Tag Archives: healthcare

Introducing…Safer Care Transitions

1 Jun

by Justin Waring (University of Nottingham) and Harm van Marwijk (University of Manchester)

Safer Care Transitions will be one of the research themes in the NIHR PSTRC Greater Manchester which will run from 1 August 2017 until 31 July 2022.

Safer Care Transitions blog icon

Patient journeys are full of care transitions. By transitions, we mean that the responsibility for patient care is transferred or handed over from one team, department or organisation to another.

If we think about someone who experiences an accident at work, they might be seen at first by a paramedic before being transported by ambulance to their local hospital’s emergency department. There they might receive urgent care before being admitted into the hospital for follow-up care. When recovered, the patient will then be discharged home or to community setting where they could receive rehabilitation, nursing care, social care and follow-up treatments by their GP, under the primary medical responsibility of the GP.  The GPs’ medical records can follow most of such transitions and provide an overarching view, but others (patients) cannot access such data now. GPs would be seen to have an overarching responsibility to facilitate seamless management between settings but little work has been done on this.

Transitions are common to virtually all patient journeys, because healthcare services are provided by specialists and professionals who work in different clinics, surgeries and hospitals. Although there is now better understanding of what makes for safer care within each of these care settings, there is less of a clear picture about what makes for safer care transitions between these care settings, and how to develop problem-based records that capture transitions and are accessible to more than GP practices.

There is mounting evidence from around the world that care transitions are a high-risk stage in the patient journey. Research from the US, for example, suggests that as many as two out of every ten hospital discharges will experience some form of safety incident. These safety incidents take the form of incorrect medicines, missing equipment, or inappropriate care planning.  Research within the NHS suggests that it is often difficult to coordinate the involvement of different professionals and specialists because of common communication breakdowns and the difficulties of finding time to work together to identify solutions to common problems or work from a shared and validated record. A recent Healthwatch report highlighted the enormous suffering and anxiety experienced by patients as they approach hospital discharge, often because of the uncertainties about when they will go home, who will look after them, and how they will cope. Current resources constraints within the health and social care sectors have seemed to make these problems worse, with limits on the availability of social care to support safe hospital discharge.

The Patient Safety Translational Research Centre Greater Manchester is leading a programme of research that will develop new learning about what makes for safer care transitions. It will look to ways of working and technological breakthroughs in other sectors to learn lessons for the NHS. For example, many courier and supply chain services use advanced technologies to track their deliveries. There is also greater scope to empower patients to coordinate their own care through developing smart technologies that enable them to manage and share their own records with different healthcare professionals. There is also much healthcare services could learn from other industries about ensuring continuous accountability for care, so that someone is always there to speak up for and protect the safety of patients, and ways to develop such support for the most vulnerable trajectories such as around cancer and frail older people.

The projects developed in this theme will address the safety of care transitions in primary and secondary care, in mental health services, in chronic conditions, cancer care, and end of life care, to ensure learning and innovations are shared across the health and social care sectors.

Further information:

Healthwatch (2016) Safely Home, London: Healthwatch. http://www.healthwatch.co.uk/safely-home

Waring, J., Bishop, S., & Marshall, F. (2016). A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service. BMC health services research, 16(1), 297.


Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of internal medicine, 138(3), 161-167.

The ‘triple aim’: a reality check

27 Jan

by Jonathan Stokes, Research Associate in the Centre for Health Economics at The University of Manchester


In December, I completed the final exam (or ‘viva’) for my PhD, which was funded by the NIHR Greater Manchester PSTRC. In the discussion section of my thesis, I presented an argument that my examiners suggested I should explore further, so I’m using this blog post to try and record some initial thoughts, which I hope to turn into an academic paper at some point (so feel free to post any feedback you have below).

