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Digital Innovation for Patient Safety, on the international stage

The International Society for Digital health was launched this year and the Digital Innovation theme are intricately involved to contribute the patient-safety perspective.

On the 25th September 2019 at the University of Leeds, the International Society for Digital Health had its official UK launch. The launch was attended by over 70 international delegates from as far as Indonesia, China, India, the Gulf and neighbouring EU countries. Members of the Digital Innovation theme were not only in attendance but our theme Lead, Owen Johnson, hosted the event; Moreover, Owen is a founding member and part of the society’s Executive Committee.

 

Leading the way on the international stage

In June 2019, Owen Johnson was invited to speak at the International Society for Digital Health 2019 conference, with a talk entitled “Patient safety: the opportunities and risks of using AI in medical diagnosis and care”. At the event, he spoke about the motivation for a patient-safety agenda in healthcare information technology. In part, the motivation arises from the consequences of a mixture of over-reliance and under-utilisation of automation. It is concerns like these that the Digital Innovation theme are addressing in our Micronarratives project, wherein we are asking how real-time intelligence is created via human sensor networks.

The difficulty in finding the balanced path of appropriate use of IT and artificial intelligence is somewhat explained by the V, and T challenges that Owen spoke about during his invited talk, at the June conference. The V challenge refers to the five Vs of big data:

  • Volume – How do we safely handle the very large amount of healthcare data being produced?;
  • Velocity – How do we safely handle the frequency with which healthcare data is updated and made obsolete?;
  • Variety – How do we safely handle the diversity of data types, formats, and delivery?;
  • Variability – How do we safely handle the differences in the way healthcare care is generated and used?; and
  • Value – How do we safely filter and prioritise the best healthcare data?.

The T challenge refers to safely handling the temporal effects of intervening with healthcare information technologies. Work by McLintcok et al. in 2014 showed how rates of coding and prescribing for incentivised conditions suggest anomalous prevalence and incidence during incentivised periods, but tend to reset to baseline values. It can be inferred that the timing of digital healthcare interventions can have anomalous effects with varying transience. These factors are front-and-centre for us in the Digital Innovation theme as we study the design and implementation of clinical decision-support tools (see Very Smart Cancer RATs).

 

What next for digital innovation of patient safety?

With these challenges in mind, the Digital Innovation theme continue to work in the overlap of digital technology, healthcare service, and safety science. Our member’s involvement in discussions at the international level facilitates collaboration and innovation for the promotion of patient safety in healthcare. The increasing digitisation and automation of society requires us to actively engage with the leading edge of our progress, and to take pre-emptive action to ensure our collective safety and effectiveness.

 

How can I get involved?

If you would like to keep up to speed or get involved with the International Society for Digital Health, join the LinkedIn open forum at https://www.linkedin.com/groups/10490340/.

You can also apply for membership by checking out http://www.theisdh.org/membership.php.

Beyond the outcomes: The benefits of the ‘process’ of doing applied health research

By Rebecca Lawton, Luke Budworth, Beth Fylan and Laura Sheard

Like other research endeavours, applied health research rewards us with new and effective interventions and technologies, a better understanding of phenomena, and evidence-based recommendations for how best to deliver a service. Uniquely, however, applied health research also helps to understand how best to translate interventions, knowledge and recommendations into everyday practice. For anyone who is interested in making a difference to patients, staff, healthcare systems and society, this is an exciting field to work in.

Nevertheless, as researchers, we often fail to consider or evaluate the impact that the process of conducting research has on these same patients, staff and healthcare systems. In this piece we focus on the huge potential that applied health research has to deliver benefits in the process of creating new knowledge. We want to open this debate up and would encourage other applied health researchers to contribute their own experiences of conducting research that made a difference ‘in the doing’.

