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  • Journal article
    Russ SJ, Sevdalis N, Moorthy K, Mayer EK, Rout S, Caris J, Mansell J, Davies R, Vincent C, Darzi Aet al., 2015,

    A Qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England lessons from the "Surgical Checklist Implementation Project"

    , Annals of Surgery, Vol: 261, Pages: 81-91, ISSN: 0003-4932

    Objectives: To evaluate how the World Health Organization (WHO) surgical safety checklist was implemented across hospitals in England; to identify barriers and facilitators toward implementation; and to draw out lessons for implementing improvement initiatives in surgery/health care more generally.Background: The WHO checklist has been linked to improved surgical outcomes and teamwork, yet we know little about the factors affecting its successful uptake.Methods: A longitudinal interview study with operating room personnel was conducted across a representative sample of 10 hospitals in England between March 2010 and March 2011. Interviews were audio recorded over the phone. Interviewees were asked about their experience of how the checklist was introduced and the factors that hindered or aided this process. Transcripts were submitted to thematic analysis.Results: A total of 119 interviews were completed. Checklist implementation varied greatly between and within hospitals, ranging from preplanned/phased approaches to the checklist simply “appearing” in operating rooms, or staff feeling it had been imposed. Most barriers to implementation were specific to the checklist itself (eg, perceived design issues) but also included problematic integration into preexisting processes. The most common barrier was resistance from senior clinicians. The facilitators revealed some positive steps that can been taken to prevent/address these barriers, for example, modifying the checklist, providing education/training, feeding-back local data, fostering strong leadership (particularly at attending level), and instilling accountability.Conclusions: We identified common themes that have aided or hindered the introduction of the WHO checklist in England and have translated these into recommendations to guide the implementation of improvement initiatives in surgery and wider health care systems.
  • Journal article
    Russ S, Rout S, Caris J, Mansell J, Davies R, Mayer E, Moorthy K, Darzi A, Vincent C, Sevdalis Net al., 2015,

    Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study

    , Journal of the American College of Surgeons, Vol: 220, Pages: 1-11.e4, ISSN: 1072-7515

    BackgroundFull implementation of safety checklists in surgery has been linked to improved outcomes and team effectiveness; however, reliable and standardized tools for assessing the quality of their use, which is likely to moderate their impact, are required.Study DesignThis was a multicenter prospective study. A standardized observational instrument, the “Checklist Usability Tool” (CUT), was developed to record precise characteristics relating to the use of the WHO's surgical safety checklist (SSC) at “time-out” and “sign-out” in a representative sample of 5 English hospitals. The CUT was used in real-time by trained assessors across general surgery, urology, and orthopaedic cases, including elective and emergency procedures.ResultsWe conducted 565 and 309 observations of the time-out and sign-out, respectively. On average, two-thirds of the items were checked, team members were absent in more than 40% of cases, and they failed to pause or focus on the checks in more than 70% of cases. Information sharing could be improved across the entire operating room (OR) team. Sign-out was not completed in 39% of cases, largely due to uncertainty about when to conduct it. Large variation in checklist use existed between hospitals, but not between surgical specialties or between elective and emergency procedures. Surgical safety checklist performance was better when surgeons led and when all team members were present and paused.ConclusionsWe found large variation in WHO checklist use in a representative sample of English ORs. Measures sensitive to checklist practice quality, like CUT, will help identify areas for improvement in implementation and enable provision of comprehensive feedback to OR teams.
  • Journal article
    Johnston MJ, King D, Arora S, Behar N, Athanasiou T, Sevdalis N, Darzi Aet al., 2015,

    Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams

    , American Journal of Surgery, Vol: 209, Pages: 45-51, ISSN: 0002-9610

    BackgroundOutdated communication technologies in healthcare can place patient safety at risk. This study aimed to evaluate implementation of the WhatsApp messaging service within emergency surgical teams.MethodsA prospective mixed-methods study was conducted in a London hospital. All emergency surgery team members (n = 40) used WhatsApp for communication for 19 weeks. The initiator and receiver of communication were compared for response times and communication types. Safety events were reported using direct quotations.ResultsMore than 1,100 hours of communication pertaining to 636 patients were recorded, generating 1,495 communication events. The attending initiated the most instruction-giving communication, whereas interns asked the most clinical questions (P < .001). The resident was the speediest responder to communication compared to the intern and attending (P < .001). The participants felt that WhatsApp helped flatten the hierarchy within the team.ConclusionsWhatsApp represents a safe, efficient communication technology. This study lays the foundations for quality improvement innovations delivered over smartphones.
  • Journal article
    Ignatowicz A, Greenfield G, Pappas Y, Car J, Majeed A, Harris Met al., 2014,

