Qualitative data from staff demonstrated a degree of staff acceptability to using the survey, including belief that patient feedback from the survey could be used for service improvement, which in turn can contribute to a culture of continuous learning. Quantitative feedback was seen to serve the purpose of indicating where there may be problems, and qualitative feedback to inform the types of changes required to improve care. However, staff within this study did not appear to engage in qual- ity improvement activities based on patient experiences of safety, and we are therefore only able to conclude that patient feedback on their safety could lead to quality im- provement, but that other individual, structural, proced- ural and cultural conditions are required to be met first.
Furthermore, codesigning a feedback mechanism ensures that it meets the requirements of different groups of users; in the case of this study, patients who are required to understand and complete the questions, and healthcare professionals who are required to collect and learn from the feedback provided. Codesign was particularly important given the differences that exist in patients ’ and healthcare professionals ’ understandings of safety, and provided an opportunity for shared learn- ing. Despite these bene ﬁ ts of using codesign, we did encounter challenges associated with the approach, including personal agendas and dominant voices. Prior to the ﬁ rst workshop, we developed inclusive strategies such as post-it notes and ﬂ ipchart paper that would enable both patient and healthcare professional partici- pants to have their voice heard, even if it was not audible. 38 The issue of personal agendas among partici- pants, where they would attempt to overly in ﬂ uence the direction of discussion, was a greater challenge. In a sys- tematic review of the impact on patient involvement on research, personal experience stories that dominated dis- cussions were identi ﬁ ed to be a challenge. 39 In order to resolve this, we used the Thinking Differently toolkit in workshop 2 to provide focus for all participants by directing thoughts and discussions to situations equally familiar to all, thus reducing the available space in which individuals could dominate discussions.
Most efforts to involve patients in safety relate to care delivered in a relatively stable secondary care setting, 16 17 in which a single provider is responsible for patient safety. There has been less attention, however, to patient experiences of safety in relation to a transition between organisations, de ﬁ ned as patients moving or being moved from one level of care to another or across different care settings. 18 The safety implications for care transitions are shown to be complex, resulting from the dif ﬁ culties of working across organisational boundaries and leading to speci ﬁ c threats to safety and potential for readmission. 19 20 With no one service having overall responsibility for the patient, existing safety systems are negated. In addition, with failures between organisations common, 21 organisational care transitions arguably increase the risk to patients due to de ﬁ cits in communi- cation and information transfer which negatively impact on patients ’ continuity of care. 22 In Switzerland, it has been reported that poor coordination of care, albeit not necessarily directly related to care transitions, was the most important risk factor about which patients could providefeedback. 23 As the patient experiences the total- ity of the transition, there is an opportunity for patients to be involved in the safety of their care by providing a unique perspective on their transition and the continu- ity of care otherwise unavailable to healthcare profes- sionals. While there are an increasing number of international studies published that have sought to obtain patient perspectives on their transitions between organisations, 24 25 no known studies have developed, with patients and clinicians, a structured approach to collecting patient feedback on safety experiences in rela- tion to organisational care transitions.
Furthermore, codesigning a feedback mechanism ensures that it meets the requirements of different groups of users; in the case of this study, patients who are required to understand and complete the questions, and healthcare professionals who are required to collect and learn from the feedback provided. Codesign was particularly important given the differences that exist in patients ’ and healthcare professionals’ understandings of safety, and provided an opportunity for shared learn- ing. Despite these bene ﬁts of using codesign, we did encounter challenges associated with the approach, including personal agendas and dominant voices. Prior to the ﬁrst workshop, we developed inclusive strategies such as post-it notes and ﬂipchart paper that would enable both patient and healthcare professional partici- pants to have their voice heard, even if it was not audible. 38 The issue of personal agendas among partici- pants, where they would attempt to overly in ﬂuence the direction of discussion, was a greater challenge. In a sys- tematic review of the impact on patient involvement on research, personal experience stories that dominated dis- cussions were identi ﬁed to be a challenge. 39 In order to resolve this, we used the Thinking Differently toolkit in workshop 2 to provide focus for all participants by directing thoughts and discussions to situations equally familiar to all, thus reducing the available space in which individuals could dominate discussions.