So, my argument, briefly, was this:

  • Health systems are recognised to have a so-called ‘triple aim’, aiming to improve health and satisfaction of patients, while reducing costs. With the move towards ‘integrated care’, policymakers argue that integration can improve all triple-aim outcomes simultaneously.
  • In the NHS, integrated care is defined around the patient’s feeling of joined-up care (i.e. around the outcome of satisfaction). However, policymakers, when setting out the aims of their integrated care models aim primarily to reduce costs, usually by reducing emergency hospital admissions (probably unsurprising given the ‘NHS crisis’ currently being covered in the media).
  • But the literature tells us that the ‘triple aim’ goals are quite complexly interlinked, so achieving one does not necessarily have a beneficial effect on all of the others. For example, the highest patient satisfaction (good) is associated with the highest overall healthcare expenditure (bad), and may be also those experiencing worse health outcomes, e.g. a higher mortality rate (very bad).
  • Therefore, there is a potential conflict between the patient-level (the feeling of more joined up care for the patient) and system-level (reducing costs) goals of integrated care in the NHS, and potentially a need to prioritise aims.

Basically, there is little evidence that the ideal scenario of not having to pay for improvements in care quality is plausible (note: that doesn’t mean we can’t have this improvement, it just implies that we would need to invest more in our health system to get it). And, if we design interventions that address the NHS definition of integration and increase satisfaction with care, then we won’t necessarily meet the pressing system aims of reducing costs in the current NHS funding crisis.

So, to my mind, if we want to contain costs, this would mean that the patient satisfaction aim (while still important, and should continue to be measured) should be bumped down the priority. This is partly because people who are healthier tend to be more satisfied in any case (so it is partially a secondary outcome of better health and should take care of itself if people get better health outcomes), but also because in a tax-funded system like the NHS, where the overarching values are delivering equity and social justice, sustainability of the system is more important than preferences of the individual (i.e. ‘consumer-focused’ healthcare). Especially when aiming primarily for satisfaction of the individual harms the system.

To try and explain why this might be, imagine that if we’re primarily aiming to improve satisfaction with care, implementing an intervention where we gave everyone a dram of whisky as they waited for their appointment might send satisfaction rates through the roof, but it would cost a fortune and might not do people’s health a lot of good.

Healthcare is a complicated process (which is why it takes so long to train healthcare professionals, who in fact never stop receiving training during their working lives). One of the ‘market failures’ in healthcare (i.e. why a normal economic free-market system, where the consumer decides, doesn’t work) is ‘information asymmetry’ (i.e. the expert knows more than others, so can make the more informed decisions). While this asymmetry is clearly in patients’ favour in some aspects (e.g. experience of disease/ experience of using health services/ treatment burden etc.), it favours the physician/expert in others (e.g. treatment course in many cases/ health system setup or organisation/ cost of care etc.). The patient is therefore not likely to make the most informed decision when it comes to overall health system costs.

In view of this, I think there’s an interesting debate to be had about the role of ‘patient-centred’ care more widely, and how this fits with our system goals. For example, I went to a seminar the other day where an NHS Vanguard programme talked about how they were shifting their approach in patient care to one where they ask the patients to define their goals, asking them ‘What matters to you?’. But, before that, we’d had a talk from NHS England about the national metrics that the Vanguards would be assessed on, centred on system goals (again, primarily about reducing avoidable emergency hospital admissions). This got me thinking: what if the patient’s goal is something that doesn’t affect our system goals whatsoever, or is even completely contrary to these? If it was in the USA, the patients themselves (or their health insurer) would pay for the option and it wouldn’t matter so much, but in a tax-funded system there is more need to think resourcefully at this wider system level (and try being poor and getting decent healthcare in the USA if you think that’s the way to go instead).

The role of the patient in influencing/defining research priorities could be another debate. For example, the PSTRC and wider NIHR funders are very focused on Public and Patient Involvement (PPI) in research. But, what if the researcher (while employing common sense, and not purely as a stereotypical ivory-tower-type) has access to more knowledge about where the current knowledge gaps are, and which questions are possible to answer and how? Is it a good use of resources to pay for the ‘lay perspective’ in all cases (or at all)? (But, of course, this is just one simplified question in the debate of the role of PPI in influencing and defining research priorities, the balance of which I hope to explore further in a future post).

In sum, I think some of the assumptions we make (in good faith, I’m sure), about the aims and delivery of health services, and research to support these services, are still open to debate. While we dwell on ideally achieving all outcomes, we neglect the reality of the need for trade-offs and priority setting. But, I’d be interested in hearing your thoughts.