To tell us about your views on this topic, as a researcher or NHS staff member, please follow link below.

https://www.surveymonkey.co.uk/r/SNW2WMW

Applied health research per se is undoubtedly beneficial for patients, healthcare staff and organisations. Within institutions with higher versus lower research participation, previous studies have identified improved patient health outcomes (including cancer mortality rates), reduced staff turnover, improved organisational efficiency and increased patient and staff satisfaction (e.g. Harding et al., 2017; Downing et al., 2015; Hanney et al., 2013). There are many potential explanations for these positive effects. For patients, this is often explained by the direct health benefits of exposure to novel interventions or procedures, and for staff, being able to develop their skills and experience. There may, however, be other, more indirect, reasons for these positive outcomes. In this blog, we are interested in those largely unrecognised benefits that funders may never find out about and that rarely, if ever, make their way into the published literature.

The benefits of research interviews

During her PhD, one of our research students reflected on how several of her participants emphasized how significant the interview process was for them, how rarely they had the opportunity to talk about their feelings with a non-judgmental listener and how they appreciated the opportunity to do this while potentially benefitting others. Many people who interview patients will be familiar with this apparent parallel between therapy and research interviews. Indeed, this benefit of the research process has received considerable attention. In 1994, Hutchinson’s review of the literature in this field concluded that catharsis, self-acknowledgement, a sense of purpose and self-awareness were all outcomes for patients associated with involvement in qualitative research.

In our own research on the experiences of staff who have been involved in patient safety events, the benefits for staff of being interviewees has revealed findings consistent with the above literature. Staff have reported that they felt a weight had been lifted, and that being given time to just talk to non-judging individuals who understood patient safety issues was highly cathartic. Indeed, for many, although it was painful, they felt they could now ‘move on’ from the event.

In the above cases, skilled interviewers have, during their work, developed much more than a better understanding of a phenomenon; they have developed a relationship of trust and mutual respect. For us, this is a mark of high quality research that we pay little attention to; often being the subject of a sentence or two in the reflective section of a thesis or manuscript.

And what about the broader benefits for staff of participating in applied health research?

For patients, this question has been investigated and there is now evidence from many studies that patients perceive a multitude of benefits to be associated with research participation, including greater knowledge and awareness of their health/condition, access to treatments or services, pride in taking part, a desire to help others, and the opportunity to talk to someone (c.f. Castillo et al., 2012; Gysels et al., 2008; Tolmie et al., 2004).

The benefits associated with the process of conducting an interview study represent only the tip of the iceberg, however. We recently asked for feedback from our team of 25 staff and PhD students, all engaged in applied health research. Below is a flavour of what they told us about the ways that the research process had benefitted staff and/or the health service involved in their work. Some of these were ideas were based on opinion, others were articulated by healthcare staff during the research process. Let’s be clear: we are absolutely not talking about the outcomes of research here, but what happened while they were collecting data, running co-design workshops, working with staff to consider how they might be involved in evaluating a new intervention, or understanding how teams work together (or don’t).

These are some of the benefits the research group identified:

  • Increased knowledge of a topic;
  • A safe space to talk about feelings, grievances, and frustrations;
  • The time to think about things differently, perhaps from a different perspective;
  • An opportunity to be more engaged at work, to do something different, to make a change;
  • An opportunity to contribute, to feel valued;
  • An opportunity to think critically/identify problems with current practice;
  • A chance to try something new, to be creative, to demonstrate expertise, to be valued and listened to;
  • A space to stop and think (particularly for staff);
  • A boost to morale through positive feedback.

Despite this list, a brief review of the literature reveals very little about the benefits of the process or activity of being involved in applied health research for staff. In 1996, Buxton and Hanney published an article examining the ‘payback’ for applied research. In this article they hint at the benefits of the process of research, referring in their model to the fact that ‘some outputs/paybacks may flow directly from the processes and the fact that the research is being carried out’ (Buxton and Hanney, 1996, p.39). However, in later frameworks of Research Impact (e.g., Kurivilla, Mays, Pleasant and Walt, 2006) the impacts of the research activity itself are not acknowledged and, given the challenges of measuring the impact of research, even when focus is on outputs alone, this is perhaps unsurprising.

