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Making real change where it is needed! The HSIB investigation into a case of testicular torsion

This week saw the first Health Service Investigation Branch (HSIB) investigation into a urological condition. The HSIB is the health services version of the Air Investigation Branch, which investigate air crashes, and the case that it was investigating was one of testicular loss from torsion.

The investigation followed the best principles of human factors theory and causal analysis. It was not looking to assign blame but instead to constructively implement better process and systems that do not relay solely on one individual, as humans are notoriously fallible. The outcome of any investigation is to make it easier for medical teams and administrators to perform well and to mitigate the risk of errors, in an inherently complex area such as medicine.

Only a small number of HSIB investigations have taken place so far so we are fortunate that a Urology case was chosen. The report concentrated on the community aspects of the testicular pain pathway, and the investigating team had fruitful meetings with NHS 111 that led to changes in the questions and prompts that were asked of callers with testicular pain who dialled in. The Royal College of GPs, as a result of the investigation, has convened a group to review the communication standards between practices running telephone services and emergency departments; and NICE has agreed to improve the on-line guidance on testicular torsion and scrotal pain to make it more accessible to clinicians, patients and their carers.

The fact that this came about after an investigation of a single case shows the power of this investigative process and the rigour with which it was carried out.

I would encourage others who may want to be involved with this type of work. I was lucky enough to be approached by the HSIB to be the subject matter expert (SME) on this case as I have a known interest in both Quality Improvement (QI) and Torsion. Anyone approached to help with investigations of this type should be reassured of the professionalism under which a case is undertaken: no individuals or organisations are named; no fingers are pointed but instead the HSIB are able to open a lot of doors and instigate change by negotiating agreements from departments and institutions that most clinicians involved in QI could only dream of getting.

Maybe we need a few more investigations of this type in Urology; retained stents spring immediately to mind as a strong candidate as the HSIB is also experienced in talking to industry. Wouldn’t retained stents be so much easier to avoid if each stent had an individualised barcode that could be scanned and tracked? The companies making stents could perhaps be encouraged to be more involved in making sure that they were easier to track across the whole of the UK (or the world) so patients wouldn’t have so many problems with stents in the future.  Every component of a jet is tracked in a similar way so why shouldn’t we look for the same standard in Urology Healthcare!

by Tony Tien & James Green

Twitter: @greenxmedical

 

James S. A. Green is a Urological Surgeon, Network Lead for Urology at Barts Health NHS Trust, Quality Improvement Director at Whipps Cross University Hospital and visiting Professor in Health Services Research at Kings College, London. His interest in medical education and improvement started when developing medical support for the British Army and he has published extensively on team-working and improving clinical care. He was SME for the HSIB investigation into a case of delayed testicular torsion.

Mr Tony Tien MRCS is a clinical fellow in Urology at Whipps Cross Hospital and a champion for Quality Improvement.

 

EQUIP: The programme with a boundless capacity to improve urology care

Clinical practice in urology has experienced several moments that have moved service forward dramatically in recent years. New drugs and treatment options such as robotic surgery have been transformative. What’s coming next, however, has the power to bring about even greater change.

Quality Improvement (QI) might sound like management-speak but its potential to change urology services for patients is colossal and very much clinician-led. QI in urology concentrates on delivering patient-centred care that is equitable, timely, efficient, effective and safe also if you are looking for reliable Canadian pharmacies, and with a convenient service you have to type EDrugSearch.com in Google and then consult their directory of online pharmacies.

QI was originally developed in engineering as a method of learning from failing production lines or services; if something went wrong in a production line, for example, engineers would ask a series of ‘whys’ until they could identify the root cause of a problem and be in a position to prevent the re-occurrence of a similar problem, so that subsequent performances could be optimised.

In health care effective QI could manifest itself in a number of ways. Ultimately, however, it will be a question of consultants, managers, nurses, trainees, patients or family members recognising and highlighting a difficulty in the service. Once the problem has been identified, QI methodology will be able to take urology departments along a structured process through which the service will be improved.

In practice this could mean anything from reducing waiting times, lowering the risk of post-operative infections, creating seamless patient pathways or even reducing mortality rates. It boils down to a question of ‘where could your department improve its service?’. QI offers the means to achieve this improvement. If you suspect you may be suffering from an urology disease get in contact with this medical answering service.