Patient Safety: Blame the System?

27 Aug

by Gavin Daker-White, Research Fellow, Multimorbidity theme, NIHR Greater Manchester PSTRC, The University of Manchester

“What we’ve got here is failure to communicate” (Cool Hand Luke, 1967, Warner Bros/Seven Arts)

Part Three - Blame the system

This is the last of 3 blogs that discusses the results of a review of qualitative studies of patient safety in primary care as undertaken by researchers at the NIHR Greater Manchester PSTRC and NUI Galway. The review, published in August 2015 (and available here) examined 48 studies grouped into 5 topic areas:

  1. Patients’ perspectives around safety (8 articles)
  2. Staff perspectives on safety (14 articles)
  3. Medication safety (10 articles)
  4. Organisational or management issues (7 articles)
  5. Care transitions between primary care and hospitals (9 articles)

The story of patient safety contained in the articles reads essentially as a clash between imperfect and infallible human beings on the one hand, and standardised medical systems on the other. In the final part of the series of blogs that discuss the results of this review we examine the findings concerning the organisation and delivery of care.

Of the 48 papers included in the review, 7 were focused on systems issues and it was noteworthy that most were ethnographic in nature; that is they relied on observation and interviews by researchers examining health services settings during normal working hours. Most of these studies had staff as participants, as opposed to patients. Whereas the studies concerned with staff perceptions of patient safety also included much concerning the organisation of care, such findings were not evident in the studies where patients were interviewed. For patients, the only relevant finding was that patients appeared unaware of normal clinical protocols or procedures, against which they would have been able to gauge and judge their own experiences, e.g. of waiting to be informed of test results.

One group of findings concerned the characteristics of computer systems that could variously increase or reduce the potential for errors according to features of design or quality of stored information. In other instances it was simply that staff had not been trained properly to use new equipment or software. Procedural standardisation of all kinds could seemingly work for or against safety in different circumstances. Thus both EHRs and clinical protocols had the capacity to create an illusion or even a false sense of security. New protocols had the capacity to create additional workloads on already overworked staff and could have knock on effects that weren’t considered prior to implementation. These findings point to a need to better investigate whether a ‘one size fits all’ approach is preferable (in safety terms) as opposed to one based around the uniqueness of individual and ‘complex’ patients.

A systems approach was preeminent in the nine articles that reported findings from studies about ‘handoff’ or ‘handover’ processes between hospitals and primary care. The main problems included patients being discharged from hospital with insufficient information or medical supplies (e.g. drugs or bandages) and the vulnerable characteristics of some patients. In the same way that patients were ignorant about how processes work in primary care, GPs were perceived to view hospitals as a “kind of black box” (Russ et al., 2009) and might be uncertain about how or whether communication between care providers takes place (Arora et al., 2010).

       Across the 48 studies, the following aspects of health systems were seen to compromise or threaten patient safety in primary care:

  •        Dispersed or insufficient patient information
  •        Byzantine organizational structures
  •            Drugs and care not transferable between primary care and hospitals
  •        Non compatible systems between sectors
  •        Budgetary constraints
  •        Perceived inflexibility and irrelevance of guidelines (e.g. in multimorbidity)

The findings of the studies pointed to the following ways of improving health systems in terms of patient safety:

  • ·         Improved medical records
  •        Effective communication between primary and secondary care
  •        Better resources
  •        Reliable systems
  •        Timely accessibility and updatability of information
  •        Standardization and improvements in knowledge, regulations, reporting and processes


Arora VM, Prochaska ML, Farnan JM, D’Arcy MJt, Schwanz KJ, et al. (2010) Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study. J Hosp Med 5: 385-391.

Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ (2009) A human factors investigation of medication alerts: barriers to prescriber decision-making and clinical workflow. AMIA Annu Symp Proc 2009: 548-552.

Patient Safety: Blame the Patient?

