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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2006.03.035 Byline: Roderick Aren Michael Iedema, Christine Jorm, Jeffrey Braithwaite, Jo Travaglia, Martin Lum Keywords: Root cause analysis; Hospital clinicians; Clinical error; Organizational learning; Australia Abstract: This paper presents evidence from a root cause analysis (RCA) team meeting that was recently conducted in a Sydney Metropolitan Teaching Hospital to investigate an iatrogenic morphine overdose. Analysis of the meeting transcript reveals on three levels that clinical members of the team struggle with framing the uncertain and contradictory details of situated clinical activity and translating these first into 'root causes', and then into recommendations for practice change. This analysis puts two challenges into special relief. First, RCA team members find themselves in the unusual position of having to derive organizational-managerial generalizations from the specifics of in situ activity. Second, they are constrained by the expectation inscribed into RCA that their recommendations result in 'systems improvements' assumed to flow forth from an extension of formal rules and spread of procedures. We argue that this perspective misrecognizes the importance of RCA as a means to engender solutions that leave the procedural detail of clinical processes unspecified, and produce cross-hospital discussions about the organizational dimensions of care. Author Affiliation: The University of NSW, Sydney, Australia

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.socscimed.2005.08.049 Byline: Roderick Aren Michael Iedema, Christine Jorm, Debbi Long, Jeffrey Braithwaite, Jo Travaglia, Mary Westbrook Keywords: Clinical incidents; Root cause analysis; Australia; Discourse analysis Abstract: In this paper, we discuss how a technique borrowed from defense and manufacturing is being deployed in hospitals across the industrialized world to investigate clinical errors. We open with a discussion of the levers used by policy makers to mandate that clinicians not just report errors, but also gather to investigate those errors using root cause analysis (RCA). We focus on the tensions created for clinicians as they are expected to formulate 'systems solutions' that go beyond blame. In addressing these matters, we present a discourse analysis of data derived during an evaluation of the NSW Health Safety Improvement Program. Data include transcripts of RCA meetings which were recorded in a local metropolitan teaching hospital. From this analysis we move back to the argument that RCA involves clinicians in 'immaterial labour', or the production of communication and information, and that this new labour realizes two important developments. First, because RCA is anchored in the principle of health care practitioners not just scrutinizing each other, but scrutinizing each others'errors, RCA is a challenging task. Second, thanks to turning the clinical gaze in on the clinical observer, RCA engenders a new level of reflexivity of clinical self and of clinical practice. We conclude with asking whether this reflexivity will lock the clinical gaze into a micro-sociology of error, or whether it will enable this gaze to influence matters superordinate to the specifics of practice and the design of clinical treatments; that is, the over-arching governance and structuring of hospital care. Author Affiliation: The University of NSW, Sydney, Australia

In Australia and internationally there is a strong policy commitment to the redesign of health services toward integrated physical and mental health care. When executed well, integrated care has been demonstrated to improve the access to, clinical outcomes from, and quality of care while reducing overtreatment and duplication. Despite the demonstrated effectiveness and promise of integrated care, exactly how integrated care is best achieved remains less clear. The aim of this review study was to identify factors that support the implementation of integrated care between physical and mental health services. An integrative review was conducted following the framework developed by Whittemore and Knafl, with quantitative and qualitative evidence systematically considered. To identify studies, Medline, PubMed, PsychINFO, CINAHL were searched for the period from 2003 to 2018, and reference lists of included studies and review articles were examined. Nineteen studies were included. Synthesis of study findings identified seven key factors supporting the implementation of integrated care between physical and mental health services: (a) adequate resourcing, (b) shared values, (c) effective communication, (d) information technology (IT) infrastructure, (e) flexible administrative organizations, (f) role clarity and accountability, and (g) staff engagement and training. There was little theoretical development in included studies, with little insight into the contextual factors or underlying mechanism required to support the implementation of integrated care initiatives. This review identified a set of inter-related barriers and facilitators which, if addressed, can improve the implementation and sustainability of truly integrated care. [ABSTRACT FROM AUTHOR]

Background: Fertility preservation (FP) is an important quality of life issue for cancer survivors of reproductive age. Despite the existence of broad international guidelines, the delivery of oncofertility care, particularly amongst paediatric, adolescent and young adult patients, remains a challenge for healthcare professionals (HCPs). The quality of oncofertility care is variable and the uptake and utilization of FP remains low. Available guidelines fall short in providing adequate detail on how oncofertility models of care (MOC) allow for the real-world application of guidelines by HCPs.Objective and Rationale: The aim of this study was to systematically review the literature on the components of oncofertility care as defined by patient and clinician representatives, and identify the barriers, facilitators and challenges, so as to improve the implementation of oncofertility services.Search Methods: A systematic scoping review was conducted on oncofertility MOC literature published in English between 2007 and 2016, relating to 10 domains of care identified through consumer research: communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, training, supportive care during treatment, reproductive care after cancer treatment, psychosocial support and ethical practice of oncofertility care. A wide range of electronic databases (CINAHL, Embase, PsycINFO, PubMed, AEIPT, Education Research Complete, ProQuest and VOCED) were searched in order to synthesize the evidence around delivery of oncofertility care. Related citations and reference lists were searched. The review was undertaken following registration (International prospective register of systematic reviews (PROSPERO) registration number CRD42017055837) and guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).Outcomes: A total of 846 potentially relevant studies were identified after the removal of duplicates. All titles and abstracts were screened by a single reviewer and the final 147 papers were screened by two reviewers. Ten papers on established MOC were identified amongst the included papers. Data were extracted from each paper and quality scores were then summarized in the oncofertility MOC summary matrix. The results identified a number of themes for improving MOC in each domain, which included: the importance of patients receiving communication that is of a higher quality and in different formats on their fertility risk and FP options; improving provision of oncofertility care in a timely manner; improving access to age-appropriate care; defining the role and scope of practice of all HCPs; and improving communication between different HCPs. Different forms of decision aids were found useful for assisting patients to understand FP options and weigh up choices.Wider Implications: This analysis identifies core components for delivery of oncofertility MOC. The provision of oncofertility services requires planning to ensure services have safe and reliable referral pathways and that they are age-appropriate and include medical and psychological oncofertility care into the survivorship period. In order for this to happen, collaboration needs to occur between clinicians, allied HCPs and executives within paediatric and adult hospitals, as well as fertility clinics across both public and private services. Training of both cancer and non-cancer HCPs is needed to improve the knowledge of HCPs, the quality of care provided and the confidence of HCPs with these consultations. [ABSTRACT FROM AUTHOR]

BackgroundComputerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence. ObjectiveThe objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance. MethodsWe conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures. ResultsThe lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized. ConclusionsThe current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels.

This developmental project was undertaken to explore how applying spatial science analysis and visualisation methods might inform societies undergoing significant structural and demographic change. China is rapidly transitioning to an aged society. It already exceeds all other countries in its population aged 65 years and over. Dementia is closely correlated with ageing and intersects with a variety of physical and cognitive disabilities. Information dashboards are a growing part of health and social policy data environments. These visual data applications increasingly include mapping capabilities. In this paper, we explore the utility of a geographic modelling approach to exploring the complex nature of population ageing and the dementias in China.