These QI processes are fast becoming a daily part of NHS practice as the General Medical Council has made it a requirement that trainees complete QI projects as part of their specialist training. Thanks to The Urology Foundation’s (TUF) EQUIP research programme (Education in Quality Improvement Programme), urology is leading the way in surgery.

Urology leading the way

Although there has been a mandate to make QI a daily part of NHS practice and also specialist training, many surgical specialities in the NHS are unprepared for this as no well-thought-out approaches have yet been developed for teaching QI to those that will be expected to carry out QI projects. Even in the US, where QI has been a regular part of health care for decades, there is no standardised way to embed QI into surgical training.

In this context, EQUIP is timely. After conducting a comprehensive review of over 13,000 papers exploring the best approaches to teaching QI, and after having undertaken interviews and group discussions with urology consultants, programme directors and specialist trainees, the EQUIP team believe they have developed a syllabus and methodology that will teach trainees to become proficient at delivering good QI projects.

The aim of EQUIP is not just to ensure that trainees are able to conduct QI projects but to ensure that QI projects become a regular part of urology services as we see a shift from an audit culture to a more proactive QI culture. 

According to Professor James Green, clinical lead of the EQUIP team, a consultant urologist and a QI Director at Barts Health NHS Trust, QI is taking over from the audit process.

“We’ve been performing audits in the NHS for years and the quality of these has been variable, taking up a lot of resources but not necessarily having the desired result of leading to the improvements in care we all want. Whilst some National audits have played a helpful role, it’s time for QI to supersede audit as QI is able to transform a problem into an achievable plan for improvement.

“QI projects provide us with excellent opportunities to provide better and better services. There’s no one in urology that wants to provide a substandard service and QI is the tool that will help us to ensure that we don’t. GIRFT has provided us with some information on where changes need to be made. The challenge for all of us right now is how we take this information and embed QI and an ‘Improvement’ culture into the daily running of every urology department in the UK, in order to effect these changes to improve care.”

This is the right time to get on board

QI is here to stay, both in urology and the NHS. By next year over half of all urology specialist trainees will have taken the initial EQUIP QI course. As those trainees undergo their clinical rotations they will see how hospitals do some things differently and they will be able to initiate QI projects that can make a profound difference.

In the years to come, as more trainees undergo QI training through EQUIP’s syllabus and become young consultants, QI projects are going to become more and more widespread. Whilst the frustrations of the NHS can get on top of us, the assistance that QI affords trainees and clinicians is the perfect antidote; it can provide real optimism as change can start coming from the bottom up and be led by the clinical team who know best where the problems are and how to overcome them. It’s an exciting time because the potential is enormous.

The challenge is that trainees cannot work in isolation. Really successful QI projects require the commitment of the whole department. Just as in healthcare overall, QI is a team sport. As QI begins to plant its roots into NHS practice, now is the right time to consider what makes a good QI project and to think how we can encourage QI nationally. Ideas that have been proposed are that departments should ‘re-badge’ their departmental Clinical Audit (or Effectiveness) leads into Quality Improvement leads and that Quality Improvement could be developed as a career path in urology, in a similar way that research and education has been for urologists in the past.

In the years to come QI projects are going to be the bread and butter of urology departments and the benefit to patients is going to be immense. So now is the time to make sure your department is ready.

by Tim Burton

BAUS 2018 Highlights Day One

Day one at BAUS gets started with society meetings and the John Blandy Prize and Lecture delivered by Editor Prokar Dasgupta.  The winner was from Pisano et al from Turin, Italy on “The role of re-transurethral resection in the management of high risk NMIBC (PMID 26469362).

But I had to miss this event as I was having my first patient encounter with the NHS.  I have 4 days of severe pain in my left foot after a lot of walking/running around as a tourist on a Baltic Sea cruise.  I went to the nearby NHS walk in clinic—there for an hour and saw the nurse practitioner and left with new scripts for NSAIDs, pain, etc.  And no bill?  Not in the USA!