12 Aug

by Gavin Daker-White, Research Fellow, NIHR Greater Manchester PSTRC, The University of Manchester

Cause and effect are never divided between two people
(Max Frisch, I’m Not Stiller)

Part One - Blame the patient-

According to the World Health Organisation, “Patient Safety” can be defined as the “reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.” This is the first of 3 blogs that discuss the results of a review of qualitative studies of patient safety in primary care as undertaken by researchers at the NIHR Greater Manchester PSTRC and NUI Galway. The review, published in August 2015 (and available here) examined 48 reports of studies grouped into 5 topic areas:

1. Patients’ perspectives around safety (8 articles)
2. Staff perspectives on safety (14 articles)
3. Medication safety (10 articles)
4. Organisational or management issues (7 articles)
5. Care transitions between primary care and hospitals (9 articles)

The findings of the review were seen to boil down to those that blamed patients for safety failures, those that blamed doctors and those which explained safety failures by shortfalls in clinical systems or the organisation of care. This blog looks at the role of patients in their own safety.

From the first of the 8 published studies concerned with patients’ perceptions of patient safety, it was noted how “trivial insults could eventually lead to more serious problems” (Kuzel et al., 2004). Thus, in another study the authors were explicitly concerned with the kinds of actions or processes that could be seen to maximise the impact of harm once an error had occurred (Elder et al. 2005). For example, if a patient became angry following an encounter with a health professional who refused to refer them on to a specialist, that might affect trust in doctors or future use of services.

Technology is increasingly a feature of health care. A study concerned with patient preferences regarding the notification of test results found that “privacy” and “assured confidentiality” were important concerns which could lead to suspicions around the use of new technologies (Baldwin et al., 2005). Similarly, another study showed how a kind of blind faith in Electronic Health Records (EHRs) could represent a safety risk given the awareness that “patient information in the EHR was scattered, incomplete, or inaccurate” (Baran et al., 2011).

One message that derived from this group of studies was that when patients had more experience of health services they were better equipped to identify potential risks and take steps to avoid or reduce harm. In this context, patient safety appeared as a ‘feeling’ engendered through successful relationships and encounters with health professionals.

In the 14 studies concerned with the perspectives of health service staff, the characteristics or behaviour of patients appeared as important factors seen to impact on safety. These factors also appeared important in the 10 studies focused on medication errors. Both groups of findings pointed to the difficulties encountered in consultations with patients with multiple health conditions (so-called ‘multimorbidity’) or problems related to hearing, comprehension and memory. So far as medications were concerned, some patient’s characteristics were seen to limit the likelihood of adherence to drug regimens and also created challenges for receptionists in understanding older patients’ prescription requests (Hesselgreaves et al., 2009).

In sum, the findings suggested that the following characteristics or behaviours of patients appear as threats to patient safety in primary care:

• Disadvantages (physical, educational, level of comprehension and understanding)
• Complex symptoms
• Problematic presentation
• Lack of health literacy and self-management skills
• Social circumstances (e.g. living alone)

By extension, individual patients could promote their own safety by becoming more actively involved in their own care, by taking more responsibility for their own care, by becoming better informed about their health conditions and skilled in the self-management of their symptoms. This was especially evident in research that had looked at safety around hospital discharge. However, the findings around becoming more active in health care encounters in other groups of studies (e.g. medications) were sometimes contradictory which suggests the need for further research about what works in this context. It was also clear that patients can help minimize the risks in health care by being adaptable in response to system requirements.

There is a tension evident in the findings concerning the safety ‘risks’ associated with patients, however. For example, somebody who faces disadvantages, complex symptoms or lacks social support might find it harder to manage their conditions or become more actively involved in their own care. These are issues we are exploring in ongoing research within the Multimorbidity research theme of the NIHR Greater Manchester PSTRC. In one study we are following people over time to learn about threats to safety and what patients might be able to do about them (“MAXIMUM”). In a video study for the website healthtalk.org we will explore the health care dilemmas faced by people with multiple health conditions and how they cope with health conditions in different ways.