As applied health researchers we often engage in participatory forms of research and work closely with those at the sharp end as well as those in managerial positions in healthcare organisations. It is this direct contact with people in the service that means the potential to do good (and bad, but this is not the focus here) is huge. Our aim in writing this piece is to start a dialogue with other researchers about the benefits of the activity or the ‘doing of’ research in health and social care settings. If we can better understand and capture these benefits then we might be in a stronger position to demonstrate the value or ‘cost-effectiveness’ of our research to funders, stakeholders and participants alike.

We are seeking feedback on:

1   Your own experiences of the benefits for healthcare staff (managers, clinicians or any other staff group) of being involved in doing research via a short survey:

https://www.surveymonkey.co.uk/r/SNW2WMW

2   Research papers that address this topic directly

3   There is one tool, Visible Impact of Research (VICTOR), developed by Jo Cooke and team within the Yorkshire and Humber CLAHRC, that has acknowledged, at least some of the benefits of the research process. Primarily, this tool aims to identify the health and economic impact of the research, the reputational benefits, the generation of knowledge and building of capacity for research. However, the VICTOR tool also includes an assessment of workforce impacts. Two of these questions ask specifically about benefits for workforce skills and practice of their involvement in the research process and another item asks about whether taking part in the research has influenced teams to do something different together. There may be other tools like this out there, that we are yet to come across – if so, please do let us know.

Improving wellbeing and safety at work using collective wisdom: what more can we learn from other sectors?

In collaboration with Veterinary Surgeons Sarah Hunt and Caroline Dennis

Our aim as a Patient Safety Translational Research Centre (PSTRC) is to learn from and draw on ideas from other sectors. Healthcare has done this successfully in the past. For example, procedures used in aviation inspired the use of the surgical safety checklist and the racing car industry has provided insight into safer handovers during complex care. However, other topics that are relevant to many safety-critical organisations, including healthcare, are how staff make difficult decisions in uncertain and difficult situations and how we enable staff to do their job safely.

Safety-critical industries: what are the links?

Sectors such as healthcare, veterinary medicine, maritime, police and fire services share important aspects in their day to day work. They are high risk, complex environments. But links run deeper than this. Workforces in these sectors are increasingly under pressure to perform well despite limited resources. Staff are working in time-critical situations where high stakes decisions have to be made, often in the context of limited or incomplete information. In addition, they are also under constant scrutiny with the threat of litigation if something goes wrong. These disciplines are therefore all facing similar issues in terms of the impact on the staff delivering the service. Staff sickness, burnout, and turnover are all consequences and the evidence of the link between wellbeing and the effectiveness and safety of the service being delivered is growing. Our own work has shown links between staff wellbeing and patient safety in a healthcare setting (e.g. Hall et al, Johnson et al, Louch et al) and conversations with colleagues working in other safety-critical sectors have indicated that they too are facing similar work-related issues that affect safety and wellbeing.

What has already been done to address this?

Colleagues in other sectors such as veterinary medicine – the VetLed HALT Campaign and Vets Now, police and the fire service now recognise the important link between staff wellbeing and safety and are beginning to develop solutions. In 2005, the BMJ and Veterinary Record issued a joint special issue which sought to stimulate debate about possible links between approaches in human and veterinary medicine to improve practice. More recently, interest in attempting to improve healthcare safety by bringing together perspectives from human and animal healthcare has emerged. However, while such initiatives demonstrate potential value, they remain sparse.

How can we move forward?

We think there is now a need to foster synergy and promote learning from each other by sharing perspectives and insights. This will allow us to develop a collective wisdom and move beyond our own professional communities; forming a collaborative approach to the shared challenges posed by the link between wellbeing and safety. Through doing this, we hope sectors will be encouraged to consider strategies that are being implemented in each other’s industries, increase knowledge about how these strategies shape the work environment and impact wellbeing and safety, and whether they are transferable to other settings. This will enable us all to develop alternative and novel strategies which are of value to others as well as within the context from which they originate.

What next: a shared interactive workshop

We are bringing together individuals interested in enhancing staff wellbeing through learning from and sharing with colleagues in other sectors for an innovative interactive workshop at our national patient safety conference on 15th October 2019.