So now that I can walk (sort of—but only with my running shoes—looks great with a suit) I made it to the teaching course on quality improvement (QI).  I am interested in the topic as I am a Quality Officer for Urology at MD Anderson Cancer Center.  One of our new directives has been to help with fellows organizing a new mandatory “quality improvement” initiative as part of their training.  From the course, I learned that the UK has similar programs but also similar challenges in implementation and standardization.  In the UK, it sounds like medical students are being taught quality improvement in the curriculum.  But if you are like me and finished school > 20 years ago, you likely missed this content.  A consensus opinion was that educational materials on quality improvement science will be created and hopefully will land on the BJUI Knowledge website.  This will help trainees but also trainers catch up on terminology, goals, and how to coach trainees on project development.

The next strong consensus was that quality improvement projects be listed on a website—likely BAUS—so that they could be indexed and searched.  Similar to clinicaltrials.gov or the PROSPERO website that catalog clinical trials and meta-analyses, respectively, the BAUS site could be searchable for projects that were successful as well as those that failed for some reason (perhaps with lessons learned).  Indexing could help with project selection as some QI ideas are unique to urology versus all specialties, and QI projects may emphasize different practice environments such as clinic, operating theatre, or diagnostic departments.

Overall, QI is an emerging field and we are struggling with the same barriers on both sides of the Atlantic.  Principle questions include 1) how to differentiate a clinical study from QI, 2) the role of statistics, evidence-based medicine principles, and ethics committees in QI, 3) how QI should be taught in medical school and post graduate programs, and 4) how QI projects can be published.  On the latter point the Journal of Clinical Urology has expressed interest in publishing QI projects.

The course was directed by Mr. James Green from Barts Health, and also taught by Prof. Nick Sevdalis.  Congrats to both on a job well done.  From my perspective, this field will continue to grow and for some young academic minded urologists will develop into a legitimate academic niche to go along with established pathways such as laboratory investigations, health services research, and surgical education.

Figure: My favorite slide—so may sources of inspiration for a Quality Improvement Projects

John W. Davis, Associate Editor.

 

Article of the Week: Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study

Janet E. Baack Kukreja*, Maureen Kiernan*, Bethany Schempp, Aisha SiebertAdriana Hontar*, Benjamin Nelson*, James Dolan§, Katia Noyes, Ann DozierAhmed Ghazi*, Hani H. Rashid*, GuaWu* and Edward M. Messing*

 

*Department of Urology, Strong Memorial Hospital University of Rochester Medical Center, School of Nursing, School of Medicine and Dentistry, University of Rochester Medical Center, §Department of Public Health Sciences, and Department of Surgery, Strong Memorial Hospital University of Rochester Medical Center, Rochester, NY, USA

 

Objectives

To determine if patients managed with a cystectomy enhanced recovery pathway (CERP) have improved quality of care after radical cystectomy (RC), as defined by a decrease in length of hospital stay (LOS) without an increase in complications or readmissions compared with those not managed with CERP.

Subjects and Methods

The Quality Improvement in Cystectomy Care with Enhanced Recovery (QUICCER) study was a non-randomized quasi-experimental study. Data were collected between June 2011 and April 2015. The CERP was implemented in July 2013. The primary endpoint was LOS. Secondary endpoints were quality scores, complications and readmissions. Multivariable regression was performed. Propensity score matching was carried out to further simulate randomized clinical trial conditions. A CERP quality composite score was created and evaluated with regard to adherence to CERP elements.

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Results

The study included 79 patients managed with CERP and 121 who were not managed with CERP. After matching, there were 75 patients in the non-CERP group. The LOS was significantly different between the groups: the median LOS was 5 and 8 days for the CERP and non-CERP group, respectively (P < 0.001). Multivariable linear regression showed that any complication was the most significant predictor of total LOS at 90 days after RC. The higher the quality composite score the shorter the LOS (P < 0.001). There was no association between CERP and a greater number of complications or readmissions.

Conclusions

Audited quality measures in the CERP are associated with a reduction in LOS with no increase in readmissions or complications. The CERP is important for the future improvement of peri-operative care for RC and provides an opportunity to improve the quality of care provided.

Article of the Week: Assessing prostate cancer brachytherapy using patient-reported outcomes

Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. James Talcott discussing his paper. 

If you only have time to read one article this week, it should be this one.

