On the Radar

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On the Radaraustralian commission on safety and quality in health care logo with radar image

Issue 216

30 March 2015

On the Radar is a summary of some of the recent publications in the areas of safety and quality in health care. Inclusion in this document is not an endorsement or recommendation of any publication or provider. Access to particular documents may depend on whether they are Open Access or not, and/or your individual or institutional access to subscription sites/services. Material that may require subscription is included as it is considered relevant.
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On the Radar

Editor: Dr Niall Johnson niall.johnson@safetyandquality.gov.au

Contributors: Niall Johnson, Luke Slawomirski, Sue Greig
Getting It Right First Time: A national review of adult elective orthopaedic services in England

Briggs T

London: British Orthopaedic Association; 2015. p. 68.




The British Orthopaedic Association has released this report reviewing current practices and outcomes of NHS hospitals providing orthopaedic surgery in England, to identify and quantify variation in clinical outcomes, processes, patient experience, patient pathways, network arrangements, financial impacts and waiting times. It includes descriptions of a pilot project aimed at improving patient experience and care using a clinically-led approach. The pilot identified significant variations in practice and outcomes in terms of device and procedure selection, clinical costs, infection rates, readmission rates, and litigation rates.

The report argues that there is significant scope to tackle many of these variations and drive short, medium and longer- term improvements in quality of delivery (through adopting best practice), reducing supplier costs (for example of implants) and thereby generating savings.

The report team summarised the measurable impacts for orthopaedics:

Journal articles
Screening and isolation to control meticillin-resistant Staphylococcus aureus: sense, nonsense, and evidence

Fätkenheuer G, Hirschel B, Harbarth S

The Lancet.385(9973):1146-9.
Should we continue to isolate patients with vancomycin-resistant enterococci in hospitals?

Karki S, Leder K, Cheng AC

Medical Journal of Australia. 2015;202(5):234-5.


Fätkenheuer et al http://dx.doi.org/10.1016/S0140-6736(14)60660-7

Karki et al http://dx.doi.org/10.5694/mja14.00672


A pair of articles that while discussing two different forms of infection both raise questions about aspects of infection control methods.

Fätkenheuer and colleagues examine the literature around MRSA. While finding that hand hygiene and decolonisation are supported by the evidence, they argue that the case for screening and isolation are not so strongly supported. They comment that “In view of the uncertainties about the efficacy of screening and the negative effects of contact isolation, the strategy of screening and isolation cannot be regarded as a gold standard”.

In a similar vein, Karki and colleagues also pick up on the negative effects of isolation in their discussion of hospital policy on managing patients with vancomycin-resistant enterococci (VRE).

Both these papers identify that success in preventing these infections is not related to a single intervention. Their findings also remind us of the rationale behind National Safety and Quality Health Service Standard 3 – Preventing and Controlling Health Care Associated Infections. This standard was implemented in January 2013 to support the quality and safety approach to preventing patients from acquiring preventable health care associated infections and to effectively manage them when they occur using evidence based strategies.

The Standard targets areas of infection prevention and control where it is apparent that here is a difference between what the evidence says should happen in a safe health care environment and what does occur. The consistent application of the multi-faceted approach of standard precaution and transmission base precautions is a good example in both these papers of how when applied effectively they can demonstrate improvement and reduction of risk to patient safety. It also highlights the difficulty of attributing success to one intervention when there are multiple interventions applied simultaneously.

For information on the National Safety and Quality Health Service Standards, see http://www.safetyandquality.gov.au/our-work/accreditation-and-the-nsqhs-standards/

For information on the Commission’s work on healthcare associated infection, see www.safetyandquality.gov.au/our-work/healthcare-associated-infection/
Transparency When Things Go Wrong: Physician Attitudes About Reporting Medical Errors to Patients, Peers, and Institutions

Bell SK, White AA, Yi JC, Yi-Frazier JP, Gallagher TH

Journal of Patient Safety. 2015 Feb 24.




This US study sought to examine the relationship between attitudes of physicians towards open and transparent communication with patients and peers following adverse events (commonly referred to as open disclosure). Responses of 3,038 US and Canadian physicians to a survey were analysed. Predictors of attitudes supporting transparent communication included female sex, age (younger more likely), academic (vs private) practice, the belief that disclosure decreased likelihood of litigation, and the belief that system changes occur after error reporting. Doctors who believed that disclosure would decrease patient trust were less likely to agree with transparency.

The Commission supports open disclosure as, not only a patient right, but a key part of quality improvement. These findings are important in that they suggest that physician attitudes towards open disclosure depend on other attitudes which are amenable to change through education and experience.

For information on the Commission’s work on open disclosure, including the Australian Open Disclosure Framework, see http://www.safetyandquality.gov.au/our-work/open-disclosure/

There’s only one enabler; come up, help us’: staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal primary health-care settings in South Australia

Newham J, Schierhout G, Bailie R, Ward PR

Australian Journal of Primary Health. 2015 [epub].




Paper presenting results from a survey of participants from eleven Aboriginal primary health-care services in South Australia. The study sought to investigate the barriers and enablers to implementation of a continuous quality improvement (CQI) program in this setting.

