged.

The national results were released today by the Health Quality and Safety Commission (HQSC). Richard Hamblin, the commission’s director of health quality evaluation, says the national response rate for the survey has risen from 24 to 27 per cent and is on track for the 40 per cent the commission is seeking.

At Waikato DHB the local response rate more than doubled from 14 to 31 per cent as the DHB experiments with better methods to contact patients.

Mo Neville, Assistant General Manager, Quality and Patient Safety

The DHB’s Quality and Patient Safety assistant general manager Mo Neville says the increased response rate has helped lift the results. “It is a much better sample this time, and we have growing confidence in the figures.”

“We are very grateful to those who do respond,” she says. “Patient feedback is really important because it gives us a clear steer where we can improve. So if someone is asked to participate in the survey, we would love them to do so. We definitely listen to what is said.”

The survey is designed primarily to allow measuring change over time at a local level rather than comparison among district health boards.

However the results show most DHBs as having similar scores in many areas, and Waikato DHB results are generally in line with the national averages.

The HQSC says new national survey of public hospital inpatients is proving its value as a tool for identifying where care improvement is necessary.

‘The implications for not working in partnership, not giving clear, understandable information andnot involving patients and family/whanau enough in decisions are well documented,’ says Dr Chris Walsh, director of the HQSC’s Partners in Care consumer engagement programme. ‘DHBs now have an opportunity with this data to explore further these important aspects of patient experience.’ Read the HQSC media release here

The first survey was done in August last year and the results were released in November.

Read more about the results here.

Twenty-nine medical and non-clinical managers from departmental to executive level were interviewed. The authors identified 3 themes: "(1) previous systems of managing clinical performance were considered to be ineffective due to insufficient empowerment of medical managers and poor quality of available performance data; (2) the implemented framework was considered to address these needs and was positively received by medical and non-clinical managers; (3) introduction of performance-related HRM required the involvement of the whole organisation to executive level and inclusion within organisational strategy, structure and training".

The authors discuss the implications of these findings.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1136/bmjqs-2014-003219 or contact your DHB library, or organisational or local library for assistance.

Trebble, T.R., et al. (2015). Clinically led performance management in secondary healthcare: Evaluating the attitudes of medical and non-clinical managers. BMJ Quality & Safety, 24, 212-220.

To read this digital report, go to:  http://www.kingsfund.org.uk/time-to-think-differently/publications/future-now

Based on their findings, they conclude that "... standardized readmission rates are lowest in the lowest volume hospitals—opposite from the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics and was only partially attenuated by examining mortality and readmission together. Our findings suggest that readmissions are associated with different aspects of care than mortality or complications".

This article is available to read in free full text at:  http://dx.doi.org/10.1136/bmj.h447 

Horwitz, L.I., et al. (2015). Association of hospital volume with readmission rates: a retrospective cross-sectional study. BMJ, 350, h447.

Health Minister Jonathan Coleman says a new hospital patient information system will be rolled out across South Island DHBs to streamline services.

“The South Island Patient Information Care System (SI PICS) will be phased in over the next two to five years, replacing seven existing patient administration systems,” says Dr Coleman.

“The IT system will make the electronic transfer of patient information safer and more efficient. The programme will also manage patient appointments, admissions, discharges, and transfers across all DHBs.

“Hospital staff will be able to reduce duplication, share resources, and spend less time on administration.

“It will also be easier to find relevant information from another DHB, and health professionals who move between DHBs will have only one system to familiarise themselves with.”

Hospital patients in Canterbury will be the first to benefit from the new IT system, with it being phased in towards the end of the year. Nelson Marlborough DHB will adopt the system in early 2016.

The South Island Alliance, a collaboration of the South Island’s five DHBs, is working with Orion Health to develop and implement SI PICS.

To view the videos:

https://www.youtube.com/watch?v=okzv7JruDp4

https://www.youtube.com/watch?v=t9xvqbcw-TI

Ten articles were included (with a level of evidence graded as low to moderate). None reported an adverse effect on perioperative morbidity or mortality. Length of stay was decreased, and readmission rates were unchanged in six of seven studies that compared these outcomes.