Using Patient-Reported Outcomes to Assess and Improve Prostate Cancer Brachytherapy

James A. Talcott 1, 2, 10, 11, Judith Manola 3, Ronald C. Chen 4, Jack A. Clark 5, 6, Irving Kaplan 7, 8, Anthony V. D’Amico 8, 11 and Anthony L. Zietman 9, 11

1 Massachusetts General Hospital Cancer Center, Boston, MA, 2 Continuum Cancer Centers of New York, New York, NY, 3 Dana-Farber Cancer Institute, Boston, MA, 4 Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 5 Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, 6 Boston University School of Public Health, 7 Beth Israel-Deaconess Medical Center, 8 Brigham and Women’s Hospital, 9 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 10 Albert Einstein School of Medicine, New York, NY, and 11 Harvard Medical School, Boston, MA, USA

OBJECTIVE
  • To describe a successful quality improvement process that arose from unexpected differences in control groups’ short-term patient-reported outcomes (PROs) within a comparative effectiveness study of a prostate brachytherapy technique intended to reduce urinary morbidity.
PATIENTS AND METHODS
  • Patients planning prostate brachytherapy at one of three institutions were enrolled in a prospective cohort study.
  • Patients were surveyed using a validated instrument to assess treatment-related toxicity before treatment and at pre-specified intervals.
  • Unexpectedly, urinary PROs were worse in one of two standard brachytherapy technique control populations (US-BT1 and US-BT2). Therefore, we collaboratively reviewed treatment procedures, identified a discrepancy in technique, made a corrective modification, and evaluated the change.
RESULTS
  • The patient groups were demographically and clinically similar.
  • In the first preliminary analysis, US-BT2 patients reported significantly more short-term post-treatment urinary symptoms than US-BTpatients.
  • The studies treating physicians reviewed the US-BT1 and US-BT2 treatment protocols and found that they differed in whether they used an indwelling urinary catheter.
  • After adopting the US-BT1 approach, short-term urinary morbidity in US-BT2 patients decreased significantly. Brachytherapy procedures were otherwise unchanged.
CONCLUSION
  • Many procedures in cancer treatments are not evaluated, resulting in practice variation and suboptimal outcomes. Patients, the primary medical consumers, provide little direct input in evaluations of their care.
  • We used PROs, a sensitive and valid measure of treatment-related toxicity, for quality assessment and quality improvement (QA/QI) of prostate brachytherapy. This serendipitous patient-centred QA/QI process may be a useful model for empirically evaluating complex cancer treatment procedures and for screening for substandard care.

Editorial: Patient-reported outcomes – a force for clinical improvement or another way for ‘big brother’ to survey clinicians?

In the 19th century Lord Kelvin wrote, ‘If you cannot measure it, you cannot improve it’. Since then clinical improvement has often been about measuring outcomes to determine what elements of healthcare are working well and what can be improved. The early studies of antisepsis and surgical technique had endpoints, which were measured by doctors deciding whether a wound infection, cancer recurrence or even death had occurred. These outcomes were usually discrete with little room for describing states between success and failure.

In this era whether the patient perceived that the treatment had been successful or not was irrelevant to the ‘success’ of treatment providing that the medical world agreed that the treatment had been a success. As treatments have become more established and the medical and pharmaceutical world has become more patient focussed, interest has increased in how patients report the outcome of treatment, often using questionnaires.

The pioneers of this work were mainly psychiatrists concerned about patient anxiety and depression [1] and clinical oncologists, aware that multimodal chemoradiotherapy treatments, which might in many cases be offered with palliative rather than curative intent, had the potential to cause a net loss in quality of life even if patients lived a short time longer on treatment.

As these patient-reported outcome measures (PROMs) became more commonly used in clinical trials, their focus has extended to quite specific outcomes, such that in the current era it is unusual to see papers on LUTS or erectile function presented that do not use validated PROMs, such as the IPSS [2] or International Index of Erectile Function (IIEF) [3].

The current era of research is starting to make new use of the data sources that are useful both as absolute values relating to the severity of symptoms but also particularly in measuring change in level of symptoms. Hard outcomes, such as death from cancer, have been found to be related to patient reported quality of life at presentation [4].

