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PubMed2005

Real time patient safety audits: improving safety every day.

BACKGROUND: Timely error detection including feedback to clinical staff is a prerequisite for focused improvement in patient safety. Real time auditing, the efficacy of which has been repeatedly demonstrated in industry, has not been used previously to evaluate patient safety. Methods successful at improving quality and safety in industry may provide avenues for improvement in patient safety. OBJECTIVE: Pilot study to determine the feasibility and utility of real time safety auditing during routine clinical work in an intensive care unit (ICU). METHODS: A 36 item patient safety checklist was developed via a modified Delphi technique. The checklist focused on errors associated with delays in care, equipment failure, diagnostic studies, information transfer and non-compliance with hospital policy. Safety audits were performed using the checklist during and after morning work rounds thrice weekly during the 5 week study period from January to March 2003. RESULTS: A total of 338 errors were detected; 27 (75%) of the 36 items on the checklist detected >or=1 error. Diverse error types were found including unlabeled medication at the bedside (n = 31), ID band missing or in an inappropriate location (n = 70), inappropriate pulse oximeter alarm setting (n = 22), and delay in communication/information transfer that led to a delay in appropriate care (n = 4). CONCLUSIONS: Real time safety audits performed during routine work can detect a broad range of errors. Significant safety problems were detected promptly, leading to rapid changes in policy and practice. Staff acceptance was facilitated by fostering a blame free "culture of patient safety" involving clinical personnel in detection of remediable gaps in performance, and limiting the burden of data collection.

Delphi Technique↗

PubMed1996

Primary hip and knee replacement surgery: Ontario criteria for case selection and surgical priority.

OBJECTIVES: To develop, from simple clinical factors, criteria to identify appropriate patients for referral to a surgeon for consideration for arthroplasty, and to rank them in the queue once surgery is agreed. DESIGN: Delphi process, with a panel including orthopaedic surgeons, rheumatologists, general practitioners, epidemiologists, and physiotherapists, who rated 120 case scenarios for appropriateness and 42 for waiting list priority. Scenarios incorporated combinations of relevant clinical factors. It was assumed that queues should be organised not simply by chronology but by clinical and social impact of delayed surgery. The panel focused on information obtained from clinical histories, to ensure the utility of the guidelines in practice. Relevant high quality research evidence was limited. SETTING: Ontario, Canada. MAIN MEASURES: Appropriateness ratings on a 7-point scale, and urgency rankings on a 4-point scale keyed to specific waiting times. RESULTS: Despite incomplete evidence panellists agreed on ratings in 92.5% of appropriateness and 73.8% of urgency scenarios versus 15% and 18% agreement expected by chance, respectively. Statistically validated algorithms in decision tree form, which should permit rapid estimation of urgency or appropriateness in practice, were compiled by recursive partitioning. Rating patterns and algorithms were also used to make brief written guidelines on how clinical factors affect appropriateness and urgency of surgery. A summary score was provided for each case scenario; scenarios could then be matched to chart audit results, with scoring for quality management. CONCLUSIONS: These algorithms and criteria can be used by managers or practitioners to assess appropriateness of referral for hip or knee replacement and relative rankings of patients in the queue for surgery.

Algorithms↗

PubMed2005

Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults - update 2004.

