Mortality case note review use for hospital care quality improvement: A methodological, psychological and qualitative investigation

Te, An Phung (2022). Mortality case note review use for hospital care quality improvement: A methodological, psychological and qualitative investigation. University of Birmingham. Ph.D.

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Evaluating hospital care quality using case-note reviews is mandated in the United Kingdom and is endorsed by many high-income countries. This thesis separately addresses both the validity of case-note reviews and the use of case-note reviews for care quality improvement. On case-note reviewing validity, there are moderate-to-high levels of disagreement (variability) between multiple clinician case-note reviewers when evaluating the overall care quality of the same case-note. The sources of this disagreement (variability) are unknown. On case-note review use, the potential factors which affect case-note reviewing in hospitals has not been well-studied in relation to their contribution to hospital care quality improvement. This thesis presents the findings of three original studies and seeks to both identify the sources for this reviewer variability and the organizational factors which influence case-note review’s likely contribution to hospital quality improvement. The introduction discusses the policy context and offers a critique of hospital mortality statistics with the prospective use of case-note reviews as an alternative approach for detecting care quality issues. Chapter 1 involved a systematic review of preventable mortality rates and a characterization of their measurement properties for evaluating care quality and subsequent hospital ranking. Findings concluded that a limitation of studies not accounting for variation between different hospitals, assuming equal variance, in the ranking process. Case-note reviews are presented as a workable alternative, to which this thesis is devoted to investigating. Chapter 2 presents the findings of an original systematic review which identified cognitive biases and heuristics related to case-note review care quality judgements. Cognitive biases and heuristics, sourced from two systematic reviews, are investigated with their plausible influence upon case-note reviewer care quality judgments using clinical scenarios derived using a systematic literature search and informed by a panel consensus. Findings indicate the plausible influence of cognitive biases and heuristics. Chapter 3 investigates the influence of reviewer attitudes; their demographics and patient case-note review characteristics upon case-note reviewer care quality judgements. Selected attitudes did not significantly influence care quality judgements and a significant proportion of care quality judgement variability is unexplained by the included independent variables. Chapter 4 describes case study fieldwork in an acute NHS Trust which explored the organizational processes around case-note review including its embedding, information flow and its perceived quality improvement contribution. We found that case-note reviews were well-embedded, with there being limited information flow from ward-to-board. Chapter 5 is a critical reflection of the research process and the assumptions made in this thesis. Chapter 6 summarizes the thesis, discusses practical implications, and identifies opportunities for future research for quality improvement from case-note reviews.

Type of Work: Thesis (Doctorates > Ph.D.)
Award Type: Doctorates > Ph.D.
Lilford, Richard
Licence: All rights reserved
College/Faculty: Colleges (2008 onwards) > College of Medical & Dental Sciences
School or Department: Institute of Applied Health Research
Funders: None/not applicable
Subjects: R Medicine > RA Public aspects of medicine > RA0421 Public health. Hygiene. Preventive Medicine


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