The authors conclude that "... ERAS protocols may be implemented in pancreatic surgery without compromising patient safety or increasing [length of stay]" They go on to say that programmes should be based upon the best available evidence, and trials involving multiple centres should be undertaken.

Now available to read in free full text at: http://dx.doi.org/10.1111/hpb.12265 

Kagedan, D. J., Ahmed, M., Devitt, K. S. and Wei, A. C. (2015), Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB, 17(1), 11–16.

To read the full story, go to p.9 of Auckland DHB's NOVA magazine:  http://www.adhb.govt.nz/Publications/Nova/NOVA%20Feb-March%20web.pdf

With rising demand, patient waits increased. The average lead time for a patient (time from entering the department to leaving) was 79 minutes. 9.3% of patients attended within two weeks of their scheduled surgery date. 10% of patients were asked to return on a later day, as there was not sufficient capacity to undertake their assessment. There were nine routes of referral in to the department.

Patients moved between different clinic rooms and the waiting area several times. Work patterns were uneven, as many attendances were from out-patient clinics which meant peak attendance times were linked to clinic times. There were substantial differences in the approaches of different nurses, making the HCA role difficult. Patients reported dissatisfaction with waits.

Using a Lean quality improvement process with rapid PDSA cycles, the service changed to one in which patients were placed in a room, and remained there for the duration of their assessment. Standard work was developed for HCWs and nurses. Rooms were standardised using 5S processes, and set up improved to reduce time spent looking for supplies. A co-ordinator role was introduced using existing staff to monitor flow and to organise the required medical assessments and ECGs. Timing of booked appointments were altered to take account of clinic times. Routes in to the department were reduced from nine to one.

Ten months after the work began, the average lead time had reduced to 59 minutes. The proportion of people attending within two weeks of their surgery decreased from 9.3% to 5.3%. Referrals for an anaesthetic opinion decreased from 30% to 20%, and in the month reviewed no one had to return to be seen as a result of limited capacity.

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1136/bmjquality.u201341.w1226

Start, C., et al. (2015). Improving patient flow in pre-operative assessment. BMJ Quality Improvement Reports, 4.

Ten English National Health Service hospitals were identified with the shortest length of stay after elective colonic surgery between January 2011 and December 2012. Semi-structured telephone interviews were conducted with a senior colorectal surgeon and ward nurse at each site. 

These units standardised clinical care based upon an Enhanced Recovery Program. Beyond this, they organised the clinical team to efficiently and reliably deliver this package of care, with the majority of day-to-day care delivered by consultants and nurses. Patients were closely monitored for postoperative deterioration, using a combination of early warning scores, nurses’ clinical judgement and regular senior medical review. Of note, operative volume and laparoscopy rates in these units were not statistically significantly different from the national average. The postoperative analgesic strategy varied widely between units, from routine epidural use to local anaesthetic infiltration or patient-controlled analgesia.

The authors conclude that the Enhanced Recovery Program may be seen as necessary but not sufficient to achieve the best length of stay results. In the study units, consultants and nurses led and delivered the majority of patient care on the ward. High quality teamwork helped detect and resolve clinical issues promptly, with nurses empowered to contact consultants directly if needed. Other units may learn from these teams by adopting protocol-based, consultant- or nurse-delivered care, and by improving coordination and communication between consultants and ward nurses.

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1186/s13037-014-0050-5

Byrne, B.E., et al. (2015). Understanding how colorectal units achieve short length of stay: An interview survey among representative hospitals in England. Patient Safety in Surgery, 9:2.

The researchers conducted interviews with staff from 8 nursing units and asked them to speak about their experience doing RTC. The results focus on 2 units chosen to highlight extreme variation in existing QI capacity. Unit B was characterized by a strong existing environment. RTC was implemented in an environment with a motivated manager and collaborative culture. Aided by the structural support provided by the organization, the QI capacity on this unit was strengthened through RTC. Staff recognized the potential of using the RTC processes to support QI work. Staff on unit E did not have the same experience with RTC. Like unit B, they had similar structural supports provided by their organization but they did not have the same existing cultural or political environment to facilitate the implementation of RTC. They did not have internal motivation and felt they were only doing RTC because they had to. Though they had some success with RTC activities, the staff did not have the same understanding of the methods that RTC could provide for continuous QI work.

