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Inpatient diabetes care: complexity, resilience and quality of care

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Abstract

It is estimated that 10–15 % of UK hospital inpatients have diabetes. Poor glycemic control is a care quality problem that has been linked to organizational factors such as inadequate training, inadequate protocols, problems with communication and teamwork, and difficulty coordinating mealtimes. Interventions using specialist diabetes teams have been effective in addressing some of these problems and have led to increased staff and patient self-efficacy and reduced length of stay. The aim of this study was to investigate how inpatient diabetes care is delivered and how resilience is created and/or breaks down, and to identify the implications for quality improvement. In-depth interviews (n = 32) with diabetes specialist and non-specialist staff were conducted in an acute medical admissions environment in an 850-bed teaching hospital. The Critical Decision Method, a content-orientated knowledge elicitation technique, was adapted to guide interview schedules, which explored key decisions, gaps and discontinuities in care and strategies for work system improvement. Care is delivered through the coordination of a multilayered team of different professionals. Specialists provide expertise and problem solving through case-based reasoning using problem-solving skills acquired through past experience. Ward staff focus on processes and immediate patient needs and are more reliant on decision protocols. Gaps in care can occur and result in delays in referring to specialists and clinical inertia. Specialists are a key source of resilience in the system and bridge gaps by acting reactively to problems, proactively monitoring and anticipating problems, providing staff education, and patient support and education. Opportunities for supporting clinicians to bridge gaps in care were identified.

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References

  • Anger K, Szumita P (2006) Barriers to glucose control in the intensive care unit. Pharmacotherapy 26:214–228

    Article  Google Scholar 

  • Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, Bailey CM, Koplan JP (1998) Nurse case management to improve glycaemic control in diabetic patients in a health maintenance organization; a randomised, controlled trial. Ann Intern Med 129:605–612

    Article  Google Scholar 

  • Barach P, Johnson JK (2006) Understanding the complexity of redesigning care around the clinical micro-system. Qual Saf Health Care 15:10–16

    Article  Google Scholar 

  • Barley S, Orr J (1997) Between craft and science: technical work in U.S. settings. IRL Press, Ithaca

  • Bates D, Clark NG, Cook RI, Garber JR, Hellman R, Jellinger PS, Kukora JS, Petal SM, Reason JT, Tourtelot JB (2005) American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. Endocr Pract 11:197–202

    Article  Google Scholar 

  • Bokenholt U, Weber EU (1992) Use of formal methods in medical decision-making: a survey and analysis. Med Decis Making 12:298–306

    Article  Google Scholar 

  • Boreham NC, Shea CE, Mackway-Jones K (2000) Clinical risk and collective competence in the hospital emergency department in the UK. Soc Sci Med 51:83–91

    Article  Google Scholar 

  • Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB (2004) Management of diabetes and hyperglycemia in hospitals. Diabetes Care 27:553–591

    Article  Google Scholar 

  • Cook RI, Rasmussen J (2005) Going solid: a model of system dynamics and consequences for patient safety. Qual Safe Health Care 14:130–134

    Article  Google Scholar 

  • Cook RI, Render M, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. BMJ 320:791–794

    Article  Google Scholar 

  • Cook CB, McNaughton DA, Braddy CM, Jameson KA, Roust LR, Smith SA, Roberts DL, Thomas SL, Hull BP (2007) Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract 13(2):117–124

    Article  Google Scholar 

  • Cook CB, Jameson KA, Hartsell ZC, Boyle ME, Leonhardi BJ, Farquhar-Snow M, Beer KA (2008) Beliefs about hospital diabetes and perceived barriers to glucose management among inpatient midlevel practitioners. Diabetes Educator 34(1):75–83

    Article  Google Scholar 

  • Courtenay M, Carey N, James J, Hills M, Roland J (2007) An evaluation of a specialist nurse prescriber on diabetes inpatient service delivery. Pract Diabetes Int 24(2):69–74

    Article  Google Scholar 

  • Daultrey H, Gooday C, Dhatariya K (2011) Increased length of inpatient stay and poor clinical coding: audit of patients with diabetes. J R Soc Med Short report 2:83

    Article  Google Scholar 

  • Davies M, Dixon S, Currie CJ, Davis RE, Peters JR (2001) Evaluation of a hospital diabetes specialist nursing service: a randomised controlled trial. Diabetic Med 18:301–307