Patient influence over research may help shift away from a problem-centred approach towards investigation of people’s strengths and capabilities (Baxter et al. 2001). This approach fits well with current moves towards partnership with patients, as stated in Standard One of the UK National Service Framework for Renal Services: a patient-centred service (Department of Health 2004). In this study, the research group oversaw all aspects of the research process, from the early stages, through face-to-face meetings and e-mail contact. Active patient involvement within the research team helped maintain the focus on patient experience within the context of their everyday lives, and reduced the tendency for the professionals to overemphasise the clinical and treatment aspects of the transition to dialysis. To ensure confidentiality, access to transcripts was not available to haemodialysis patient team members, and participant anonymity was maintained throughout.
Patient influence over research may help shift away from a problem-centred approach to a ds i estigatio of people s st e gths a d apa ilities (Ba te et al. 2001). This approach fits well with current moves towards partnership with patients, as stated in Standard One of the UK National Service Framework for Renal Services: a patient-centred service (Department of Health 2004). In this study, the research group oversaw all aspects of the research process, from the early stages, through face-to-face meetings and e-mail contact. Active patient involvement within the research team helped maintain the focus on patient experience within the context of their everyday lives, and reduced the tendency for the professionals to overemphasise the clinical and treatment aspects of the transition to dialysis. To ensure confidentiality, access to transcripts was not available to haemodialysis patient team members, and participant anonymity was maintained throughout.
percentile for gender and age. We did not measure BMI at the end of 12 weeks as this study focused on feasibility. BMI will be a future measurement of program outcomes.
We have shown that a community-based diabetes prevention group for youth and their families is feasible and positively received by participants. We found that many families want this service but struggle to take advantage of it due to difficulties with transportation, work schedules and other competing priorities. Families that did attend regularly continued to engage in the program past the 12 week curriculum cycle. Satisfaction surveys indicate that families enjoy the physical activity, cooking sessions and social support provided by the group setting.
The establishment of good process safety management (PSM) is widely considered as the most effective means of improving safety levels in process industries. This study was conducted to evaluate the feasibility of establishing and implementing PSM requirements based on Occupational Health and Safety Assessment Series 18001 standards (OHSAS 18001) and Health, Safety and Environment management systems (HSE-MS) in an Iranian petrochemical plant. Firstly, the requirements of PSM, OHSAS 18001 standards and HSE-MS were compared via literature review and their levels of agreement were determined. Next, the degree of implementation of PSM requirements at a selected petrochemical site was investigated. The study’s results show that PSM requirements complied with HSE-MS to a greater degree than with OHSAS 18001 standards. Although the plant studied had not yet formally applied process safety management requirements, based on the HSE-MS and OHSAS 18001 it had already applied, 67% of PSM requirements had in effect been put in place. By revising certain requirements of existing management systems, including PSM requirements in them, and providing the outstanding necessary documentation, this study concludes that the establishment of a PSM system in the plant is feasible.
Patients appreciated the interest and the attention they received in the project. The results of the randomized controlled study of Allen et al.  confirm that volun- teers could be trained to deliver an intervention achiev- ing improvements in outcome similar to the results found with other providers. High motivation and dedica- tion of the volunteers were perceptible throughout the whole project. Volunteers were very reflective and dem- onstrated capability for introspection. However, compar- ing the answers in the questionnaire with the guided interview some discrepancies in self-reported skills and appraisal of biography work were seen. Even though vol- unteers characterized themselves as good or rather good listeners in the questionnaire the evaluation of the inter- views highlighted that listening was not attentive enough and that silence was hard to bear. In contrast, four vol- unteers expected difficulties in the interview in the ques- tionnaire, but the evaluation of the interviews showed no such problems. None of the volunteers expected diffi- culties in writing the story but four volunteers reported technical difficulties, time exposure, and problems with the outline of the story.
also regarding the number of treatment sessions. This heterogeneity could be considered as a methodological limitation. On the other hand, this heterogeneity might give first hints on potential indications and general applic- ability of the procedure in different groups of patients with severe liver failure. Furthermore, any reporting bias could be avoided, since we reported on all patients who have ever been treated with ADVOS in our ICU. Despite feasi- bility, safety and efficacy of the intervention, the overall outcome was poor, which might be related to the use of ADVOS as a rescue therapy in this study which predom- inantly included patients without the option to undergo LTX. Another limitation is the low number of patients in- cluded that precludes more robust conclusions regarding the outcome. Conclusions regarding the outcome are fur- ther limited by the lack of a randomized control group or matched controls. Finally, even in case of randomized controls the statistical power would be low due to the re- stricted number of comparisons.