    Achieving Provider Engagement: Providers' Perceptions of Implementing and Delivering Integrated Care

    , Qualitative Health Research, Vol: 24, Pages: 1711-1720, ISSN: 1552-7557

    The literature on integrated care is limited with respect to practical learning and experience. Although some attention has been paid to organizational processes and structures, not enough is paid to people, relationships, and the importance of these in bringing about integration. Little is known, for example, about provider engagement in the organizational change process, how to obtain and maintain it, and how it is demonstrated in the delivery of integrated care. Based on qualitative data from the evaluation of a large-scale integrated care initiative in London, United Kingdom, we explored the role of provider engagement in effective integration of services. Using thematic analysis, we identified an evolving engagement narrative with three distinct phases: enthusiasm, antipathy, and ambivalence, and argue that health care managers need to be aware of the impact of professional engagement to succeed in advancing the integrated care agenda.
  • Journal article
    Hughes-Hallett A, Mayer E, Pratt P, Mottrie A, Darzi A, Vale Jet al., 2014,

    A census of robotic urological practice and training: a survey of the robotic section of the European Association of Urology.

    , Journal of Robotic Surgery, Vol: 8, Pages: 349-355, ISSN: 1863-2483

    To determine the current state of robotic urological practice, to establish how robotic training has been delivered and to ascertain whether this training was felt to be adequate. A questionnaire was emailed to members of the European Association of Urology robotic urology section mailing list. Outcomes were subdivided into three groups: demographics, exposure and barriers to training, and delivery of training. A comparative analysis of trainees and independently practising robotic surgeons was performed. 239 surgeons completed the survey, of these 117 (48.9 %) were practising robotic surgeons with the remainder either trainees or surgeons who had had received training in robotic surgery. The majority of robotic surgeons performed robotic-assisted laparoscopic prostatectomy (90.6 %) and were undertaking >50 robotic cases per annum (55.6 %). Overall, only 66.3 % of respondents felt their robotic training needs had been met. Trainee satisfaction was significantly lower than that of independently practising surgeons (51.6 versus 71.6 %, p = 0.01). When a subgroup analysis of trainees was performed examining the relationship between regular simulator access and satisfaction, simulator access was a positive predictor of satisfaction, with 87.5 % of those with regular access versus 36.8 % of those without access being satisfied (p < 0.01). This study reveals that a significant number of urologists do not feel that their robotic training needs have been met. Increased access to simulation, as part of a structured curriculum, appears to improve satisfaction with training and, simultaneously, allows for a proportion of a surgeon's learning curve to be removed from the operating room.
  • Journal article
    Greenfield G, Ignatowicz AM, Belsi A, Pappas Y, Car J, Majeed A, Harris Met al., 2014,

    Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study.

    , BMC Health Services Research, Vol: 14, ISSN: 1472-6963

    BackgroundPerson-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient¿s world. Patient-centeredness has been commonly defined through physician¿s behaviors aimed at delivering patient-centered care. Yet, it is unclear how `person-centeredness¿ is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context.MethodsWe conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison.ResultsWe identified six themes representing core `ingredients¿ of person-centeredness in the integrated care context: ¿Holism¿, ¿Naming¿, ¿Heed¿, ¿Compassion¿, ¿Continuity of care¿, and ¿Agency and Empowerment¿, all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt `unseen¿ by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional `Space¿ to be `seen¿ and heard vs. feeling `translucent¿, `unseen¿, and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a `dyad¿, the meanings patients attributed to `care&
  • Journal article
    Russ SJ, Rout S, Caris J, Moorthy K, Mayer E, Darzi A, Sevdalis N, Vincent Cet al., 2014,

    The WHO surgical safety checklist: survey of patients' views

    , BMJ QUALITY & SAFETY, Vol: 23, Pages: 939-946, ISSN: 2044-5415
  • Journal article
    Mayer E, 2014,

    Processes of Care and the Impact of Surgical Volumes on Cancer-specific Survival: A Population-based Study in Bladder Cancer COMMENT

    , UROLOGY, Vol: 84, Pages: 1056-1056, ISSN: 0090-4295
  • Journal article
    Saddi FC, Harris M, Pego RA, Batista SR, Macinko Jet al., 2014,

    Elections could rekindle health debate in Brazil.

