Measuring and Improving the Safety and Quality of Care in Older Medical Inpatients

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