Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial

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Title: Translating staff experience into organisational improvement: the HEADS-UP stepped wedge, cluster controlled, non-randomised trial
Authors: Pannick, SAJ
Athanasiou, T
Long, SJ
Beveridge, I
Sevdalis, N
Item Type: Journal Article
Abstract: Objectives: Frontline insights into care delivery correlate with patients’ clinical outcomes. These outcomes might be improved through near-real time identification and mitigation of staff concerns. We evaluated the effects of a prospective frontline surveillance system on patient and team outcomes. Design: Prospective, stepped wedge, non-randomised, cluster controlled trial; pre-specified per protocol analysis for high fidelity intervention delivery. Participants: Seven interdisciplinary medical ward teams, from two hospitals in the United Kingdom. Intervention: Prospective clinical team surveillance (PCTS): structured daily interdisciplinary briefings to capture staff concerns, with organisational facilitation and feedback. Main measures: The primary outcome was excess length of stay (eLOS): an admission more than 24 hours longer than the local average for comparable patients. Secondary outcomes included safety and teamwork climates, and incident reporting. Mixed-effects models adjusted for time effects, age, comorbidity, palliation status, and ward admissions. Safety and teamwork climates were measured with the Safety Attitudes Questionnaire. High fidelity PCTS delivery comprised high engagement and high briefing frequency. Results: Implementation fidelity was variable, both in briefing frequency (median 80% working days/month, interquartile range 65-90%), and engagement (median 70 issues/ward/month, interquartile range 34-113). 1714/6518 (26.3%) intervention admissions had eLOS vs 1279/4927 (26.0%) control admissions, an absolute risk increase of 0.3%. PCTS increased eLOS in the adjusted intention-to-treat model (OR 1.32, 95% CI 1.10-1.58, p=0.003). Conversely, high fidelity PCTS reduced eLOS (OR 0.79, 95% CI 0.67-0.94, p=0.006). High fidelity PCTS also increased total, high yield, and non-nurse incident reports (incidence rate ratios 1.28-1.79, all p<0.002). Sustained PCTS significantly improved safety and teamwork climates over time. Conclusions: This study highlighted the potential benefits and pitfalls of ward-level interdisciplinary interventions. Whilst these interventions can improve care delivery in complex, fluid environments, benefiting team and patient outcomes, the manner of their implementation is paramount. Suboptimal implementation may have an unexpectedly negative impact on performance.
Issue Date: 18-Jul-2017
Date of Acceptance: 7-Apr-2017
ISSN: 2044-6055
Publisher: BMJ Publishing Group
Journal / Book Title: BMJ Open
Volume: 7
Copyright Statement: © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:
Sponsor/Funder: Imperial College Healthcare NHS Trust
National Institute for Health Research (NIHR)
West Middlesex University Hospital NHS Trust
Imperial College Healthcare Charity
Funder's Grant Number: RDPSC 79560
RDPSC 79560
Research Fellow
Keywords: interdisciplinary care
medical wards
patient safety
stepped wedge trial
Publication Status: Published
Article Number: e014333
Appears in Collections:Division of Surgery
Faculty of Medicine

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