The workshop will include colleagues from veterinary medicine, fire, police, maritime and healthcare services who will:

  • explore the concept of well-being and its impact on aspects of safe practice from each of their service sector perspectives
  • share experiences and insight across different service sectors
  • explore common factors affecting well-being at work and identify current strategies to address these
  • explore how to take forward shared learning and insight

How can I get involved?

You can follow our workshop on Twitter #wellbeing4safety

For more information about this work please contact: Jane Heyhoe or Gillian Janes

 

Supporting the ‘second victims’ of patient safety incidents

Researchers at our PSTRC have developed a unique range of online support to help the ‘second victims’ of patient safety incidents: clinicians and healthcare workers.

Patient safety incidents are any unintended or unexpected incident, such as a medical error or system failure, which could have, or did, lead to harm for a patient receiving healthcare. When things go wrong in the NHS the first priority is always to support the patient affected and their family. But this sometimes means that the needs of healthcare workers at the centre of patient safety incident investigations are almost forgotten, even when the impact can have far-reaching consequences for the person and their organisation.

Now health researchers from the PSTRC, the Yorkshire Quality and Safety Research Group and the Improvement Academy, based at the Bradford Institute for Health Research, have launched a website www.secondvictim.co.uk with a wealth of resources to support clinicians and organisations.

The project is focused on how clinicians are supported through these events; not because their needs are greater than the patient or their family’s – far from it, but because the impact of the event on the clinician has a knock-on effect on the care they are able to give their next patient. One clinician described it in this way:

It hit me for the first time that I’ve had something actually go wrong, then that opened a door to me imagining, second guessing everything all the time, imagining things going wrong. And how you can have an effect on a person’s life if something does go wrong. I think that’s what really hit me, and knocked my confidence for that time.

This clinician, with others, has told their story by film on the website. Users of the website have found these films helpful, and several have offered to share their own experiences. It’s been so useful for the project team to hear the real experiences of people who will be able to benefit from using the website, and to recognise the impact that making a mistake has on the clinician and their colleagues. In particular this story stands out because when the incident was investigated the clinician was found to be not at fault, due to a communication error about what needed to be done.

These stories clearly resonate with other clinicians, but importantly when clinicians talk about mistakes it enables learning; in this instance the way that treatment plans are communicated around the hospital could be improved, reducing the risk of a recurrence for another patient.

To hear these stories go to www.secondvictim.co.uk

Plugging in the safety gaps: An integrative approach to gathering safety information from patients via Electronic Health Records

By Dr Abigail Albutt (Research Fellow within the NIHR Yorkshire and Humber PSTRC) and the Patient Involvement in Patient Safety research team

I recently attended the Sixth Annual NIHR Imperial PSTRC Symposium held in London. This year the conference had a focus on using innovations in digital technology to enhance healthcare quality and safety. A keynote presentation came from Professor David Bates, Harvard University, who is an internationally renowned expert in patient safety. Professor Bates discussed the use of patient monitoring technologies on medical surgical wards where patients are not typically continuously monitored, and how such information technologies are vital to the delivery of high quality, safe patient care. Cal Leeming, Security Advisor at River Oakfield, followed to talk about the importance of cyber security which led to a thought provoking panel discussion about this topic.

Next, Professor Rebecca Lawton, Director of the NIHR Yorkshire and Humber PSTRC chaired a panel discussion about enhancing patient and public involvement and engagement (PPIE) in safety. This discussion revealed many useful tips about how to engage patients and the public in patient safety research, particularly those from ‘hard to reach’ groups. Going to where the people are rather than inviting them to you, and finding a shared language, were proposed as key success factors. The discussion moved on to the interesting idea of whether PPIE is necessary for healthcare staff-facing interventions. Ultimately, as all interventions affect patients; the consensus was that PPIE is always necessary.

I was delighted to present a poster at the symposium, outlining one of our projects exploring how we might advance patient involvement in patient safety specifically within a primary care setting. It is now widely accepted that patients can meaningfully provide feedback on the safety of their care, and recent efforts have concentrated on novel ways of gathering this feedback. Increasingly, patients are encouraged to access their Electronic Health Record (EHR), with access associated with improved patient satisfaction and enhanced patient safety, by identifying medication errors for example.

