Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame.

Measurement of quality and safety has an important role in improving healthcare, but is susceptible to unintended consequences. One frequently made argument is that optimising the benefits from measurement requires controlling the risks of blame, but whether it is possible to do this remains unclear. We examined responses to a programme known as the NHS Safety Thermometer (NHS-ST).

Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England.

Introduction: Harm from catheter-associated urinary tract infections is a common, potentially avoidable, healthcare complication. Variation in catheter prevalence may exist and provide opportunity for reducing harm, yet to date is poorly understood. This study aimed to determine variation in the prevalence of urinary catheters between patient groups, settings, specialities and over time.

Learning from the design, development and implementation of the Medication Safety Thermometer.

Quality Issue: Approximately 10% of patients are harmed by healthcare, and of this harm 15% is thought to be medication related. Despite this, medication safety data used for improvement purposes are not often routinely collected by healthcare organizations over time.

Initial Assessment: A need for a prospective medication safety measurement tool was identified.

Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach.

Objectives: We aimed to evaluate whether a large-scale two-phase quality improvement programme achieved its aims and to characterise the influences on achievement.

Setting: National Health Service (NHS) in England.

Participants: NHS staff.

Target CLAB Zero: A national improvement collaborative to reduce central line-associated bacteraemia in New Zealand intensive care units.

Aim: Central line-associated bacteraemia (CLAB) is a preventable cause of patient morbidity and mortality in intensive care units. Target CLAB Zero was a national campaign that ran from October 2011 to March 2013 across all New Zealand ICUs (intensive care units). The campaign aimed to reduce the national CLAB rate to less than one incident per 1,000 line days and to establish a national measurement system for CLAB.

Learning from the design and development of the NHS Safety Thermometer.

Quality Issue: Research indicates that 10% of patients are harmed by healthcare but data that can be used in real time to improve safety are not routinely available.

Initial Assessment: We identified the need for a prospective safety measurement system that healthcare professionals can use to improve safety locally, regionally and nationally.

Choice Of Solution: We designed, developed and implemented a national tool, named the NHS Safety Thermometer (NHS ST) with the goal of measuring the prevalence of harm from pressure ulcers, falls, urinary tract infection in patients with catheters and venous thromboembolism on one day each month for all NHS patients.

Did a quality improvement collaborative make stroke care better? A cluster randomized trial.

Background: Stroke can result in death and long-term disability. Fast and high-quality care can reduce the impact of stroke, but UK national audit data has demonstrated variability in compliance with recommended processes of care. Though quality improvement collaboratives (QICs) are widely used, whether a QIC could improve reliability of stroke care was unknown.

How collaborative are quality improvement collaboratives: a qualitative study in stroke care.

Background: Quality improvement collaboratives (QICs) continue to be widely used, yet evidence for their effectiveness is equivocal. We sought to explain what happened in Stroke 90:10, a QIC designed to improve stroke care in 24 hospitals in the North West of England. Our study drew in part on the literature on collective action and inter-organizational collaboration.

There is another way: empowering frontline staff caring for acutely unwell adults.

Quality Problem Or Issue: It is estimated that only 17% of patients survive an in-hospital cardiac arrest. Medical evidence indicates that many patients show signs of deterioration during the 24 h period prior to their cardiac arrest.

Initial Assessment: At Salford Royal NHS Foundation Trust (SRFT) 135 patients (outside critical care areas) suffered a cardiac arrest between March 2007 and April 2008.

What is the NHS Safety Thermometer?

The English National Health Service (NHS) announced a new programme to incentivize use of the NHS Safety Thermometer (NHS ST) in the NHS Operating Framework for 2012/13. For the first time, the NHS is using the Commissioning for Quality and Innovation (CQUIN) scheme, a contract lever, to incentivize ALL providers of NHS care to measure four common complications (harms) using the NHS ST in a proactive way on one day per month. This national CQUIN scheme provides financial reward for the collection of baseline data with a view to incentivizing the achievement of improvement goals in later years.

The imperative to improve safety in NHS healthcare organisations.

Since the publication of a report on learning from adverse events in the NHS a decade ago, healthcare organisations have signed up to programmes to improve safety, investing staff, time and other resources in systems for reporting events and developing processes to ensure better outcomes. This article highlights initiatives that build on this work.