    Article  Google Scholar 

  • Davies JB, Ross AJ, Wallace B, Wright L (2003) Safety management: A qualitative systems approach. Taylor and Francis, London

    Book  Google Scholar 

  • Dekker S, Cilliers P, Hofmeyr JH (2011) The complexity of failure: implications of complexity theory for safety investigations. Safety Sci 49(6):939–945

    Article  Google Scholar 

  • Dekker S, Bergström J, Amer-Wåhlin I, Cilliers P (2012 Jan) Complicated, complex, and compliant: best practice in obstetrics. Cogn Tech Work 1–7. doi:10.1007/s10111-011-0211-6

  • Department of Health (2001) National service framework for diabetes; standards. Department of Health, London

    Google Scholar 

  • Deville JC (1991) A theory of quota surveys. Surv Methodol 17:163–181

    Google Scholar 

  • Diabetes UK (2009) Position statement: improving inpatient diabetic care-what care adults with diabetes should expect when in hospital. Diabetes UK, London

    Google Scholar 

  • Diabetes UK (2010) Diabetes in the UK 2010: key statistics on diabetes. Diabetes UK, London

    Google Scholar 

  • Flach J (2012) Complexity: learning to muddle through. Cogn Tech Work 14(3):187–197

    Article  Google Scholar 

  • Flanagan JC (1954) The critical incident technique. Psych Bull 51:327–358

    Article  Google Scholar 

  • Giangola J, Olohan K, Longo J, Goldstein JM, Gross PA (2008) Barriers to hyperglycaemic control in hospitalised patients: a descriptive epidemiologic study. Endocr Pract 14(7):813–819

    Article  Google Scholar 

  • Hoffman RR, Militello LG (2008) Perspectives on cognitive task analysis: historical origins and modern communities of practice. CRC Press/Taylor and Francis, Boca Raton

    Google Scholar 

  • Hoffman RR, Crandall B, Shadbolt N (1998) Use of the critical decision method to elicit expert knowledge: a case study in the methodology of cognitive task analysis. Hum Factors 40(2):254–276

    Article  Google Scholar 

  • Holling CS (1996) Engineering resilience versus ecological resilience. In: Schulze PC (ed) Engineering within ecological constraints. NAP, Washington D.C., pp 31–44

    Google Scholar 

  • Hollnagel E (2004) Barriers and accident prevention. Ashgate Publishing Limited, Hampshire

    Google Scholar 

  • Hollnagel E (2009) The four cornerstones of resilience engineering. In: Nemeth C, Hollnagel E, Dekker S (eds) Resilience engineering perspectives vol. 2 preparation and restoration. Ashgate, Farnham, pp 17–134

    Google Scholar 

  • Hollnagel E (2010) Prologue: the scope of resilience engineering. In: Hollnagel E, Paries J, Woods D, Wreathall J (eds) Resilience engineering in practice: a guidebook. Ashgate, Farnham, pp 3–8

    Google Scholar 

  • Hutchins E, Klausen T (1998) Distributed cognition in an airline cockpit. In: Engestro Y, Middleton D (eds) Cognition and communication at work. Cambridge University Press, Cambridge, pp 15–34

    Google Scholar 

  • Iedema R (2009) New approaches to researching patient safety. Soc Sci Med 69:1701–1704

    Article  Google Scholar 

  • Ioannidis J, Lau J (2001) Evidence on interventions to reduce medication errors: an overview and recommendations for future research. J Gen Intern Med 16:325–334

    Article  Google Scholar 

  • James J, Gosden C, Winocour P, Walton C, Nagi D, Turner B, Williams R, Holt RIG (2009) Diabetes specialist nurses and role evolvement: a survey by Diabetes UK and ABCD of specialist diabetes services. Diabetic Med 26(5):560–565

    Article  Google Scholar 

  • Klein HA, Lippa KD (2012) Assuming control after system failure: type II diabetes self-management. Cogn Tech Work 14(3):243–251

    Article  Google Scholar 

  • Klein HA, Meininger A (2004) Self management of medication and diabetes: a cognitive control task. IEEE Trans. Syst. Man Cybern-Part A 34:718–725

    Article  Google Scholar 

  • Klein GA, Calderwood R, MacGregor D (1989) Critical decision method for eliciting knowledge. IEEE Trans. Syst. Man Cybern 19(3):462–472