The barriers were reported to exist at the macro (resource constraints and access to project support), meso (senior level management and leadership for quality improvement and the level of organisational readiness) and micro (knowledge and attitudes of staff and lack of team tenure) levels.

The survey also revealed the belief—from lived experience that—“successful and sustained implementation of CQI requires both organisational systems and individual behaviour change.”

The study recommends seeking improvements “through continuing regional level collaborations and using a systems approach to develop an integrated regional level CQI framework, which includes building organisational and clinic team CQI capacity at the health centre level”.

Development and measurement of perioperative patient safety indicators

Emond YE, Stienen JJ, Wollersheim HC, Bloo GJ, Damen J, Westert GP, et al

British Journal of Anaesthesia. 2015 [epub].




Paper reporting on a Dutch effort at developing patient safety indicators (PSIs) to support the implementation of evidence-based perioperative safety guidelines.

The project developed 11 PSIs (7 structure, 2 process and 2 outcome indicators) that were then tested 8 hospitals. The testing revealed wide variations in compliance. The authors identify various “Improvement opportunities”, including the use of perioperative stops, timely administration of antibiotics, availability of protocols on perioperative anticoagulants and on prospective risk analysis of medical equipment, presence of a surveillance system for postoperative wound infections, and a morbidity and mortality registration.

A systematic review of human factors and ergonomics (HFE)-based healthcare system redesign for quality of care and patient safety

Xie A, Carayon P

Ergonomics. 2014 2015/01/02;58(1):33-49.




Over the years a fair amount has been said about the scope for human factors and ergonomics (HFE) to change healthcare. This paper presents a systematic review examining how HFE is applied to redesign healthcare work systems and processes and improve quality and safety of care. The authors state that the evidence shows that HFE-based healthcare system redesign does have the potential to improve quality of care and patient safety. They go on to say that “Healthcare organisations need to recognise the importance of HFE-based healthcare system redesign to quality of care and patient safety, and invest resources to integrate HFE in healthcare improvement activities.”

BMJ Quality and Safety online first articles




BMJ Quality and Safety has published a number of ‘online first’ articles, including:

  • How to study improvement interventions: a brief overview of possible study types (Margareth Crisóstomo Portela, Peter J Pronovost, Thomas Woodcock, Pam Carter, Mary Dixon-Woods)

Online resources
Aboriginal and Torres Strait Islander Quality Improvement Framework and Toolkit for Hospital Staff


A toolkit designed to give hospitals a systematic approach to improving Aboriginal health service delivery. The Framework and Toolkit have been developed by the Improving the Culture of Hospitals Project which examined hospitals that were performing well in the area of Aboriginal and Torres Strait Islander health. The project explored successful programs undertaken by hospitals, within a quality improvement framework, to see how this could be replicated and sustained across a wide range of hospital environments.
[UK] NICE Guidelines and Quality Standards


The UK’s National Institute for Health and Care Excellence (NICE) has published new (or updated) guidelines and quality standards. The latest updates are:

  • NICE Quality Standard QS82 Smoking: reducing tobacco use http://www.nice.org.uk/guidance/qs82

  • NICE Quality Standard QS83 Alcohol: preventing harmful alcohol use in the community http://www.nice.org.uk/guidance/qs83

  • NICE Quality Standard QS84 Physical activity: encouraging activity in all people in contact with the NHS http://www.nice.org.uk/guidance/qs84

  • NICE Quality Standard QS85 Managing medicines in care homes http://www.nice.org.uk/guidance/qs85

  • NICE Quality Standard QS86 Falls in older people: assessment after a fall and preventing further falls http://www.nice.org.uk/guidance/qs86

  • NICE Guideline NG4 Safe midwifery staffing for maternity settings http://www.nice.org.uk/guidance/ng4

  • NICE Guideline NG5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes http://www.nice.org.uk/guidance/ng5

  • NICE Guideline NG7 Maintaining a healthy weight and preventing excess weight gain among adults and children http://www.nice.org.uk/guidance/ng7

  • NICE Clinical Guideline CG28 Depression in children and young people: Identification and management in primary, community and secondary care http://www.nice.org.uk/guidance/cg28

[UK] NICE Evidence Updates


The UK’s National Institute for Health and Care Excellence (NICE) publishes updates on their Evidence Updates site. The latest updates are on Fertility and Psychosis in children and young people. The new Evidence Updates focus on a summary of selected new evidence relevant to NICE guidelines ‘Fertility: Assessment and treatment for people with fertility problems’ (February 2013) and ‘Psychosis and schizophrenia in children and young people: Recognition and management’ (January 2013).

  • Fertility http://arms.evidence.nhs.uk/resources/hub/1043055/attachment

  • Psychosis in children and young people http://arms.evidence.nhs.uk/resources/hub/1043085/attachment

[UK] The Edge


The Edge is a free, online hub produced by NHS Improving Quality for those who are supportive of action for change in health and care. It brings together the latest thinking, learning opportunities and projects so you can learn, share, discuss and make NHS change a reality and is aimed at everyone from leaders to front line change activists, improvement specialists to educationalists and researchers to senior leaders.


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

On the Radar Issue 216

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