Process evaluation of a multifaceted intervention to improve cardiovascular disease prevention in general practice

OBJECTIVES

To perform a process evaluation of a multifaceted intervention to improve cardiovascular and diabetes care in general practice.

METHODS

The feasibility of the intervention, carried out by outreach visitors in 62 practices, was addressed by evaluating whether the intervention programme was performed as planned and the extent to which it was accepted by the practice team. In addition, the costs of the programme were determined.

RESULTS

The intervention was largely carried out as planned, although the intervention period had to be extended by three months. Of the 18 topics that could be addressed during the intervention period, 12 (mean) were addressed. The number of outreach visits per practice was 15.2 (mean), each visit lasted about one hour. Most practice members endorsed both the key recommendations for clinical decision-making and cardiovascular risk profiling. The majority of GPs (range 63-98%) agreed with the guidelines for clinical decision-making, and 29-97% had a positive opinion about the guidelines for practice organisation. According to practice staff members, the outreach visitor had sufficient knowledge and skills to support them in changing the practice organisation. GPs were less positive about the outreach visitor's knowledge and skills in optimising clinical decision-making; however 78% believed that the outreach visitor contributed to effecting change in their clinical decision-making. The total costs of the intervention per practice were Euro 4317.

CONCLUSIONS

This process evaluation demonstrated that the intervention was usually carried out as planned and achieved a high satisfaction rating from the participating practice members.

Cyclic fluctuations in hospital bed occupancy in Roma (Italy): supply or demand driven?

The objective of this study was to assess hospital bed occupancy both by planned and unplanned cases, and to assess how supply and demand affect bed occupancy. Data was obtained from the Lazio Hospital Information System (HIS) dataset on all hospital discharges from July 1998 to June 2001. Using Diagnosis Related Groups (DRG) as the reason for hospital stay, admissions were classified into four categories: 'planned stay', 'presumed planned stay', 'presumed unplanned stay', and 'unplanned stay'. Time series analysis of daily bed occupancy by category of stay was performed. Generalized Additive Models (GAMs) were used to asses the effect of weekdays and holidays on bed occupancy. Fluctuations in daily occupancy were observed in all categories of stay-in general, bed occupancy decreased over weekends, on national holidays, and during the major holiday season of August. In comparison with unplanned stays, the largest fluctuations were observed for planned stays while presumed planned and unplanned stays showed lesser fluctuations. It is possible to distinguish planned and unplanned hospital stays by using DRG grouping. Cyclic rigidities in the supply of services rather than the availability of beds or demand for beds seem to dictate hospital use in Roma so that restrictions in services hamper any reallocation of beds for 'planned stay' when demand for 'unplanned stay' beds declines.

Changing the face of emergency medicine

Discover how one hospital in Salt Lake City nearly eliminated patient waiting time in its emergency department and the department essentially became the front door to the hospital.

Knowledge and process management in health care organizations

OBJECTIVE

Medical knowledge management and care process management have become to be considered as valuable strategic assets that can lead to sustained increase in Health Care Organization (HCO) performance. Thus, it is essential to investigate which are the enablers for promoting knowledge-based organizations (people, organization, process, and system perspectives). Although they are essential for a HCO to manage knowledge effectively, it is still unclear how to employ them in more principled fashion. This requires innovative management strategies to determine effective ways of utilizing knowledge resources and capabilities available both within and outside the organization.

METHOD

This paper reviews knowledge and process management theories, methods, and technologies that are potentially effective in building high performance HCOs. They come from a variety of fields behind computer science and medical informatics, e.g. from business and organization sciences to psychological and cognitive sciences, from epistemology to sociology. However, the success in developing future Health Information Systems (HIS) requires their incorporation into a new conceptual framework after recognizing how peculiar are the characteristics of HCOs with respect to other organizations. Investigating the nature of knowledge, in general, and of medical knowledge, in particular, is essential to define which services the future HIS should provide to foster collaboration between patients and health professionals. The knowledge creation process is then described in order to emphasize its dynamic and social characteristics. The potential of workflow technology for building innovative HISs is analyzed together with several basic research issues which are very challenging for researchers in the field.

RESULT

A framework for augmenting the conceptual analysis of theories, methods, tools and effects of knowledge management in building high performance HCOs.

Processes of Care During a Randomized Trial of Office-based Treatment of Opioid Dependence in Primary Care

Improving office-based treatment of opioid dependence requires an evaluation of processes of care. We evaluated the care provided by physicians to opioid dependent patients during a trial of office-based methadone maintenance. We conducted chart audits and a focus group. Audits identified lapses in monitoring of urine toxicology results and paperwork completion. The focus group identified the logistics of dispensing, the receipt of urine toxicology results, difficulties arranging psychiatric services, communications with the opioid treatment program, and non-adherence to medication as problematic. Strategies to support logistical aspects of office-based care should be developed. Chart audits and mentoring should be considered as a mechanism to foster quality care. These processes of care are likely to require attention for treatment using methadone or buprenorphine.