    Article  Google Scholar 

  • Kushniruk WA (2001) Analysis of complex decision-making processes in health care: cognitive approaches to health informatics. J Biomed Inform 34:365–376

    Article  Google Scholar 

  • Leveson NG (2002) System safety engineering: back to the future. MIT, Cambridge

    Google Scholar 

  • McHugh MD, Shang J, Sloane DM, Aiken LH (2011) Risk factors for hospital-acquired ‘poor glycemic control’: a case–control study. Int J Qual Health Care 23(1):44–51

    Article  Google Scholar 

  • McKeeney L (2003) Are link-nurse systems an effective means for improving patient care? Prof Nurse 19(4):203–206

    Google Scholar 

  • McManus S, Seville E, Brunsdon D, Vargo J (2007) Resilience management: a framework for assessing and improving the resilience of organisations. http://ir.canterbury.ac.nz/bitstream/10092/2810/1/12606763_Resilience%20Management%20Research%20Report%20ResOrgs%2007-01.pdf. Accessed 16 Aug 2012

  • Mendonca D (2008) Measures of resilient performance. In: Hollnagel E, Nemeth C, Dekker S (eds) Remaining sensitive to the possibility of failure. Resilience engineering perspectives. Ashgate Publishing, Aldershot, pp 29–48

  • Nemeth C (2008) Resilience engineering: the birth of a notion. In: Hollnagel E, Nemeth C, Dekker S (eds) Remaining sensitive to the possibility of failure. Resilience engineering perspectives 1. Ashgate Publishing, Aldershot, pp 3–9

  • Nemeth CP, Cook RI, Wears RL (2007) Studying the technical work of emergency care. Ann Emerg Med 50(4):384–386

    Article  Google Scholar 

  • Nemeth CP, Wears RL, Woods DD, Hollnagel E, Cook RI (2008) Minding the gaps: creating resilience in healthcare. In: Henriksen K, Battles JB, Keyes MA, Grady ML (eds) Advances in patient safety: new directions and alternative approaches vol 3 performance and tools. AHRQ, Rockville

    Google Scholar 

  • Nemeth C, Wears RL, Patel S, Rosen G, Cook R (2011) Resilience is not control: healthcare, crisis management, and ICT. Cogn Tech Work 13(3):189–202

    Article  Google Scholar 

  • Novak JD (1977) A theory of education. Cornell University Press, Ithaca

    Google Scholar 

  • Novak JD, Canas AJ (2006) The theory underlying concept maps and how to construct and use them. Technical Report IHMC. http://cmapihmcus/Publications/ResearchPapers/TheoryUnderlyingConceptMapspdf. Accessed 30 May 2012

  • Nyssen AS (2007) Coordination in hospitals: organized or emergent process? Cogn Tech Work 9(3):149–154

    Article  Google Scholar 

  • Patterson E, Cook R, Woods D, Render M (2006a) Gaps and resilience. Online. http://ctlab.protectedsite.net/documents/HEinMedv26-Gaps%20and%20Resilience.pdf. Accessed 15 Aug 2012

  • Patterson ES, Woods DD, Roth EM, Cook RI, Wears RL, Render ML (2006b) Three key levers for achieving resilience in medication delivery with information technology. J Patient Saf 2(1):33–38

    Google Scholar 

  • Perrow C (1984) Normal accidents: living with high risk technology. Basic Books, New York

    Google Scholar 

  • Perry S, Wears R (2009) Notes from the underground. In: Nemeth C, Hollnagel E, Dekker S (eds) Resilience engineering perspectives 2: preparation and restoration. Ashgate, Aldershot, pp 167–178

    Google Scholar 

  • Poses RM, Cebul RD, Wigton RS (1995) You can lead a horse to water—improving physicians knowledge of probabilities may not affect their decisions. Med Decis Making 15:65–75

    Article  Google Scholar 

  • Rasmussen J (1983) Skills, rules, knowledge; signals, signs, and symbols, and other distinctions in human performance models. IEEE Transactions on Systems, Man and Cybernetics 13:257–266

    Article  Google Scholar 

  • Reynolds LR, Cook AM, Lewis DA, Colliver MC, Legg SS, Barnes NG, Conigliaro J, Lofgren RP (2007) An institutional process to improve inpatient glycemic control. Qual Health Care 16(3):239–249

    Google Scholar 

  • Roberts KH, Libuser C (1993) From Bhopal to banking: organizational design can mitigate risk. Organ Dyn 21:15–26