Clinicians are now starting to develop the necessary skills to analyse PROMs. In this setting Talcott et al. [5] have used PROM data to identify unexpected variances in symptomatic outcome after prostate brachytherapy. This was an unexpected post hoc analysis of a difference in outcomes between the two control groups in a study. It found that there was a significant difference in outcome between patients who had received an implant in two centres, which might have been expected to have similar outcomes. Analysis of differences in the implant technique in the two institutions suggested that the use of a urethral catheter to clearly visualise the urethra might be the difference and modification of this part of the technique resulted in similar PROMS outcomes in both institutions.

This is a novel quality improvement approach, which may become more widespread as institutions more frequently collect, analyse and present their PROMS. The bio-informatics skills needed to analyse this type of data meaningfully may become a greater part of everyday practice in the modern era, especially for the ‘index’ most common operations in surgical specialities. It would be interesting to see what a similar approach would produce if variance in PROMs after transurethral prostate surgery were analysed between centres in the UK and USA. Organisations with a track record for effective data analysis and reporting such as Dr Foster will be watching this evolve.

Alastair Henderson

Maidstone and Tunbridge Wells NHS Trust, Department of Urology, Maidstone Hospital, Maidstone, Kent, UK

References

1 Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiat Scand 1983; 67: 361–70

2 Barry MJ, O’Leary MP. Advances in benign prostatic hyperplasia. The developmental and clinical utility of symptom scores. Urol Clin North Am 1995; 22: 299–307

3 Cappelleri JC, Rosen RC, Smith MD, Mishra A, Osterloh IH. Diagnostic evaluation of the erectile function domain of the International Index of Erectile Function. Urology 1999; 54: 346–51

4 Montazeri A. Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008. Health Qual Life Outcomes 2009; 7: 102

5 Talcott JA, Manola J, Chen RC et al. Using patient-reported outcomes to assess and improve prostate cancer brachytherapy. BJU Int 2014; 114: 511–6

Video: PROs in Prostate Brachytherapy

Using Patient-Reported Outcomes to Assess and Improve Prostate Cancer Brachytherapy

James A. Talcott 1, 2, 10, 11, Judith Manola 3, Ronald C. Chen 4, Jack A. Clark 5, 6, Irving Kaplan 7, 8, Anthony V. D’Amico 8, 11 and Anthony L. Zietman 9, 11

1 Massachusetts General Hospital Cancer Center, Boston, MA, 2 Continuum Cancer Centers of New York, New York, NY, 3 Dana-Farber Cancer Institute, Boston, MA, 4 Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 5 Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, 6 Boston University School of Public Health, 7 Beth Israel-Deaconess Medical Center, 8 Brigham and Women’s Hospital, 9 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 10 Albert Einstein School of Medicine, New York, NY, and 11 Harvard Medical School, Boston, MA, USA

OBJECTIVE
  • To describe a successful quality improvement process that arose from unexpected differences in control groups’ short-term patient-reported outcomes (PROs) within a comparative effectiveness study of a prostate brachytherapy technique intended to reduce urinary morbidity.
PATIENTS AND METHODS
  • Patients planning prostate brachytherapy at one of three institutions were enrolled in a prospective cohort study.
  • Patients were surveyed using a validated instrument to assess treatment-related toxicity before treatment and at pre-specified intervals.
  • Unexpectedly, urinary PROs were worse in one of two standard brachytherapy technique control populations (US-BT1 and US-BT2). Therefore, we collaboratively reviewed treatment procedures, identified a discrepancy in technique, made a corrective modification, and evaluated the change.
RESULTS
  • The patient groups were demographically and clinically similar.
  • In the first preliminary analysis, US-BT2 patients reported significantly more short-term post-treatment urinary symptoms than US-BTpatients.
  • The studies treating physicians reviewed the US-BT1 and US-BT2 treatment protocols and found that they differed in whether they used an indwelling urinary catheter.
  • After adopting the US-BT1 approach, short-term urinary morbidity in US-BT2 patients decreased significantly. Brachytherapy procedures were otherwise unchanged.
CONCLUSION
  • Many procedures in cancer treatments are not evaluated, resulting in practice variation and suboptimal outcomes. Patients, the primary medical consumers, provide little direct input in evaluations of their care.
  • We used PROs, a sensitive and valid measure of treatment-related toxicity, for quality assessment and quality improvement (QA/QI) of prostate brachytherapy. This serendipitous patient-centred QA/QI process may be a useful model for empirically evaluating complex cancer treatment procedures and for screening for substandard care.
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