BACKGROUND: Gastroesophageal reflux disease (GERD) is the most prevalent acid-related disorder in Canada and is associated with significant impairment of health-related quality of life. Since the last Canadian Consensus Conference in 1996, GERD management has evolved substantially. OBJECTIVE: To develop up-to-date evidence-based recommendations relevant to the needs of Canadian health care providers for the management of the esophageal manifestations of GERD. CONSENSUS PROCESS: A multidisciplinary group of 23 voting participants developed recommendation statements using a Delphi approach; after presentation of relevant data at the meeting, the quality of the evidence, strength of recommendation and level of consensus were graded by participants according to accepted principles. OUTCOMES: GERD applies to individuals who reflux gastric contents into the esophagus causing symptoms sufficient to reduce quality of life, injury or both; endoscopy-negative reflux disease applies to individuals who have GERD and a normal endoscopy. Uninvestigated heartburn-dominant dyspepsia - characterised by heartburn or acid regurgitation - includes erosive esophagitis or endoscopy-negative reflux disease, and may be treated empirically as GERD without further investigation provided there are no alarm features. Lifestyle modifications are ineffective for frequent or severe GERD symptoms; over-the-counter antacids or histamine H2-receptor antagonists are effective for some patients with mild or infrequent GERD symptoms. Proton pump inhibitors are more effective for healing and symptom relief than histamine H2-receptor antagonists; their efficacy is proportional to their ability to reduce intragastric acidity. Response to initial therapy - a once-daily proton pump inhibitor unless symptoms are mild and infrequent (fewer than three times per week) - should be assessed at four to eight weeks. Maintenance medical therapy should be at the lowest dose and frequency necessary to maintain symptom relief; antireflux surgery is an alternative for a small proportion of selected patients. Routine testing for Helicobacter pylori infection is unnecessary before starting GERD therapy. GERD is associated with Barrett's epithelium and esophageal adenocarcinoma but the risk of malignancy is very low. Endoscopic screening for Barrett's epithelium may be considered in adults with GERD symptoms for more than 10 years; Barrett's epithelium and low-grade dysplasia generally warrant surveillance; endoscopic or surgical management should be considered for confirmed high-grade dysplasia or malignancy. CONCLUSION: Prospective studies are needed to investigate clinically relevant risk factors for the development of GERD and its complications; GERD progression, on and off therapy; optimal management strategies for typical GERD symptoms in primary care patients; and optimal management strategies for atypical GERD symptoms, Barrett's epithelium and esophageal adenocarcinoma.

Adult↗

PubMed2003

Assessing residents' competence in psychotherapy.

OBJECTIVE: This article describes the development of a method for assessing resident competence in the five forms of psychotherapy specified in the program requirements for residency training in psychiatry. METHOD: Concomitant with the rise of evidence-based medicine. There has been a movement toward evidence-based training from the Accreditation Council for Graduate Medical Education (ACGME). In the year 2000, the Residency Review Committee (RRC) for psychiatry issued specific requirements for the assessment of residency competence in five forms of psychotherapy. This article describes how a system of assessment was developed using "brainstorming" and the Delphi method to meet these requirements and gives examples of the assessment tools that were utilized. CONCLUSION: A simple system that does not overly tax limited faculty resources can be developed to meet the new RRC requirements.

Delphi Technique↗

PubMed2004

Clinical characteristics of community forensic mental health services.

OBJECTIVE: Community forensic mental health teams are a new service within the widening range of specialized community mental health services. The characteristics of these novel services are poorly defined. Two commonly described service models in the United Kingdom are the integrated model (forensic specialists working within community mental health teams) and the parallel model (forensic specialists working on a separate specialist team). The study reported here aimed to establish clear definitions of these service models. METHODS: A literature review and a focus group of ten service professionals were conducted to identify candidate characteristics of services in community forensic mental health teams. A total of 31 characteristics were identified and used to prepare the first-round questionnaire for the two rounds of a modified Delphi consultation, which is an expert opinion and consensus method, with a multidisciplinary panel of 32 mental health professionals experienced in community forensic work. RESULTS: Twenty-nine staff (91 percent) completed the two rounds of consultation. Thirteen service characteristics differentiated the integrated and parallel models. Key characteristics of parallel teams included having their own team base, separate referral meetings, a specialist management line, specialist supervision, protected funding, forensic psychology, good links with criminal justice systems, and capped caseloads. Integrated teams were distinguished by their close links with community mental health services and acceptance of more referrals from primary care. CONCLUSIONS: Integrated and parallel models of community forensic mental health teams differ on many service characteristics. Defining these characteristics will help in researching the pros and cons of each model in the treatment and risk management of mentally ill offenders in the community.

