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Older people, often frail with multiple co-morbidities, constitute the largest proportion of hospital inpatient populations. Yet existing ways of measuring the quality and safety of care that they receive are not usually designed with the unique problems encountered by this vulnerable population in mind. The aims of the work presented in this thesis were to investigate what is known about the types, incidence and causes of safety and quality issues in older medical inpatients, to develop and test novel tools to measure the safety and quality of care that they receive and finally to design and test interventions to improve care. In Section 1 of the thesis (Chapters 1 and 2), an introduction of patient safety and quality in older people is presented, with an overview of current strategies for measurement and improvement, and the rationale for undertaking this research. Section 2 (Chapters 3 - 5) contains three exploratory studies in which different approaches (a systematic review of the literature and re-analysis of the major adverse event studies, a qualitative study involving staff who are involved in the care of older people, and an exploratory retrospective case record review) were used to produce an overall picture of safety and quality issues in older medical inpatients. This information was used to develop two novel case record review tools (the “Long tool” and “COMPACT”) to measure the quality and safety of care in older medical inpatients, using a combination of outcome and process measures. Section 3 (Chapters 6 and 7) describes the development and testing of these tools. Next, Section 4 (Chapters 8 and 9) of the thesis consists of two studies which were designed to provide the basis for further safety and quality improvement work in older medical inpatients. In Chapter 8, an investigation of the importance and trainability of safety skills (attributes of the safe practitioner) that may form the basis of a template for future patient safety curricula is described. In Chapter 9, a different improvement approach is described - the development and use of a multidisciplinary goal sheet on a medicine for the elderly ward, its effect on quality of care as measured by COMPACT, on staff perceptions of the incidence of adverse events, teamwork and communication, and on goal understanding. Finally, the discussion (Section 5, Chapter 10) reflects on the overall findings, strengths and weaknesses of the studies, and implications for clinical practice and future research.

There has been increasing interest in involving patients in patient safety. Whilst interventions have been introduced to support this, there are still barriers to patient involvement. Currently, there is a focus upon the clinical risk paradigm, where policymakers, academics and healthcare professionals define patient safety; however, evidence suggests that patients and healthcare professionals may conceptualise patient safety differently. This means that patient safety, as it is currently defined, may not be meaningful or accessible to patients. It is therefore necessary to understand, value and incorporate the patient perspective to support genuine patient involvement. This thesis aims to explore and compare different stakeholder perspectives of patient safety using qualitative methods, and reconcile these in a new patient safety paradigm. Chapter 1 provides the background to patient safety and patient involvement, and addresses the rationale for the thesis. Chapter 2 details the qualitative methods to be used in this research. Chapter 3 presents a systematic review using meta-study methodology to synthesise the current qualitative evidence that explores patient and healthcare professional perceptions of patient safety. Chapters 4 and 5 use constructivist grounded theory to explore patient and healthcare professional perceptions of patient safety within acute medicine for the elderly, elective surgery and maternity, and develop explanatory theory for their conceptualisations of patient safety. Additionally, these chapters allow a comparison of healthcare professional and patient conceptualisations, as well as comparison to existing definitions and models for patient safety. Chapter 6 presents the results of a co-design workshop involving patients and healthcare professionals in elective surgery; this utilises the qualitative findings of the thesis to develop a practical product that, if implemented, will broaden the current patient safety paradigm by identifying, understanding and using the patient perspective. Finally, Chapter 7 discusses the implications of this research for patient safety policy and practice.

General medical wards deliver the majority of inpatient care. Despite technological and therapeutic advances, these wards expose 10% of patients to preventable adverse events, and disproportionately contribute to preventable hospital deaths. Improving ward team performance is often proposed as a mechanism to improve patient outcomes. The overarching goal of this thesis is to identify effective strategies to improve interdisciplinary team care on the medical ward. Chapter 1 introduces key concepts in healthcare quality, and specific issues in the delivery and measurement of interdisciplinary ward care. The existing literature for ward improvement strategies is then described. A narrative review identifies common targets for ward interventions [chapter 2], and a systematic review evaluates interdisciplinary team care interventions, finding little evidence of significant impact on objective patient outcomes [chapter 3]. The development and evaluation of prospective clinical team surveillance (PCTS) is then reported. PCTS is a novel interdisciplinary team care intervention, engaging staff to identify barriers to care delivery, with facilitation and feedback. A programme theory and mixed methods evaluation are presented, using a stepped wedge, cluster controlled trial [chapter 4]. Mixed-effects models show a significant reduction in excess length of stay with high fidelity PCTS [chapter 5]. Surveys, focus groups and auto-ethnography identify PCTS' mechanisms of action, and its impact on incident reporting, safety and teamwork climates [chapter 6]. Implementation outcomes, facilitators and barriers are described in chapter 7. Other perspectives on improvement are also explored. A model of organisational alignment is developed [chapter 8], and an interview study with patients and carers elicits their priorities [chapter 9]. Finally, chapter 10 summarises the findings, highlighting opportunities to develop medical ward outcome sets and construct a model of interdisciplinary team effectiveness. These can be used to support improvements in interdisciplinary care, through changes in policy and practice.