    , Lancet, Vol: 384, Pages: e47-e48, ISSN: 1474-547X
  • Journal article
    Mobasheri MH, Johnston M, King D, Leff D, Thiruchelvam P, Darzi Aet al., 2014,

    Smartphone breast applications - What's the evidence?

    , BREAST, Vol: 23, Pages: 683-689, ISSN: 0960-9776
  • Journal article
    Steedman MR, Hughes-Hallett T, Marie Knaul F, Knuth A, Shamieh O, Darzi Aet al., 2014,

    Innovation can improve and expand aspects of end-of-life care in low- and middle-income countries

    , Health Affairs, Vol: 33, Pages: 1612-1619, ISSN: 0278-2715

    Provision for end-of-life care around the world is widely variable and often poor, which leads to millions of deaths each year among people without access to essential aspects of care. However, some low- and middle-income countries have improved specific aspects of end-of-life care using innovative strategies and approaches such as international partnerships, community-based programs, and philanthropic initiatives. This article reviews the state of current global end-of-life care and examines how innovation has improved end-of-life care in Nigeria, Uganda, India, Bangladesh, Myanmar, and Jordan. Specifically, we examine how opioids have been made more available for the treatment of pain, and how training and education programs have expanded the provision of care to the dying population. Finally, we recommend actions that policy makers and individuals can take to improve end-of-life care, regardless of the income level in a country.
  • Journal article
    King D, Thompson P, Darzi A, 2014,

    Enhancing health and wellbeing through 'behavioural design'

    , JOURNAL OF THE ROYAL SOCIETY OF MEDICINE, Vol: 107, Pages: 336-337, ISSN: 0141-0768
  • Journal article
    Keown OP, Warburton W, Davies SC, Darzi Aet al., 2014,

    Antimicrobial Resistance: Addressing The Global Threat Through Greater Awareness And Transformative Action

    , HEALTH AFFAIRS, Vol: 33, Pages: 1620-1626, ISSN: 0278-2715
  • Journal article
    Keown OP, Parston G, Patel H, Rennie F, Saoud F, Al Kuwari H, Darzi Aet al., 2014,

    Lessons From Eight Countries On Diffusing Innovation In Health Care

    , HEALTH AFFAIRS, Vol: 33, Pages: 1516-1522, ISSN: 0278-2715
  • Journal article
    Hughes-Hallett A, Mayer E, Marcus HJ, Cundy T, Pratt PJ, Parston G, Vale JA, Darzi Aet al., 2014,

    Quantifying innovation in surgery

    , Annals of Surgery, Vol: 260, Pages: 205-211, ISSN: 1528-1140

    Objectives: The objectives of this study were to assess the applicability of patents and publications as metrics of surgical technology and innovation; evaluate the historical relationship between patents and publications; develop a methodology that can be used to determine the rate of innovation growth in any given health care technology.Background: The study of health care innovation represents an emerging academic field, yet it is limited by a lack of valid scientific methods for quantitative analysis. This article explores and cross-validates 2 innovation metrics using surgical technology as an exemplar.Methods: Electronic patenting databases and the MEDLINE database were searched between 1980 and 2010 for “surgeon” OR “surgical” OR “surgery.” Resulting patent codes were grouped into technology clusters. Growth curves were plotted for these technology clusters to establish the rate and characteristics of growth.Results: The initial search retrieved 52,046 patents and 1,801,075 publications. The top performing technology cluster of the last 30 years was minimally invasive surgery. Robotic surgery, surgical staplers, and image guidance were the most emergent technology clusters. When examining the growth curves for these clusters they were found to follow an S-shaped pattern of growth, with the emergent technologies lying on the exponential phases of their respective growth curves. In addition, publication and patent counts were closely correlated in areas of technology expansion.Conclusions: This article demonstrates the utility of publically available patent and publication data to quantify innovations within surgical technology and proposes a novel methodology for assessing and forecasting areas of technological innovation.
  • Journal article
    Johnston MJ, King D, Arora S, Cooper K, Panda NA, Gosling R, Singh K, Sanders B, Cox B, Darzi Aet al., 2014,

    Requirements of a new communication technology for handover and the escalation of patient care: a multi-stakeholder analysis

    , Journal of Evaluation in Clinical Practice, Vol: 20, Pages: 486-497, ISSN: 1356-1294