Believing in every examinee’s right to total concentration during the assessment, I will do my best to provide and maintain an environment conducive to assessment.
I shall administer assessments only in areas where I have the competence.
I shall not allow the competency assessment to be an instrument for corruption.
One of the key challenges in developing eﬀective PPDPs linked to individual appraisal and personal development planning is not only to identify, but also to record existing knowledge and skills, and future CPD needs of the entire primary care workforce. The implementers in this study identiﬁed this as an im- portant issue, and helped to develop documentary templates and systems to enable recording and access of key information. However, the notion that PDPs could be accessible to PCTs and not just the appraisee and appraiser was understandably met with resistance in some quarters. Implementers reported that this resistance was either due to a perceived challenge to GPs’ independence, or an expressed insecurity about not achieving the goals outlined in a PDP. Arguably, it is essential that PDPs and CPD needs are made explicit and linked to the needs of the practice setting if eﬀective PPDPs are to be developed in the future. 5 One way to accomplish this aim is through a trans- parent and accessible system that identiﬁes priorities and at the same time respects conﬁdentiality and professional integrity.
The Ministry of Health has introduced various programs to transform NCD care including the ‘Reviewed Approach’ in 2007 7 which incorporated chronic disease screening as well as the introduction of a National Diabetes Registry (NDR) in the public primary healthcare system. Another initiative was the NCD Prevention-1Malaysia (NCDP-1M), which has introduced positive changes at the ground level to improve chronic disease delivery of care including PHC dedicated clinics specifically for T2DM and HPT. 7 Despite struggles and attempts by the policy makers and public healthcare providers to provide the best care for NCD patients, many fall short due to the high workload and constraints in resources. 5 Shortages in trained personnel impedes the implementation of a multidisciplinary team to manage NCD. 5,8 Limited access to newer pharmacological agents and increasing burden in the prevalence of NCD result in sub-optimal management, poor clinical outcomes and high complication rates. 4,9 A study conducted in the Malaysian public primary healthcare setting demonstrated that 52.6% of T2DM patients received sub-optimal management of related cardiovascular risk factors and these patients had poor glycaemic control. 8 With regards to treatment of HPT, a report from the 2006 NHMS III found that only 32.4% of patients were taking their antihypertensive medication and from that group, only 26.8% had their blood pressure controlled. 9
framework by improving the patient experience of care, enhancing population health, and reducing per capita health care costs. 17 A review of literature showed that no single intervention was effective in reducing hospital reuse. 18 Several studies of geriatric patients, including 2 randomized controlled trials 19, 20 suggest that caretransition bundles can increase adherence to follow-up plans and reduce hospital reuse. 21 Key components of these bundles include: use of a transitions coach, predischarge confirmation of patient/caregiver discharge readiness, caregiver education and understanding of essential components of the care plan, and a postdischarge phone call to review and clarify information. 18 – 26
Nevertheless, there are inherent limitations in our current study. Our sample size was small, meaning that our findings should be viewed as preliminary. Further- more, our data comes from healthcare professionals who owned a smartphone and could use it in their day-to- day clinical work. Our focus group participants were nurses who worked on the general surgery unit. Thus, additional studies are needed to determine whether our findings would generalize to other healthcare settings and specialties. Moreover, we have not managed to cap- ture the absolute amount of time that our participants have spent using the application. We have also not com- pared the amount of time they have send using our ap- plication against other healthcare applications. The authors acknowledge that the questions we have asked might not be comprehensive enough to capture con- cerns pertaining to the integration of M-health in delir- ium education at the bedside. The results which the authors have acquired have not assessed how such an application could have improved clinical care, as there is no further analysis done to determine if this results in a reduction in the absolute length of stay. Lastly, the au- thors have not made use of validated questionnaires to determine user perception quantitatively.