Community Mental Health Services↗

PubMed1997

The applicability of selected rational-emotive therapy principles for pastoral counseling.

Examines the compatibility and possibility of communication between pastoral counseling and Rational-Emotive Therapy (RET). Uses a Delphi technique to determine whether a randomly selected group of pastoral counselors (N = 15) believe that the basic principles of RET can be used without surrendering theological tenets foundational to pastoral counseling. Concludes that some RET principles may be applicable for pastoral counseling.

Data Collection↗

PubMed2005

Achieving consensus on leadership competencies and outcome measures: The Pediatric Pulmonary Centers' experience.

Pediatric Pulmonary Centers (PPCs) are federally funded interdisciplinary leadership training programs aiming to improve the health of families and children. This article describes the process PPCs used to efficiently and effectively achieve consensus on leadership training competencies and outcome measures among a large and diverse group of health professionals. Phase 1 used a modified Delphi technique to develop an initial set of competencies and outcome measures. Phase 2 used the nominal group technique and modified focus group strategies to refine and prioritize the competencies and outcomes measures. Participants reported being highly satisfied with the process and outcomes. In Phase 3, a formal program evaluation instrument was implemented, designed to measure the competency and describe the career paths and leadership accomplishments of previous trainees. The consensus process adopted can serve as a model for academic and public health entities seeking to achieve consensus on program goals, strategies, methods, priorities, and outcomes.

Child↗

PubMed1994

An assessment taxonomy for designing nursing research programs.

Clinical nursing research programs are a common structural component within nursing service organizations. Descriptive literature identifies many design features that are important in the development and success of organizational innovations, among which is the need to design programs that are congruent with the overall organization. Two exploratory Delphi studies were conducted to identify and classify organizational attributes that clinical nurse researchers considered critically important to the success of nursing research programs. Nadler and Tushman's Congruence Model for Organization Analysis was used as a framework to develop an assessment taxonomy for classification of the 64 critically important attributes identified by clinical nurse researchers.

Clinical Nursing Research↗

PubMedDate not supplied

Keeping birth normal: research findings on midwifery care during childbirth.

OBJECTIVE: This study describes processes and outcomes of midwifery care through narratives told by exemplary midwives. DESIGN: Narrative analysis. SETTING: Midwifery practices in hospital, birth center, and home settings. PARTICIPANTS: Purposive sample of 14 midwives drawn from a large national Delphi panel on exemplary midwifery practice. DATA ANALYSIS: Systematic analysis of interview data was conducted until interpretive consensus was achieved across all text and codes. Results were compared with two prior qualitative studies conducted by the first author on midwifery practice for congruence and emergence of new findings. RESULTS: The support of normalcy was identified as a significant process of midwifery care during labor and birth. CONCLUSIONS: The midwives believed that birth is normal, and many of their actions were specifically aimed toward the support of it as a physiologic, rather than pathologic, process. Through their words, we see subtle care processes focused on meeting a woman's individual needs and tapping into her personal strength. Implications for practice and further research to link their approach to caring for women with perinatal outcomes are reviewed.

Adult↗

PubMed1990

The development of a points system to compare the potential running costs of different development options for new hospitals.

The points system provides a simple method of assessing the design aspects of health care facilities which have a significant influence on their eventual operating costs. It is intended to assist planning teams working in the early stages of designing a health care facility. The system offers a systematic form of analysis which should be used in the preparation of development proposals as an aide-memoir, and as a method of comparing and evaluating alternative design solutions. It comprises seventeen worksheets which should be used by planning teams as a checklist of Design for Reduced Operating Costs factors. The system was developed by using the 'delphi' methodology and has been tested in a series of repeatability tests and field trials; and it is now being used for developments within the NHS.