A FMEA clinical laboratory case study: how to make problems and improvements measurable

The authors have experimented the application of the Failure Mode and Effect Analysis (FMEA) technique in a clinical laboratory. FMEA technique allows: a) to evaluate and measure the hazards of a process malfunction, b) to decide where to execute improvement actions, and c) to measure the outcome of those actions. A small sample of analytes has been studied: there have been determined the causes of the possible malfunctions of the analytical process, calculating the risk probability index (RPI), with a value between 1 and 1,000. Only for the cases of RPI > 400, improvement actions have been implemented that allowed a reduction of RPI values between 25% to 70% with a costs increment of < 1%. FMEA technique can be applied to the processes of a clinical laboratory, even if of small dimensions, and offers a high potential of improvement. Nevertheless, such activity needs a thorough planning because it is complex, even if the laboratory already operates an ISO 9000 Quality Management System.

The challenge of promoting integration: conceptualization, implementation, and assessment of a pilot care delivery model for patients with type 2 diabetes

BACKGROUND

The Côte-des-Neiges diabetes pilot project strove to conceptualize, implement, and assess an integrated health care system for Type 2 diabetes. Using a disease management and population-based approach, a multidisciplinary team sought to (1). organize health care in an integrative framework, (2). promote behavior changes in patients to foster self-care, (3). introduce tools to allow family physicians to modify their practices, and (4). encourage local community action to support patients and providers.

METHODS

Information from a needs assessment helped guide the development of the care model, which was implemented over a 1-year period. A preliminary assessment was undertaken using qualitative methods. Data were collected through in-depth interviews, focus groups, participant observation, and document analysis.

RESULTS

(1). Physicians and patients appreciated having access to a multidisciplinary team and related services, and personalized communication was preferred to computerized links. (2). Patients also perceived the benefit of individualized assessment and self-care educational sessions allowing them to participate in their illness management. (3). A diabetes care flow sheet altered the management strategies of physicians. (4). Limited time prevented full development of networking efforts to promote community mobilization.

CONCLUSIONS

Approaches to chronic diseases such as diabetes require integrative health care strategies to support patients and providers in their community. In spite of time constraints, patients perceived the value of education with increasing involvement in their illness, physicians reported changes in their practice, and steps were initiated to mobilize community resources.

Assessing the Patient's Mammogram Experience

This study overviews an operational blueprint that diagrams the activities and interactions of all participants in a typical screening mammography appointment in a large medical center. The blueprint is constructed from multiple sources of data collected from mammography patients, service providers in the radiology department, and medical records. The benefits from using patient perspectives, the insights gained from the blueprint development process, and the value of the resulting screening mammography appointment blueprint are included.

Standing with assistance of a tilt table in intensive care: A survey of Australian physiotherapy practice

Although tilt tables are used by physiotherapists to reintroduce patients to the vertical position, no quantitative evidence is available regarding their use within intensive care units (ICUs) of Australian hospitals. The purpose of this study was to evaluate the use of tilt tables in physiotherapy management of patients in ICUs across Australia. Ninety-nine physiotherapists working in Australian public ICUs were contacted via mail and asked to complete a questionnaire regarding their use of tilt tables in practice. Reasons for the use of the tilt table, contraindications, commonly used adjuncts, monitoring, and outcome measures were also investigated. Eighty-six questionnaires were returned (87% response). The tilt table was used by 58 physiotherapists (67.4%). The most common reasons for inclusion of tilt table treatment were to: facilitate weight bearing (94.8% of those who tilt); prevent muscle contractures (86%); improve lower limb strength (81%); and increase arousal (70%). The tilt table was most frequently applied to patients with neurological conditions (63.8%) and during long-term ICU stay (43.1%). Techniques often combined with tilt table treatment included upper limb exercises (93.1%) and breathing exercises (86.2%). Standing with assistance of the tilt table is used by the majority of physiotherapists working in Australian ICUs. A moderate level of agreement is demonstrated by physiotherapists regarding indications to commence tilt table treatment and adjunct modalities combined with standing with assistance of the tilt table.

Designing multi-ethnic stroke studies: the Brain Attack Surveillance in Corpus Christi (BASIC) project

The Brain Attack Surveillance in Corpus Christi (BASIC) project is a population-based stroke study comparing Mexican Americans and non-Hispanic whites. Extensive effort is made to detect all patients regardless of ethnicity and ensure equal participation in the interview among both groups. We describe here the study's design and process evaluation with a focus on reducing bias in case ascertainment and participation. During the first 28 months of the project, 11,829 subjects were screened. Availability of neuroimaging did not differ by ethnicity (P=0.22), nor did confidence in the validated diagnosis of stroke (P=0.10). Participation rate in the interview also did not differ by ethnicity (P=0.92). There was excellent agreement of ethnic classification between chart abstraction and self-report (kappa=0.94, P<0.001). We conclude that multi-ethnic stroke comparison studies are feasible. Utilizing epidemiologic principles to design, recruit and analyze data are critical. Process evaluation to examine for sources of bias is important to study conduct.