Reducing Clostridium difficile infection in acute care by using an improvement collaborative.

Problem: In 2006, despite a focus on infection control, Salford Royal had the fourth highest rate of Clostridium difficile infection in north west England.

Design: Interrupted time series in five collaborative wards (intervention group) and 35 non-collaborative wards (control group).

Setting: University teaching hospital with 850 acute beds.

Spatiotemporal visualizations for the measurement of oropharyngeal transit time from videofluoroscopy.

Videofluoroscopy remains one of the mainstay methods for clinical swallowing assessment, yet its interpretation is both complex and subjective. This, in part, reflects the difficulties associated with estimation of bolus transit time through the oral and pharyngeal regions by visual inspection, and problems with consistent repeatability. This paper introduces a software-only framework that automatically determines the time taken for the bolus to cross 1-D anatomical landmarks representing the oral and pharyngeal region boundaries ( Fig.

Predicting aspiration after hemispheric stroke from timing measures of oropharyngeal bolus flow and laryngeal closure.

Deglutitive aspiration is common after stroke, affecting up to 50% of patients and predisposing them to pneumonia, yet it is virtually impossible to predict those patients at greatest risk. The aim of this study was to develop a robust predictive model for aspiration after stroke. Swallowing was assessed by digital videofluoroscopy (VF) in 90 patients following hemispheric stroke.

Evaluation of a service development to implement the top three process indicators for quality stroke care.

Rationale, Aim And Objective: Stroke mortality remains unacceptably high with up to 30% of patients dying within 1 month. Early swallow screen and computerized tomography (CT) brain scan, facilitate delivery of aspirin, which together are recognized as the top three process indicators for quality stroke care. Evidence indicates that treatment with aspirin (300 mg) saves lives and should commence within 48 h of stroke onset.

Evaluating oral stimulation as a treatment for dysphagia after stroke.

Deglutitive aspiration is common after stroke and can have devastating consequences. While the application of oral sensory stimulation as a treatment for dysphagia remains controversial, data from our laboratory have suggested that it may increase corticobulbar excitability, which in previous work was correlated with swallowing recovery after stroke. Our study assessed the effects of oral stimulation at the faucial pillar on measures of swallowing and aspiration in patients with dysphagic stroke.

Awareness of dysphagia by patients following stroke predicts swallowing performance.

Patients' awareness of their disability after stroke represents an important aspect of functional recovery. Our study aimed to assess whether patient awareness of the clinical indicators of dysphagia, used routinely in clinical assessment, related to an appreciation of "a swallowing problem" and how this awareness influenced swallowing performance and outcome in dysphagic stroke patients. Seventy patients were studied 72 h post hemispheric stroke.

Differential changes in human pharyngoesophageal motor excitability induced by swallowing, pharyngeal stimulation, and anesthesia.

We investigated the effects of water swallowing, pharyngeal stimulation, and oropharyngeal anesthesia on corticobulbar and craniobulbar projections to human swallowing musculature. Changes in pathway excitability were measured via electromyography from swallowed intraluminal pharyngeal and esophageal electrodes to motor cerebral and trigeminal nerve magnetic stimulation. After both water swallowing and pharyngeal stimulation, pharyngoesophageal corticobulbar excitability increased (swallowing: pharynx = 59 +/- 12%, P < 0.

Driving plasticity in human adult motor cortex is associated with improved motor function after brain injury.

Changes in somatosensory input can remodel human cortical motor organization, yet the input characteristics that promote reorganization and their functional significance have not been explored. Here we show with transcranial magnetic stimulation that sensory-driven reorganization of human motor cortex is highly dependent upon the frequency, intensity, and duration of stimulus applied. Those patterns of input associated with enhanced excitability (5 Hz, 75% maximal tolerated intensity for 10 min) induce stronger cortical activation to fMRI.

Patterns of excitability in human esophageal sensorimotor cortex to painful and nonpainful visceral stimulation.

To better understand the relationship between cortical plasticity and visceral pain, we developed a pain-induced model of altered esophageal corticobulbar excitability. In eight healthy volunteers, corticoesophageal electromyographic responses were recorded via an intraluminal catheter, following magnetic stimulation of the right sensorimotor cortex using perithreshold intensities. Corticothenar responses were used as control.