Costs and Cost Analysis↗

PubMed1996

Policy options for a regulatory body for nursing in South Africa.

This article describes the use of a Policy Delphi to explore the options for restructuring the regulatory body for nursing in South Africa. Two rounds using postal questionnaires were used, the second of which also included group interviews. Aspects such as the statutory home of the body, its structure, who should appoint or elect members, and its composition, were explored. To a large extent, there was agreement on many issues. It would seem that this approach to consulting the profession is a profitable one, which informs while it consults.

Attitude of Health Personnel↗

PubMedDate not supplied

A survey of pediatric oncology nurses' perceptions of parent educational needs.

Educating parents of children with cancer is a primary nursing responsibility in pediatric oncology. A survey using Delphi techniques was conducted with nurses attending a Children's Oncology Group Nursing Workshop to identify priority educational topics from pediatric oncology nurses' perspective. In round 1 of the survey, nurses were asked to identify 5 priority educational topics and 5 topics they spend the most time teaching parents. Twenty-four educational categories were identified by 199 nurses, and responses were sorted by category and frequencies tabulated. Information about treatment was the most frequently cited priority. Bone marrow suppression (BMS) was the second most important priority and was the topic nurses spent most time in teaching. Round 2 of the survey was sent via e-mail to 132 consenting participants from round 1. Nurses were asked to rate the importance of the categories from round 1 (presented in random order) during 4 time periods (diagnosis, initial treatment, maintenance, and off therapy). Nurses reported different teaching priorities across the continuum of treatment. Of note, teaching about end-of-life issues and alternative therapy were ranked as low in importance across all time points. These findings can be used to inform educational programs and materials development for parents of children with cancer.

Adaptation, Psychological↗

PubMed1996

Swedish Health care personnel's perceptions of disease and treatment-related problems experienced by children with cancer and their families.

In recent decades, the intensification of treatment of children with cancer has resulted in a considerable increase in the number of those cured. The intensive treatment has also led to several problems for the children and their families. The aim of the present study was to identify the physical, psychological, social, and existential problems; symptoms and inconvenience caused by the disease and treatment or the hospital stay determined by Swedish health care personnel to be the most troublesome for children with cancer and their families. A modified three-round Delphi technique was used. In this way, 207 different problems were identified by 24 health care personnel. According to the personnel, the child is most troubled by physical symptoms, and family members are most troubled by feelings of anxiety about future events or possible events. The personnel interpreted the family members' problems as significantly worse than the child's. The results are related to the age and the diagnosis of the child.

Adult↗

PubMed1993

Setting a research agenda to promote nursing research.

This study is a first step in the process of focusing research efforts in a developing nursing research program. A two-round Delphi technique, a method for formulating consensus, was employed to address the aim of organizationally reaching consensus regarding nursing research priorities. Questionnaires were mailed to "experts," defined as all registered nurses within the division (N = 634). Round 1 respondents identified 609 different research items, which were then sorted and categorized into a 100-item Round 2 questionnaire. Research directives and program planning will center around the priority areas.

Delphi Technique↗

PubMed2002

Personal and professional characteristics of exemplary school nurses.

This article describes a study conducted to identify the professional and personal characteristics of exemplary school nurses. During Phase 1 of the study, a content analysis was completed using nomination portfolios of 10 school nurses who were selected as School Nurse of the Year from 1986 to 1998 in the state of New York. Further content analyses were conducted using transcriptions of a focus group and individual open-ended interviews with exemplary school nurses. These analyses yielded 54 personal characteristics and 74 professional characteristics of exemplary school nurses. Using a Delphi technique in Phase 2 of the study, these characteristics were validated and refined by a national sample of exemplary school nurses who had been chosen to be their state nominees for the National Association of School Nurses' School Nurse of the Year award. Descriptive data were collected on the organizational/structural characteristics of the school systems in which these nurses practiced and on the nurses' individual characteristics. This article identifies areas for clinical and research use of the study's findings.