Standard, routine and non‐routine processes in health care

Quality management methods have been introduced into health care with variable success. Industrial approaches, such as standardization, are not always applicable professional services, because of fundamental differences in conceptions of aims and the predictability of the results of action. Processes in health care can be classified into standard, routine and non-routine depending on the level of repetition and amount of variation, variety and uncertainty. Quality problems are different in each type: standard processes may produce deviations from targets, routines errors in classification, and non-routines failures in interpretation. Different management approaches for each type are discussed. A metaphor to assist discussion, The Broom, is introduced.

Using Patient Waiting-Time Data to Improve the Hospital Bed-Assignment Process

An improvement activity involving use of real-time waiting-time data resulted in reductions in bed-assignment times and overall diversion hours.

Cultural competence and dental hygiene care delivery: integrating cultural care into the dental hygiene process of care

As the population of the United States becomes increasingly diverse, effective, client-centered, contemporary dental hygiene practice will be realized only if clinicians are equipped to interact with and provide care for clients of varied cultural backgrounds. The purpose of this investigation is to explore ways to incorporate cultural care into the dental hygiene process of care. In addition to a discussion of the integration of cultural sensitivity into communication, assessment, dental hygiene diagnosis, treatment planning, implementation provides recommendations for further research and for the education of both dental hygiene students and practicing dental hygienists in order to facilitate quality care for a culturally diverse clientele.

To err is human: improving patient safety through failure mode and effect analysis

Patient care errors occur in the laboratory. Traditionally, most errors have been thought to occur because of individual human failure. The assumption is that with adequate training, education; and orientation, technologists will perform flawlessly. Laboratory processes are designed on the premise that nothing will go wrong. Health-care professionals are looking at new methods of error prevention including Failure Mode and Effect Analysis (FMEA). Based on long experience in the engineering field, FMEA assumes everything will fail, humans err frequently, and the cause of an error often is beyond the individual's control. FMEA is a proactive, systematic, multidisciplinary team-based approach to error prevention. Patient safety is now a high priority with the Joint Commission on Accreditation of Healthcare Organizations, and this article introduces FMEA, a new method for improving our processes to enhance patient safety.

[Vagina cytological screening--follow up of unsatisfactory specimens]

During the screening of vaginal cytological samples to determine the pre-stages of cervical cancer, some samples cannot be evaluated, usually as a result of the presence of inflammatory cells. In this study, we compare the clinical handling of these samples at two cytology laboratories at the Norra Alvsborgs Hospital, NAL, in Trollhättan, Sweden and the Södra Alvsborgs Hospital, SAS, in Borås, Sweden. We also present a follow-up of the women involved. At the NAL, the women were treated with anti-inflammatory drugs and new samples were then taken after three months. At the SAS, on the other hand, new samples were simply taken after the next menstruation. The results indicate that no differences can be seen when it comes to the ease of evaluation.

Implementing practical interventions to support chronic illness self-management

BACKGROUND

Self-management support (SMS) is the area of disease management least often implemented and most challenging to integrate into usual care. This article outlines a model of SMS applicable across different chronic illnesses and health care systems, presents recommendations for assisting health care professionals and practice teams to make changes, and provides tips and lessons learned. Strategies can be applied across a wide range of conditions and settings by health educators, care managers, quality improvement specialists, researchers, program evaluators, and clinician leaders. Successful SMS programs involve changes at multiple levels: patient-clinician interactions; office environment changes; and health system, policy, and environmental supports. PATIENT-CLINICIAN INTERACTION LEVEL: Self-management by patients is not optional but inevitable because clinicians are present for only a fraction of the patient's life, and nearly all outcomes are mediated through patient behavior. Clinicians who believe they are in control or responsible for a patient's well-being are less able to adopt an approach that acknowledges the central role of the patient in his or her care.

SUMMARY AND CONCLUSIONS

Self-management should be an integral part of primary care, an ongoing iterative process, and patient centered; use collaborative goal setting and decision making; and include problem solving, outreach, and systematic follow-up.