The authors conclude that RTC has the potential to be a strong tool for engaging units to do QI. This occurs best when RTC is implemented in a supporting environment. One size does not fit all and administrative bodies must consider the unique context of each environment prior to implementing large-scale QI projects. 

This is an open access article and can be read in free full text at: http://dx.doi.org/10.1186/s12913-014-0642-x

Hamilton, J., et al. (2014). One size does not fit all: A qualitative content analysis of the importance of existing quality improvement capacity in the implementation of Releasing Time to Care: the Productive Ward™ in Saskatchewan, Canada. BMC Health Services Research, 14:642.

Each overview covers health insurance, public and private financing, health system organization and governance, health care quality and coordination, disparities, efficiency and integration, use of information technology and evidence-based practice, cost containment, and recent reforms and innovations.

In addition, summary tables provide data on a number of key health system characteristics and performance indicators, including overall health care spending, hospital spending and utilization, health care access, patient safety, care coordination, chronic care management, disease prevention, capacity for quality improvement, and public views.

To read the report in full text, go to: http://www.commonwealthfund.org/publications/fund-reports/2015/jan/international-profiles-2014

The objective of this systematic review and meta-analysis was to determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

The authors included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. They found 184 studies that met the inclusion criteria and provided data for analysis.

The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management.

Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as the authors found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

The authors conclude that very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

This report is available to read in free full text at:  http://www.journalslibrary.nihr.ac.uk/hsdr/volume-2/issue-54#hometab0

Panagioti M, Richardson G, Murray E, Rogers A, Kennedy A, Newman S, et al. (2014). Reducing Care Utilisation through Self-management Interventions (RECURSIVE): A systematic review and meta-analysis. Health Services and Delivery Research, 2(54).

The study population was 263,482 participants in the 45 and Up Study. The data assessed were linked records of hospital admissions in the 12 months following completion of a baseline questionnaire. All cause and ambulatory care sensitive admission rates and length of stay were examined.

Prevalence of diabetes was 9.0%. Age adjusted admission rates for all-cause hospitalisation were 631.3 and 454.8 per 1,000 participant years and the mean length of stay was 8.2 and 7.1 days respectively for participants with and without diabetes. In people with and without diabetes, the risk of hospitalisation was associated with age, gender, household income, smoking, BMI, physical activity, and health and wellbeing. However, the increased risk of hospitalisation was attenuated for participants with diabetes who were older, obese, or had hypertension or hyperlipidaemia and enhanced for those participants with diabetes who were male, on low income, current smokers or who had anxiety or depression.

The authors conclude that the attenuation of risk associated with some factors is likely to be due to correlation between diabetes and factors such as age and obesity. The increased risk in association with other factors such as gender and low income in participants with diabetes is likely to be due to their synergistic influence on health status and the way services are accessed.

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1186/s12913-014-0666-2

Comino, E.J., et al. (2015). Impact of diabetes on hospital admission and length of stay among a general population aged 45 year or more: A record linkage study. BMC Health Services Research, 15:12.

This review included 11 publications from three countries on observational time study techniques and patient transfers as a nurse activity.

"All studies used timing techniques to explore nurse work associated with the transfer process. The review highlights the duration of time spent by nurses on certain aspects of the transfer process. However, as few studies published results from timings, the impact on nurse time is likely to be higher than indicated". The authors recommend further research.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/ijn.12290 or contact your DHB library, or organisational or local library for assistance.

Blay, N., Duffield, C. M., Gallagher, R. and Roche, M. (2014), A systematic review of time studies to assess the impact of patient transfers on nurse workload. International Journal of Nursing Practice, 20: 662–673.

These case studies found that the implementation of these visual management systems enabled the hospital to improve its discharge processes.

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