Dr Abigail Albutt at the Sixth Annual NIHR Imperial PSTRC Symposium.

Bringing together these bodies of literature, the poster described an interview study exploring primary care user perspectives on identifying errors in their EHR and providing feedback about care experiences via their EHR. Most patients felt they would benefit from interacting with their EHR, and the majority of patients interviewed welcomed the opportunity to identify and report errors and the possibility of using EHRs as a portal to provide feedback about their care experiences.

Download the full poster 

Presenting the poster generated much discussion around the process of implementing such a system in practice. These discussions reinforced the importance of the next phase of this study, talking to primary care staff, to ensure this potential integrative approach to gathering safety information from patients in primary care is acceptable to staff. I will be presenting this work orally at the British Journal of General Practice Research Conference in March which will provide a brilliant opportunity to talk to primary care staff and begin to progress the study to explore staff perceptions.

 

 

This research is funded by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). The views expressed in this article / presentation are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

 

 

Stopping medicines: Hearing the voices of those involved

By Dr Iuri Marques and Dr Daisy Payne

In our autumn newsletter (https://yhpstrc.org/newsletter/) we discussed our work on improving the management of medicines by optimising the process of stopping problematic medicines in primary care. Here we move our focus to how we are capturing patient views about reducing the number of medicines they take.

As people get older and develop health conditions, many are prescribed long-term medicines. With time, more health conditions may develop, more medicines are prescribed and patients risk experiencing medicines-related problems as well as decreased quality of life or frequent unplanned hospital admissions. Patients may also be treated by multiple healthcare professionals in both primary and secondary care at different times. For example, if a patient is admitted to hospital, a consultant may decide to stop one or more medicines, and when the patient is discharged into primary care, the GP may decide to restart them. Consequently, managing medicines is a complex process, and one that can be quite confusing and upsetting for the patient.

The Safe Use of Medicines theme for the NIHR Yorkshire and Humber PSTRC is investigating how we can improve the process of stopping medicines for patients, ensuring the patient understands the reasons behind any decision being made, and takes an active role in the discussions about their care and medicines. We believe that since the process of stopping medicines is so complex, it is important to hear the voices of everyone involved. The first step we took was to engage with patients and members of the public in the development of our study, to ensure we focused on the important aspects of the process and asked the right questions.  They were instrumental in identifying research priorities and co-designing all participant documents so that they were patient friendly. Now, we are interviewing patients who have recently had a medicine stopped, their supporting peers (i.e. friends or relatives who play an active role in the management of patients’ medicines and conditions) and healthcare professionals, to understand their views and experiences.

The healthcare professionals we have interviewed have given us invaluable insight into the process of reducing medicines, including the purpose, usefulness and clinical justification for stopping a medicine and how they communicate this to their patients. However, whilst they are able to reflect on this process, only the patients themselves can provide insight into what it is like to live with these decisions. It is crucial therefore that we speak to patients, since they can provide insights and relate experiences that healthcare professionals cannot.

As well as talking to patients, we are talking to supporting peers – people who are not part of the formal health and care team yet have some involvement in managing patients’ medicines. Supporting peers add a unique and currently unexplored insight into the experiences of patients when medicines are stopped. Their views about what is best for the patient, and their care priorities may differ from the priorities of the patient themselves.

Stopping medicines is and will continue to be a complex process. The best way to improve it is by including everyone who is directly or even indirectly involved, understand their views and experiences, and ultimately give them a voice in how care is delivered in the future.

This research is funded by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). The views expressed in this article / presentation are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care

 

Setting the agenda for future patient safety research

The research team at the NIHR Yorkshire and Humber Patient Safety Translational Research Centre (PSTRC) needs your help developing its future research agenda. We want you to challenge us with your ideas for patient safety research for the next 5-10 years, informed by your knowledge of delivering, receiving or researching care.

You can tell us what you think by suggesting research questions here: https://www.surveymonkey.co.uk/r/VJN3967

Or read on for some background about patient safety and about our PSTRC.