Adult↗

PubMedDate not supplied

Crossing the quality chasm: the role of information technology departments.

Integrating information technology (IT) into medical settings is considered essential to transforming hospitals into 21st-century health care institutions. Yet the role of IT departments in maximizing the effectiveness of information systems is not well understood. This article reports a 3-round Delphi panel of Veterans Administration personnel experienced with provider order entry electronic systems. In round 1, 35 administrative, clinical, and IT personnel answered 10 open-ended questions about IT strategies and structures that best support successful transformation. In round 2, panelists rated item importance and ranked proposed strategies. In round 3, panelists received aggregate feedback and rerated the items. Four domains emerged from round 1: IT organization, IT performance monitoring, user-support activities, and core IT responsibilities (eg, computer security, training). In rounds 2 and 3, IT performance monitoring was rated the most important, closely followed by clinical support. Strategies associated with each domain are identified and discussed.

Adult↗

PubMedDate not supplied

Quality of vision: A consensus building initiative for a new ophthalmologic concept.

PURPOSE: Many studies have addressed the quantification of visual acuity, and the conventional method of measuring it has so far demonstrated serious limitations. Vision testing requires new methods that can more precisely express the quality of vision as perceived by the patient. METHODS: This study employed the Delphi method of consensus building. Concepts associated with quality of vision (QoV) were identified by a board of experts and proposed to participating specialists in two subsequent questionnaires. Upon receipt of the completed questionnaires, the replies were classified to determine the building blocks of a consensus. RESULTS: By analyzing the replies to the two questionnaires, the authors determined the key elements of QoV on which a consensus was found among the respondents. CONCLUSIONS: A consensus was reached on the opinion that the quantification of visual acuity by traditional means is inadequate for investigating QoV. Although visual acuity is still a basic element for testing, the experts believe that contrast sensitivity, reading speed, and microperimetry are additional parameters necessary for quantifying QoV. The use of a psychometric questionnaire on visual function could allow a better interpretation of visual impairment.

Consensus↗

PubMed1999

Consensus development methods: a review of best practice in creating clinical guidelines.

BACKGROUND: Although there is debate about the appropriate place of guidelines in clinical practice, guidelines can be seen as one way of assisting clinicians in decision-making. Given the likely diversity of opinion that any group of people may display when considering a topic, methods are needed for organising subjective judgements. Three principal methods (Delphi, nominal group technique, consensus development conference) exist which share the common objective of synthesising judgements when a state of uncertainty exists. OBJECTIVES: To identify the factors that shape and influence the clinical guidelines that emerge from consensus development methods and to make recommendations about best practice in the use of such methods. METHODS: Five electronic databases were searched: Medline (1966-1996), PsychLIT (1974-1996), Social Science Citation Index (1990-1996), ABI Inform and Sociofile. From the searches and reference lists of articles a total of 177 empirical and review articles were selected for review. RESULTS: The output from consensus development methods may be affected by: the way the task is set (choice of cues, recognition of contextual cues, the focus of the task, the comprehensiveness of the scenarios); the selection of participants (choice of individuals, degree of homogeneity of the group, their background, their number); the selection and presentation of scientific information (format, extent to which its quality and content is assessed); the way any interaction is structured (number of rating rounds, ensuring equitable participation, physical environment for meetings); and the method of synthesising individual judgements (definition of agreement, rules governing outliers, method of mathematical aggregation). CONCLUSIONS: Although a considerable amount of research has been carried out, many aspects have not been investigated sufficiently. For the time being at least, advice on those aspects has, therefore, to be based on the user's own commonsense and the experience of those who have used or participated in these methods. Even in the long term, some aspects will not be amenable to scientific study. Meanwhile, adherence to best practice will enhance the validity, reliability and impact of the clinical guidelines produced.

Benchmarking↗