    Article  Google Scholar 

  • Roman S, Chassin M (2001) Windows of opportunity to improve diabetes care when patients with diabetes are hospitalized for other conditions. Diabetes Care 24(8):1371–1376

    Article  Google Scholar 

  • Rubin DJ, Moshang J, Jabbour SA (2007) Diabetes knowledge: are resident physicians and nurses adequately prepared to manage diabetes? Endocr Pract 13(1):17–21

    Article  Google Scholar 

  • Sampson MJ, Crowle T, Dhatariya K, Dozio N, Greenwood RH, Heyburn PJ, Jones C, Temple RC, Walden E (2006) Trends in bed occupancy for inpatients with diabetes before and after the introduction of a diabetes inpatient specialist nurse service. Diabetic Med 23:1008–1015

    Article  Google Scholar 

  • Sampson M, Brennan C, Dhatariya K, Jones C, Walden E (2007) A national survey of in-patient diabetes services in the United Kingdom. Diabet Med 24(6):643–649

    Article  Google Scholar 

  • Smith DK, Bowen J, Bucher L, Hawkins T, Jurkovitz C, Reed J III, Volk S (2009) A study of perioperative hyperglycemia in patients with diabetes having colon, spine, and joint surgery. J Perianesth Nurs 24(6):362–369

    Article  Google Scholar 

  • Tagg C, Crowley C (2002) International journal of social research methodology. Taylor and Francis, London

    Google Scholar 

  • Taylor CB, Miller NH, Reilly KR, Greenwald G, Cunning D, Deeter A, Abascal L (2003) Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes. Diabetes Care 26(4):1058–1063

    Article  Google Scholar 

  • Thorndike RL (1951) Reliability. In: Lindquist EF (ed) Educational measurement. ACE, Washington, DC, pp 560–620

    Google Scholar 

  • Wallace B, Ross AJ (2006) Beyond human error: taxonomies and safety science. CRC Press, Boca-Raton

    Book  Google Scholar 

  • Wild D, von Maltzahn R, Brohan E, Christensen T, Clauson P, Gonder-Frederick L (2007) A critical review of the literature on fear of hypoglycaemia in diabetes: implications for diabetes management and patient education. Patient Educ Couns 68:10–15

    Article  Google Scholar 

  • Wilson T, Holt T (2001) Complexity and clinical care. Brit Med J. 323(7314):685–688

    Article  Google Scholar 

  • Wirstad J (1988) On knowledge structures for process operators. In: Goodstein LP, Andersen HB, Olsen SE (eds) Tasks, errors, and mental models. Taylor and Francis, London, pp 50–69

    Google Scholar 

  • Woods DD, Cook RI (2002) Nine steps to move forward from error. Cogn Tech Work 4(2):137–144

    Article  Google Scholar 

  • Woods DD, Wreathall J (2006) Essential characteristics of resilience. In: Hollnagel E et al (eds) Resilience engineering: concepts and precepts. Ashgate, Aldershot, pp 21–34

    Google Scholar 

  • Yong A, Power E, Gill G (2002) Improving glycaemic control of insulin-treated diabetic patients-a structured audit of specialist nurse intervention. J Clin Nurs 11(6):773–776

    Article  Google Scholar 

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Acknowledgments

This work was supported by the UK National Institute for Health Research (NIHR). The views expressed in this publication are those of the authors and not necessarily those of UK National Health Service, NIHR or the UK Department of Health.

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Authors and Affiliations

  1. SaIL Centre, King’s Health Partners, London, UK

    A. J. Ross

  2. Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK

    J. E. Anderson

  3. School of Applied Social Science, University College Dublin, Dublin, Ireland

    N. Kodate

  4. Department of Applied Social Studies, University of Bedfordshire, Luton, UK

    K. Thompson

  5. King’s College Hospital, NHS Foundation Trust, London, UK

    A. Cox & R. Malik

  6. Simulation and Interactive Learning Centre, St Thomas’ Hospital, 1st floor, St Thomas’ House, London, SE1 7EH, UK

    A. J. Ross

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  1. A. J. Ross
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Correspondence to A. J. Ross.

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Ross, A.J., Anderson, J.E., Kodate, N. et al. Inpatient diabetes care: complexity, resilience and quality of care. Cogn Tech Work 16, 91–102 (2014). https://doi.org/10.1007/s10111-012-0247-2

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