Selecting outcome parameters in studies aimed at improving rational use of antibiotics - practical considerations

When designing studies of the optimal use of antimicrobial drugs, it is important to define at an early stage, which outcome parameters to use. It must be clear to which category a parameter to be measured belongs: the structure, the process or a clinical outcome. Attention must be paid to the measurement scales as well as the statistical tests to be used. The outcome measure must be sensitive, specific and reliable. Furthermore, the timeframe chosen for the performance of a study should be validated. Whether process parameters or clinical outcomes are to be preferred depends on the settings and the intended purpose. The essential point is the appropriate choice of outcome measure for the study. Examples drawn from the field of quality of use of antimicrobial drugs are discussed.

Factors impeding dispatcher-assisted telephone cardiopulmonary resuscitation

STUDY OBJECTIVE

Dispatcher-assisted telephone cardiopulmonary resuscitation (CPR) instruction can increase the proportion of sudden cardiac arrest victims who receive bystander CPR and has been associated with improved survival. Most sudden cardiac arrest victims, however, do not receive bystander CPR. The study objective was to examine factors that may impede implementation of telephone CPR.

METHODS

We reviewed dispatcher audio recordings and emergency medical services reports for 404 cases of sudden cardiac arrest that occurred from July 1, 2000, to June 30, 2002, in the study county to assess the phase (1, instructions not offered; 2, instructions offered but declined; or 3, instructions offered and accepted but CPR not implemented) and specific factors within each phase that potentially impede telephone CPR.

RESULTS

Twenty-five percent (99/404) of victims received bystander CPR without dispatch assistance, 34% (139/404) received telephone CPR, and 41% (166/404) did not receive bystander CPR. Each phase of telephone CPR process impeded the implementation of CPR: (1) instructions not offered in 48% (80/166); (2) instructions offered but declined in 31% (52/166); and (3) instructions offered and accepted but CPR not implemented in 21% (34/166). During the first phase, telephone CPR was potentially impeded most frequently because the victim was reported to have signs of life (51/80, 64%); during the second and third phases, telephone CPR was most often impeded because of bystander physical limitation (32/86, 37%). Emotional distress, disease transmission, disagreeable victim characteristics, or medicolegal concerns uncommonly impeded telephone CPR (10/86, 12%).

CONCLUSION

Factors potentially impeding telephone CPR can be identified. Although many are logistically challenging, some may be addressable and hence provide opportunities to strengthen the chain of survival.

Patient flow product taps hidden capacity

Significant revenue opportunities and reduced cost per case are possible. Methodology focuses on creating new measures of effectiveness for key factors. People, process, and tools addressed to drive culture change.

Improving patient safety across a large integrated health care delivery system

OBJECTIVE

Patient safety is moving up the list of priorities for hospitals and health care delivery systems, but improving safety across a large organization is challenging. We sought to create a common patient safety strategy for the Partners HealthCare system, a large, integrated, non-profit health care delivery system in the United States.

DESIGN

Partners identified a central Patient Safety Officer, who then formed a Patient Safety Advisory Group with local expert members, as well as a Patient Safety Leaders Group comprised of personnel responsible for patient safety at each member institution. The latter group meets monthly to help determine future projects and to share the results of piloting and implementation. There was broad consensus that interventions should include the areas of culture change, process change, and process measurement.

SETTING

A large, integrated health care delivery system in the Boston, Massachusetts, area.

RESULTS

Key milestones to date include implementation of Executive WalkRounds, development of accountability principles, agreement to create a common system-wide adverse event reporting system, and agreement to implement computerized physician order entry in all hospitals. These efforts have heightened awareness of patient safety considerably within the network. Most influenced to date have been the senior leaders of the hospitals, which has resulted in substantial support for patient safety initiatives.

CONCLUSIONS

This loosely integrated delivery system represents a daunting landscape for the development and institution of patient safety concepts. Many projects aimed at different components of patient safety must occur at the same time for significant change, yet culture and care-related beliefs vary substantially within the system, and measurement is especially challenging. Moreover, with many potential interventions, and limited resources, prioritization and selection is difficult. Nonetheless, consensus about some issues has been reached, in particular because of a well delineated patient safety structure. We believe the net result will be substantial improvement in patient safety.

Methoden des Prozessmanagements in der Radiologie

The main emphasis in health care has been on quality and availability but increasing cost pressure has made cost efficiency ever more relevant for nurses, technicians, and physicians. Within a hospital, the radiologist considerably influences the patient's length of stay through the availability of service and diagnostic information. Therefore, coordinating and timing radiologic examinations become increasingly more important. Physicians are not taught organizational management during their medical education and residency training, and the necessary expertise in economics is generally acquired through the literature or specialized courses. Beyond the medical service, the physicians are increasingly required to optimize their work flow according to economic factors. This review introduces various tools for process management and its application in radiology. By means of simple paper-based methods, the work flow of most processes can be analyzed. For more complex work flow, it is suggested to choose a method that allows for an exact qualitative and quantitative prediction of the effect of variations. This review introduces network planning technique and process simulation.