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- Fernholm, Rita, et al.
(author)
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Financial incentives linked to quality improvement projects in Swedish primary care : a model for improving quality of care.
- 2019
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In: BMJ open quality. - : BMJ Publishing Group Ltd. - 2399-6641. ; 8:2
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Journal article (peer-reviewed)abstract
- Background: Quality improvement (QI) is necessary in all healthcare, but quality of healthcare is hard to measure. To use financial incentives to improve care is difficult and may even be harmful. However, conducting QI projects is a well-established way to increase quality in healthcare.Problem: In 2015, there were few QI projects conducted in primary care in the Stockholm Region, Sweden. There was no structured support or way to share the QI projects with other general practitioner (GP) practices. To use financial incentives could increase the number of projects performed and could possibly improve the quality of care. The aim was to increase the number of GP practices performing QI projects in the Stockholm Region through financial incentives.Method: To study QI projects performed during 2016 and 2017 in the Region Stockholm. This was compared with 2015 in Stockholm and with the Region Jönköping in Sweden during 2016 and 2017.Interventions: First, the healthcare administration started to reimburse GP practices for conducting and reporting QI projects in 2016. Second, a 4-hour course in QI was offered. Third, feedback on plans for QI projects was given. The year after the projects were prerformed, they were published online to stimulate sharing and inspiration between the GP practices.Results: For 2016, there were 166 (80%) of the GP practices that presented a QI project and in 2017, 164 (79%) did so. The number of projects in Stockholm increased almost by 100 per years compared with 2015.Conclusion: QI work has increased in Stockholm since 2016, probably because of the financial incentives from the Stockholm Region.
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| 2. |
- Fernholm, Rita
(author)
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Patient safety in primary and emergency care
- 2020
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Doctoral thesis (other academic/artistic)abstract
- This thesis explores aspects of risk and safety in health care. Patient safety is about preventing harm to patients. A perspective of resilience is used, which is a proactive approach to making care safer. Resilient organisations recognise the fact that work is done in a complex and adaptive system that can be improved, not only by studying what goes wrong, but even more so by studying what works well. The thesis adds to previous research by studying patient safety in first-contact care, primary health care and the emergency department, resulting in new knowledge that could be used to make care safer. We investigated reported preventable harm and serious safety incidents in primary health care and in emergency departments (Study I). In these contexts, diagnostic error was the most common type. A diagnostic error is when a patient does not receive the correct diagnosis within a reasonable timeframe when there were clear opportunities to establish the correct diagnosis. The consequence is delayed adequate treatment. There is limited knowledge of the panorama of diagnoses that are involved in diagnostic errors. We explored the diagnoses that were most frequent in this material. Cancer was the most common missed diagnosis in primary health care, in particular colorectal cancer, and fractures were the most common missed diagnoses in the emergency departments. Furthermore, little is known about patient-related risk factors for preventable harm. We explored factors associated with an increased risk of reported pre- ventable harm, or serious safety incidents, in primary health care and in the emergency departments (Study II). The most prominent risk was psychiatric disease. This was, to our knowledge, the first study in an out-patient setting, with all types of psychiatric diseases. This thesis also examines what patients and health care professionals per- ceived as the major risks in primary health care and what solutions they would prefer (Study III and IV). Solutions generated from the people in the system are likely to be more accurate and easier to implement than top- down solutions. In Study III, qualitative analysis of free-text answers to structured questionnaires was performed. The results were used to build a survey for Study IV, where specified risks and solutions were rated accord- ing to importance. Regarding risks, the areas that were thought to need most improvement were continuity of care, communication and knowledge. Solutions included: information about what to do when tests were fine, but symptoms remained, so called safety-netting; the use of a nationwide medication record online; and a personal doctor with a restricted number of patients per doctor, to facilitate continuity of care. These studies support future work for safer and more resilient health care. There were suggestions from the level of the general practice up to the national level. Further research should test interventions that proactively support systems in improved accuracy in diagnosis and correct medication, for example, an intervention to improve continuity of care or to practice safety-netting. Proactive interventions like these could probably improve the resilience of the system in question.
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| 3. |
- Fernholm, Rita, et al.
(author)
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Patients' and clinicians' views on the appropriate use of safety-netting advice in consultations : an interview study from Sweden
- 2023
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 13:10
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Journal article (peer-reviewed)abstract
- Background A promising approach to manage clinical uncertainty and thereby reduce the risk of preventable diagnostic harm is to use safety-netting advice (ie, communicating structured information to patients about when and where to reconsult healthcare).Aim To explore clinicians’ and patients’ views on when and how safety-netting can be successfully applied in primary-care and emergency-care settings.Design and setting An exploratory qualitative research design; we performed focus groups and interviews in a Swedish setting.Participants Nine physicians working in primary or emergency care and eight patients or caregivers participated. The participants were an ethnically homogeneous group, originating from Western European or Australian backgrounds.Method Data were analysed inductively, using the framework method. The results are reported according to the Standards for Reporting Qualitative Research guidelines for reporting qualitative research.Results In order to manage diagnostic uncertainty using safety-netting, clinicians and patients emphasised the need to understand the preconditions for the consultation (ie, the healthcare setting, the patient’s capacity and existing power imbalance). Furthermore, participants raised the importance of establishing a mutual understanding regarding the patient’s perspective and the severity of the situation before engaging in safety-netting advice.Conclusion The establishment of a shared mental model between clinician and patient of the preconditions for the clinical encounter is a vital factor affecting how safety-netting advice is communicated and received and its ability to support patients in problem detection and planning after the visit. We suggest that successful safety-netting can be viewed as a team activity, where the clinician and patient collaborate in monitoring how the patient’s condition progresses after the care visit. Furthermore, our findings suggest that to be successfully implemented, safety-netting advice needs to be tailored to the clinical context in general and to the patient–clinician encounter in particular.
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| 5. |
- Wannheden, Carolina, et al.
(author)
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Safety-netting strategies for primary and emergency care: A codesign study with patients, carers and clinicians in Sweden
- 2024
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In: BMJ Open. - 2044-6055.
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Journal article (peer-reviewed)abstract
- Objectives To codesign safety-netting strategies for primary and emergency care settings by integrating the experiences and ideas of patients, carers and clinicians. Design A codesign process involving two focus group discussions, eight individual interviews and five workshops. All sessions were audio recorded and transcribed verbatim. Data were analysed using qualitative content analysis and reported using the Consolidated criteria for Reporting Qualitative research guidelines. Setting Primary and emergency care in Sweden, focusing on the Stockholm region. Participants 7 (5 women) individuals with patient expertise, 1 (man) individual with carer expertise, 18 (12 women) individuals with clinical expertise. Results Three main categories reflecting strategies for applying safety-netting were developed: first, conveying safety-netting advice, which involves understanding patient concerns, tailoring communication and using appropriate modalities for communicating; second, ensuring common understanding, which involves summarising information, asking a teach-back question and anticipating questions post consultation; and third, supporting safety-netting behaviour, which involves facilitating reconsultation, helping patients and carers to navigate the health system and explaining the care context and its purpose. Conclusions Our study highlights the collaborative nature of safety-netting, engaging both the clinician and patient, sometimes supported by carers, in an iterative process. Adding to previous research, our study also emphasises the importance of anticipating postconsultation inquiries and facilitating reconsultation.
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