The role of perceived team effectiveness in improving chronic illness care

Explaining variation in perceived team effectiveness: results from eleven quality improvement collaboratives

AIMS AND OBJECTIVES

Explore effectiveness of 11 collaboratives focusing on 11 different topics, as perceived by local improvement teams and to explore associations with collaborative-, organisational- and team-level factors.

BACKGROUND

Evidence underlying the effectiveness of quality improvement collaboratives is inconclusive and few studies investigated determinants of implementation success. Moreover, most evaluation studies on quality improvement collaboratives are based on one specific topic or quality problem, making it hard to compare across collaboratives addressing different topics.

DESIGN

A multiple-case cross-sectional study.

METHODS

Quality improvement teams in 11 quality improvement collaboratives focusing on 11 different topics. Team members received a postal questionnaire at the end of each collaborative. Of the 283 improvement teams, 151 project leaders and 362 team members returned the questionnaire.

RESULTS

Analysis of variance revealed that teams varied widely on perceived effectiveness. Especially, members in the Prevention of Malnutrition and Prevention of Medication Errors collaboratives perceived a higher effectiveness than other groups. Multilevel regression analyses showed that educational level of professionals, innovation attributes, organisational support, innovative culture and commitment to change were all significant predictors of perceived effectiveness. In total, 27·9% of the individual-level variance, 57·6% of the team-level variance and 80% of the collaborative-level variance could be explained.

CONCLUSION

The innovation's attributes, organisational support, an innovative team culture and professionals' commitment to change are instrumental to perceived effectiveness. The results support the notion that a layered approach is necessary to achieve improvements in quality of care and provides further insight in the determinants of success of quality improvement collaboratives.

RELEVANCE TO CLINICAL PRACTICE

Understanding which factors enhance the impact of quality improvement initiatives can help professionals to achieve breakthrough improvement in care delivery to patients on a wide variety of quality problems.

Systems antecedents for dissemination and implementation: a review and analysis of measures

There is a growing emphasis on the role of organizations as settings for dissemination and implementation. Only recently has the field begun to consider features of organizations that affect dissemination and implementation of evidence-based interventions. This manuscript identifies and evaluates available measures for five key organizational-level constructs: (a) leadership, (b) vision, (c) managerial relations, (d) climate, and (e) absorptive capacity. Overall the picture was the same across the five constructs--no measure was used in more than one study, many studies did not report the psychometric properties of the measures, some assessments were based on a single response per unit, and the level of the instrument and analysis did not always match. One must seriously consider the development and evaluation of a robust set of measures that will serve as the basis of building the field, allow for comparisons across organizational types and intervention topics, and allow a robust area of dissemination and implementation research to develop.

Challenge of changing nursing home prescribing culture

This article described a framework for improving prescribing in nursing homes (NH) by focusing on the whole facility as a system that has created a "prescribing culture." We offered this paradigm as an alternative to focused interventions that target prescribers only. We used the example of atypical antipsychotics to illustrate the approach. We also highlighted elements of the NH culture change movement that are germane to medication prescribing, and illustrated which elements of NH culture were shown to be associated with suboptimal quality of care. We concluded by describing current models, including our study funded by the Agency for Healthcare Research and Quality, to identify the best methods of disseminating evidence-based medication use guides in NHs.

Employing continuous quality improvement in community-based substance abuse programs

PURPOSE

This article aims to describe continuous quality improvement (CQI) for substance abuse prevention and treatment programs in a community-based organization setting.

DESIGN/METHODOLOGY/APPROACH

CQI (e.g., plan-do-study-act cycles (PDSA)) applied in healthcare and industry was adapted for substance abuse prevention and treatment programs in a community setting. The authors assessed the resources needed, acceptability and CQI feasibility for ten programs by evaluating CQI training workshops with program staff and a series of three qualitative interviews over a nine-month implementation period with program participants. The CQI activities, PDSA cycle progress, effort, enthusiasm, benefits and challenges were examined.

FINDINGS

Results indicated that CQI was feasible and acceptable for community-based substance abuse prevention and treatment programs; however, some notable resource challenges remain. Future studies should examine CQI impact on service quality and intended program outcomes.

RESEARCH LIMITATIONS/IMPLICATIONS

The study was conducted on a small number of programs. It did not assess CQI impact on service quality and intended program outcomes. Practical implications- This project shows that it is feasible to adapt CQI techniques and processes for community-based programs substance abuse prevention and treatment programs. These techniques may help community-based program managers to improve service quality and achieve program outcomes.

ORIGINALITY/VALUE

This is one of the first studies to adapt traditional CQI techniques for community-based settings delivering substance abuse prevention and treatment programs.

Behaviors of successful interdisciplinary hospital quality improvement teams

BACKGROUND

Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams.

OBJECTIVE

We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times.

DESIGN

Qualitative study.

PARTICIPANTS

Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times.

MEASUREMENTS

Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals.

RESULTS

Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively.

CONCLUSIONS

The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff.