tools and technology. A key aim will be to identify areas of interest for more focused and targeted observations in sub- sequent sweeps, which will involve in-depth observations of important mechanisms such as handover, multi- disciplinary meetings and ward rounds. These will be ob- served by shadowing clinical staff and may involve short discussions and facilitated reflection from staff on aspects of the CARE model. Full descriptive field notes will be pro- duced immediately after each observational session. Par- ticipant bias caused by sensitivity to the presence of the researcher is a recognised risk in qualitative observational studies  but can be minimised by ensuring that ob- servers have frequent presence in the research setting, which can lead to habituation to their presence, re- searcher’ s sensitivity to and respect for clinicians’ concerns, and their ability to build relationships and trust. The re- searchers in this study are experienced in healthcare re- search, and the research team, including clinicians, will be available to discuss and resolve any emerging difficulties.
Firstly, the records are reviewed in order to detect whether they contain a trigger. If a trigger is found in a patient’s record, then it should be reviewed in more de- tail to determine whether the patient experienced any harm. For the purpose of this research study, harm is de- fined as “anything that happens as a result of interaction with health services (environment, workers, treatment) that you would not want to happen to you or your rela- tives” . If no harm is detected, or the reviewer is un- sure, they should not record the incident. If harm is detected, the reviewer should classify the severity of the harm and determine whether it was avoidable. This audit should prompt reflection, learning, and/or further action within the general practice. The reviewer should use the process to identify possible immediate actions based upon the findings of the audit (e.g. intervene to address any issue(s) with specific patients or to tackle any system hazards that are identified, identify a targeted interven- tion to prevent future occurrences). Moreover, members of the practice will also be encouraged to discuss, with their colleagues, any recent events/cases that may not have been identified in the chart review but that may have implications for patient safety. Any actions to be taken on the basis of the chart audit or in-practice dis- cussion are to be decided by the practice. The reviewer will also share their findings with the practice team in order to foster collective learning. The practices will only be asked to share summary information about the review with the researchers. This information will include the number of chart reviews, which triggers were identified, number of incidents of harm and level of severity, whether the harm was preventable, and a brief description of any measures that were taken as a result of the review.
Progressiveness is a positive variable for both market groups and therefore not an urgent matter. Since it is a stimulating variable however and respondents talked a lot about its im- portance, Nedap could consider to invest in progressiveness as part of the organisational culture anyway. Respondents have given ideas to focus on enhancing the team spirit in order to increase a feeling of trust and safety and thereby decreasing barriers to ask, provide and use feedback. It was argued that a strong team spirit positively influences the dimension excellence as part of the progressiveness. Respondents mainly gave suggestions about determining a vision of the team where team members express what they want to achieve with the team and what is important in the process towards the achievement of that vision. They also argued that celebrating suc- cesses with each other could be a boost for the team spirit and when failures come across it is expressed that it is a burden for the whole team, not just for some individuals of that team. The top management could discuss these options with all market group leaders. The market group leaders can communicate these ideas to the team captains and the other employees. Market group leaders can contribute to the feeling of unity in the market group by following the same approaches for the whole market group. When one team in the market group had a success it can be shared with the whole market group for example.
implementation of various peer-based activities is one strategy that could be used to address this barrier. The utilization of a buddy system in which patients preparing to transition are paired with someone who has already gone through the transition process could potentially alleviate some of these concerns and expectations. By being able to hear firsthand accounts of patients’ experiences with the adult care system, individuals would be able to find out whether their fears are truly justified or not. Additionally, group meetings in the pediatric setting in which individuals can freely express their concerns with other patients preparing to transition may also prove helpful. Moreover, these group meetings do not necessarily have to be something that is organized by the clinic itself. For example, the CHP Sickle Cell Clinic has a partnership with a local community-based organization, the Children’s Sickle Cell Foundation (CSCF). At specific times throughout the year, CSCF holds a month-long transition program for young adults with sickle cell disease. This program is an additional source of support and educational opportunities for continued development. Providing patients with information about this program is another resource that could be offered by the CHP Sickle Cell Clinic.