The findings of our review can be used to inform patients more generally about how to enhance their safety in healthcare. Of course some patient characteristics that can be seen to affect safety (e.g. being cognitively impaired or living in particular social or economic circumstances) are less easy for people to do anything about themselves. However, this points to situations or circumstances in which it could be beneficial to make use of advocates or carers for maintaining safety vigilance. Alternatively, instances where staff or services need to monitor cases or processes with extra detail or care are highlighted.

The influences of health care staff on patient safety will form the next blog in this 3-part series.


Baldwin D, Quintela J, Duclos C, Staton E, Pace W (2005) Patient preferences for notification of normal laboratory test results: A report from the ASIPS Collaborative. BMC Family Practice 6: 1-7.

Baran SD, Lapin JA, Beasley JW, Smith PD, Karsh B-T (2011) Identifying Hazards in Primary Care: The Elderly Patient’s Perspective. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 55: 1130-1134.

Elder NC, Jacobson CJ, Zink T, Hasse L (2005) How experiencing preventable medical problems changed patients’ interactions with primary health care. Ann Fam Med 3: 537-544.

Hesselgreaves H, Lough M, Power A (2009) The perceptions of reception staff in general practice about the factors influencing specific medication errors. Educ Prim Care 20: 21-27.

Kuzel AJ, Woolf SH, Gilchrist VJ, Engel JD, LaVeist TA, et al. (2004) Patient reports of preventable problems and harms in primary health care. Ann Fam Med 2: 333-340.

Tsang C, Majeed A, Aylin P (2012) Consultations with general practitioners on patient safety measures based on routinely collected data in primary care. JRSM Short Rep 3: 5.

Can computer software programmes be used to help clinicians with their diagnoses?

23 Jun

by Rahul Alam, Research Associate in General Practice theme

Isabel screenshot

Figure 1 Screenshot of a differential diagnosis list

General Practitioners (GPs) and nurse practitioners in general practice are required to recall a large number of illnesses and diseases as well as a large number of tests and drugs that can be ordered and prescribed. Given such breadth, arriving at the correct diagnoses can be a difficult task, particularly when patients present with unusual symptoms. As a result, diagnostic errors can, and do, occur. One potential resource for helping clinicians to make the correct diagnoses are specialised computer software programmes, otherwise known as differential diagnosis (DDx) generators. They are aimed at helping clinicians with the diagnostic process to reduce the possibility of clinicians missing, delaying or making incorrect diagnoses. In principle, clinicians can enter the patient’s clinical symptoms and the DDx generator produces a list of potentially relevant diagnoses the clinician might want to consider (please see figure 1). This information may be utilised by clinicians as part of the differential diagnostic process to whittle the potential diagnoses down to those most likely. Isabel is one such commercially available web-based DDx generator.

However, little is known about how DDx generators will be viewed and whether they can be used by clinicians in routine practice.  There is also limited evidence on how accurate programmes like Isabel are. In order to ascertain the potential feasibility and utility (benefits) of using this program, we are conducting a small one-practice study divided into two separate components.

The first component of the study will investigate the diagnostic ‘accuracy’ of Isabel in relation to cases of diagnostic uncertainty. Two situations that are likely to involve elements of diagnostic uncertainty relate to referrals to secondary care for follow-up investigations and people who frequently attend the practice (those whose attendance rate is in the top 3% of the practice). Two GPs will review and select all cases of diagnostic uncertainty and the patient details will be entered into Isabel and compared to the final discharge diagnosis from the hospital or the final recorded diagnosis to determine Isabel’s accuracy rate.

In the second component we aim to ascertain the feasibility of clinician’s using Isabel in routine practice when diagnosing patients. We have conducted 11 interviews with 9 GPs and 2 nurse practitioners to ascertain their views and experiences of using a differential diagnosis tool such as Isabel.  We then trained all clinical staff at the practice to use Isabel and they have now had a 6-month opportunity to use Isabel. A remote monitoring system captured wider data such as usage rates, links accessed and time taken to use. We are now conducting post-use interviews with the clinicians to obtain their feedback and opinions on Isabel as a diagnostic aide in routine general practice.

We hope that the findings of the two components of this study can help assess the diagnostic accuracy of Isabel in UK general practice as well provide useful insights in to the feasibility of utilising Isabel in routine clinical practice.