What is patient safety?
Patient safety is the ‘prevention of errors and adverse effects to patients associated with health care’.(1) We know that in the UK, Europe, Australia and the US, about 1 in 10 patients admitted to hospital suffer some harm that is preventable. Since the late 1990s there has been a focus on preventing this unintended harm to patients. The focus of attention can often be on serious failures in care, such as wrong site surgery, incorrect doses of medication or feeding tubes inserted into the lungs that cause harm or even death. Yet the 2010 Mid Staffordshire NHS Foundation Trust Inquiry led by Sir Robert Francis brought attention to the ‘considerable suffering’ patients experienced due to failures of basic care such as hydration and hygiene.(2) Reports such as this have highlighted how safety problems are rarely caused by individuals, but by “systems, procedures, conditions, environment and constraints”. (3)

Recently, patient safety researchers have called for a new focus on what goes right in healthcare, instead of the focus on deconstructing incidents, recognising that for most patients healthcare is successful and they are unharmed. They have argued that emphasis must be placed on understanding how staff members adapt their performance to prevent harm occurring in response to difficult and varying conditions. (4)

What is a patient safety translational research centre (PSTRC)?
A PSTRC develops and tests ideas and tools to improve the safety of patient care. Our Yorkshire and Humber PSTRC started delivering research in August 2017 and our priority research areas for the first two years are already set – they include enabling patients to play a central role in their own safety, the potential for digital technology to improve safety, how we create workplaces that people want to work in, and how we can enhance the safe use of medicines across care settings. You can find out more about our work on our website.

We now want to find out what you think the most important safety improvement research questions are so we can plan our future work. So far our advisory board, clinician and patient groups have given us an idea of what they think is important. Here’s a taste of what they have asked us – you can tell us if you agree.

  • Can you really hand over a patient safely in 15 minutes?
  • What do sheltered care homes have a protocol to dial 999 for every fall?
  • How do we reduce barriers to staff being heard in teams due to hierarchy, power, ethnicity, and gender?
  • Is it safe for patients to self-administer medicines on the ward?
  • Is there a link between patient safety incidents and a lack of activity on mental health wards?

Over to you

We want you to tell us what you think the most important patient safety research questions are. You may have ideas from a recent experience of care or from your experiences in delivering care. You may agree with some of the questions above or think that some vital areas for research are missing.

Tell us what you think by submitting research questions here: https://www.surveymonkey.co.uk/r/VJN3967

 

 

References

1 The World Health Organization. Patient Safety. 2018. Available online http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/patient-safety

2 The Mid Staffordshire NHS Foundation Trust Inquiry. Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009. 2010.

3 National Advisory Group on the Safety of Patients in England. A Promise to Learn – a Comittment to Act. Improving the Safety of Patients in England. 2013.

4 Braithwaite, J., Wears, R.L., Hollnagel, E. Resilient health care: turning patient safety on its head, International Journal for Quality in Health Care, 2015;27(5):418–420.

 

 

This project is funded by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre (NIHR Yorkshire and Humber PSTRC). The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

In the name of safety: Identifying and letting go of low-value safety practices

By Rebecca Lawton, Gillian Janes and Abi Albutt

Why is this necessary?

Within an NHS that has an acute shortage of time and resources, the often heard demand is ‘to do more with less’. However, evidence suggests that as much as 25% of healthcare is unecessary (Grol & Grimshaw, 2003). The NHS is characterised by a tendency to add more initiatives, protocols, interventions in an attempt, at least in part, to make care safer. Such processes and practices are not always evidence based but they may become integrated in a complex healthcare system and embedded within the culture of the institution.