    Rationale, aims and objectivesIn order to enable safe and efficient information transfer between health care professionals during clinical handover and escalation of care, existing communication technologies must be updated. This study aimed to provide a user‐informed guide for the development of an application‐based communication system (ABCS), tailored for use in patient handover and escalation of care.MethodsCurrent methods of inter‐professional communication in health care along with information system needs for communication technology were identified through literature review. A focus group study was then conducted according to a topic guide developed by health innovation and safety researchers. Fifteen doctors and 11 nurses from three London hospitals participated in a mixture of homogeneous and heterogeneous sessions. The sessions were recorded and transcribed verbatim before being subjected to thematic analysis.ResultsSeventeen information system needs were identified from the literature review. Participants identified six themes detailing user perceptions of current communication technology, attitudes to smartphone technology and anticipated requirements of an application produced for handover and escalation of care. Participants were in favour of an ABCS over current methods and expressed enthusiasm for a system with integrated patient information and group‐messaging functions.ConclusionDespite concerns regarding confidentiality and information governance a robust guide for development and implementation of an ABCS was produced, taking input from multiple stakeholders into account. Handover and escalation of care are vital processes for patient safety and communication within these must be optimized. An ABCS for health care professionals would be a welcome innovation and may lead to improvements in patient safety.
  • Journal article
    Harris MJ, 2014,

    PRIMARY HEALTHCARE AND MORTALITY We could all learn from Brazil's Family Health Program

    , BMJ-BRITISH MEDICAL JOURNAL, Vol: 349, ISSN: 0959-535X
  • Journal article
    Harris MJ, 2014,

    We could all learn from Brazil's Family Health Program.

    , BMJ, Vol: 349
  • Journal article
    Cowling TE, Harris MJ, Watt HC, Gibbons DC, Majeed Aet al., 2014,

    Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey.

    , Br J Gen Pract, Vol: 64, Pages: e434-e439

    BACKGROUND: The annual number of unplanned attendances at accident and emergency (A&E) departments in England increased by 11% (2.2 million attendances) between 2008-2009 and 2012-2013. A national review of urgent and emergency care has emphasised the role of access to primary care services in preventing A&E attendances. AIM: To estimate the number of A&E attendances in England in 2012-2013 that were preceded by the attending patient being unable to obtain an appointment or a convenient appointment at their general practice. DESIGN AND SETTING: Cross-sectional analysis of a national survey of adults registered with a GP in England. METHOD: The number of general practice consultations in England in 2012-2013 was estimated by extrapolating the linear trend of published data for 2000-2001 to 2008-2009. This parameter was multiplied by the ratio of attempts to obtain a general practice appointment that resulted in an A&E attendance to attempts that resulted in a general practice consultation estimated using the GP Patient Survey 2012-2013. A sensitivity analysis varied the number of consultations by ±12% and the ratio by ±25%. RESULTS: An estimated 5.77 million (99.9% confidence interval = 5.49 to 6.05 million) A&E attendances were preceded by the attending patient being unable to obtain a general practice appointment or a convenient appointment, comprising 26.5% of unplanned A&E attendances in England in 2012-2013. The sensitivity analysis produced values between 17.5% and 37.2% of unplanned A&E attendances. CONCLUSION: A large number of A&E attendances are likely to be preceded by unsuccessful attempts to obtain convenient general practice appointments in England each year.
  • Journal article
    Mastellos N, Gunn L, Harris M, Majeed A, Car J, Pappas Yet al., 2014,

    Assessing patients' experience of integrated care: a survey of patient views in the North West London Integrated Care Pilot.

    , International Journal of Integrated Care, Vol: 14, ISSN: 1568-4156

    INTRODUCTION: Despite the importance of continuity of care and patient engagement, few studies have captured patients' views on integrated care. This study assesses patient experience in the Integrated Care Pilot in North West London with the aim to help clinicians and policymakers understand patients' acceptability of integrated care and design future initiatives.METHODS: A survey was developed, validated and distributed to 2029 randomly selected practice patients identified as having a care plan.RESULTS: A total of 405 questionnaires were included for analysis. Respondents identified a number of benefits associated with the pilot, including increased patient involvement in decision-making, improved patient-provider relationship, better organisation and access to care, and enhanced inter-professional communication. However, only 22.4% were aware of having a care plan, and of these only 37.9% had a copy of the care plan. Knowledge of care plans was significantly associated with a more positive experience.CONCLUSIONS: This study reinforces the view that integrated care can improve quality of care and patient experience. However, care planning was a complex and technically challenging process that occurred more slowly than planned with wide variation in quality and time of recruitment to the pilot, making it difficult to assess the sustainability of benefits.

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