Quality and safety during the off hours in medicine units: A mixed methods study of front-line provider perspectives

BACKGROUND: Hospital off-hours care is associated with poor outcomes. Mutual conceptualization among provider groups may facilitate improvement efforts. Provider-perceived threats to quality are unreported. OBJECTIVES: The objectives of this study were to identify perceived off-hours quality and safety issues, assess the most significant, and evaluate differences between nurses, and attending and housestaff physicians, and providers with day and night experience. DESIGN: Prospective, sequential, exploratory mixed-methods study. MEASURES: Open-ended descriptions of adverse events/near misses occurring overnight (n=190) were analyzed using thematic analysis. From these results, a survey was developed to assess perceptions of quality/frequency of each issue (7-point scale, 7=the highest rating) and highest-quality overnight period (7-10 pm, 10 pm-1 am, 1-4 am, 4-7 am). RESULTS: Primary issues related to mismanagement, delivery processes, and communication/coordination. Of 214 surveys, 160 responses (75%) were received. Least-optimal issues related to "communication" (2.93) and "timeliness/safety" (3.89) of emergency department transfers; most-optimal issues related to timely lab reporting (4.70). On the 7-point scale, comparisons among nurses, and attending and housestaff physicians revealed differences in quality of "communication between physicians" (4.29 vs 6.00 vs 5.14) and "communication between consultants-primary providers" (3.46 vs 5.75 vs 4.35, P<0.001). Comparisons between day-night providers revealed lower ratings from day providers in 12/24 items (P<0.05), including "communication during emergency department transfers" (4.81 vs 3.86). All groups ranked 4 to 7am lowest in quality. CONCLUSIONS: Nurses, and attending and housestaff physicians lack a shared mental model of off-hours care. Several issues, including emergency department transfers and timeliness of consults, were identified by all providers as problematic, meriting further investigation and intervention.