There is increasing recognition that some clinical procedures are unnecessary and can do more harm than good. The Choosing Wisely campaign is actively encouraging health professionals to help patients choose care that is: supported by evidence, not duplicative of other tests or procedures already received, free from harm and truly necessary (http://www.choosingwisely.org/our-mission/). This campaign and much of the work to date has focussed on the removal of health technologies (Haas et al, 2012)  and clinical practices such as specific tests and treatments that offer little or no benefit (see for example Bekelis et al 2017). In other words, the focus has been on clinical practices. However, to build a safer healthcare system, reduce costs and improve the process of care we must also consider the necessity of non-clinical safety practices, rules and procedures that do not necessarily result in safety improvements or no longer add value (Norton et al 2017). Whilst there is a lack of published evidence on this topic, making progress on this issue could also help create the space and time needed for healthcare staff to deliver more effective, patient-centred care.

How might it be achieved?

Whilst a common language for the process of removing practices that are no longer useful is still lacking (Davidoff, 2015; Bekelis 2017), terms such as decommissioning and disinvestment are often used. These reflect the top-down strategies most often deployed for this purpose by which external policy makers and commissioners decide what practices are least cost ineffective or evidence based and discourage health professionals from their use, based on funding disincentives and guidelines (Roosenhas et al 2015). This approach to influencing the clinical practice of health professionals is challenging and difficult to implement (Haas et al, 2012) with limited success thus far.  It is plausible, however, that the staff themselves might know best which safety practices are not fit-for-purpose, do not result in benefits for safety or are just not possible to implement. While the use of bottom-up processes may prove more promising, there is little evidence on how to do this work or whether staff are able to identify low value safety practices that might represent opportunities for ‘disinvestment’ in the context of safety.

Moreover, if we are able to identify low-value safety practices, we do not yet know how easy it will be for staff to ‘stop’ doing these things. Enrico Coiera (2017) uses the term ‘mindful forgetting’ to highlight the conscious decision-making process that is needed to let go of low-value practices. In other words, concerted effort may be required. For example, there may be awareness that a safety rule, process or practice is not very effective, but this doesn’t mean it will automatically be stopped (Roman and Asch, 2014).  The best way to approach the cessation or ‘mindful forgetting’ of inefficient or unhelpful safety practices in healthcare however is little understood (Niven et al 2015; Bekelis et al, 2017) and may be even more difficult for staff than the adoption of new innovations (Ubel et al 2015). It may be that the use of evidence-based behaviour change techniques could be considered to support staff in the cessation of unhelpful safety practices.

How can you get involved?

Researchers in the Yorkshire and Humber Patient Safety Translational Research Centre are working to address this evidence gap. Initially, we are seeking to understand what safety rules, processes and practices frontline healthcare staff perceive as low-value. Where the evidence supports this we will then work with staff and patients to develop interventions to support and evaluate ‘mindful forgetting’ of these in practice.

If you work in frontline patient care and would like to contribute to this new patient safety initiative, tell us your example(s) of low-value safety rules, practices or processes for consideration.

Tell us here

 

References

Bekelis K; Skinner J, Gottlieb D, Goodney P (2017) et al  De-adoption and exnovation in the use of carotid revascularization: retrospective cohort study BMJ 359:j4695 doi: 10.1136/bmj.j4695

Choosing Wisely campaign http://www.choosingwisely.org/our-mission/

Coeira E (2017) The Forgetting Health System Learn Health Sys. 1:e10023 https://doi/org/10/1002/lrh2.10023

Davidoff F (2015) On the Undiffusion of Established Practices  JAMA Internal Medicine 175(5): 809-811

Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients’ care Lancet 362(9391): 1225-1230

Haas  M, Hall J, Viney R, Gallego G (2012) Breaking up is hard to do: why disinvestment in medical technology is harder than investment  Australian Health Review 36(2): 148-152

Roman BR, Asch DA (2014) Faded promises: the challenges of de-adopting low-value care Ann Intern Med 161(2): 149-151

Roosenhas L, Owen-Smith A, Hollingworth W, Badrinath P, Beynon C, Donovan JL (2015) “I won’t call it rationing…”:’ An ethnographic study of healthcare disinvestment in theory and practice Social Science and Medicine 128: 273-281

Ubel PA, Asch DA, Chase C (2015) Commentary: Creating Value in Health by Understanding and Overcoming Resistance to De-Innovation Health Affairs 34(2): 239-244