A longitudinal, multi-level comparative study of quality and safety in European hospitals: the QUASER study protocol

BACKGROUND

although there is a wealth of information available about quality improvement tools and techniques in healthcare there is little understanding about overcoming the challenges of day-to-day implementation in complex organisations like hospitals. The 'Quality and Safety in Europe by Research' (QUASER) study will investigate how hospitals implement, spread and sustain quality improvement, including the difficulties they face and how they overcome them. The overall aim of the study is to explore relationships between the organisational and cultural characteristics of hospitals and how these impact on the quality of health care; the findings will be designed to help policy makers, payers and hospital managers understand the factors and processes that enable hospitals in Europe to achieve-and sustain-high quality services for their patients.

METHODS/DESIGN

in-depth multi-level (macro, meso and micro-system) analysis of healthcare quality policies and practices in 5 European countries, including longitudinal case studies in a purposive sample of 10 hospitals. The project design has three major features: • a working definition of quality comprising three components: clinical effectiveness, patient safety and patient experience • a conceptualisation of quality as a human, social, technical and organisational accomplishment • an emphasis on translational research that is evidence-based and seeks to provide strategic and practical guidance for hospital practitioners and health care policy makers in the European Union. Throughout the study we will adopt a mixed methods approach, including qualitative (in-depth, narrative-based, ethnographic case studies using interviews, and direct non-participant observation of organisational processes) and quantitative research (secondary analysis of safety and quality data, for example: adverse incident reporting; patient complaints and claims).

DISCUSSION

the protocol is based on the premise that future research, policy and practice need to address the sociology of improvement in equal measure to the science and technique of improvement, or at least expand the discipline of improvement to include these critical organisational and cultural processes. We define the 'organisational and cultural characteristics associated with better quality of care' in a broad sense that encompasses all the features of a hospital that might be hypothesised to impact upon clinical effectiveness, patient safety and/or patient experience.

Validity and usefulness of members reports of implementation progress in a quality improvement initiative: findings from the Team Check-up Tool (TCT)

BACKGROUND

Team-based interventions are effective for improving safety and quality of healthcare. However, contextual factors, such as team functioning, leadership, and organizational support, can vary significantly across teams and affect the level of implementation success. Yet, the science for measuring context is immature. The goal of this study is to validate measures from a short instrument tailored to track dynamic context and progress for a team-based quality improvement (QI) intervention.

METHODS

DESIGN

Secondary cross-sectional and longitudinal analysis of data from a clustered randomized controlled trial (RCT) of a team-based quality improvement intervention to reduce central line-associated bloodstream infection (CLABSI) rates in intensive care units (ICUs).

SETTING

Forty-six ICUs located within 35 faith-based, not-for-profit community hospitals across 12 states in the U.S.

POPULATION

Team members participating in an ICU-based QI intervention.

MEASURES

The primary measure is the Team Check-up Tool (TCT), an original instrument that assesses context and progress of a team-based QI intervention. The TCT is administered monthly. Validation measures include CLABSI rate, Team Functioning Survey (TFS) and Practice Environment Scale (PES) from the Nursing Work Index.

ANALYSIS

Temporal stability, responsiveness and validity of the TCT.

RESULTS

We found evidence supporting the temporal stability, construct validity, and responsiveness of TCT measures of intervention activities, perceived group-level behaviors, and barriers to team progress.

CONCLUSIONS

The TCT demonstrates good measurement reliability, validity, and responsiveness. By having more validated measures on implementation context, researchers can more readily conduct rigorous studies to identify contextual variables linked to key intervention and patient outcomes and strengthen the evidence base on successful spread of efficacious team-based interventions. QI teams participating in an intervention should also find data from a validated tool useful for identifying opportunities to improve their own implementation.

A systematic exploration of differences in contextual factors related to implementing the MOVE! weight management program in VA: a mixed methods study

BACKGROUND

In January 2006, Veterans Affairs (VA) disseminated the MOVE!® Weight Management Program to VA medical centers to address the high prevalence of overweight/obesity. In its second year, MOVE! implementation varied widely across facilities. The objective of this study was to understand contextual factors that facilitated or impeded implementation of MOVE! in VA medical centers in the second year after its dissemination.

METHODS

We used an embedded mixed methods cross-sectional study design. Qualitative and quantitative data were collected simultaneously with the primary purpose to explore contextual factors most likely to influence MOVE! implementation effectiveness at five purposively selected facilities. Facilities were selected to maximize variation with respect to participation in MOVE! by candidate Veterans. Semi-structured phone interviews were conducted with 24 staff across the five facilities. Quantitative responses were elicited followed by open-ended questions. The quantitative measures were adapted from a published implementation model. Qualitative analysis was conducted using rigorous content analysis methods.

RESULTS

Qualitative and quantitative data converged to strengthen findings that point to several recommendations. Management support can help increase visibility of the program, commit needed resources, and communicate the importance of implementation efforts. Establishing a receptive implementation climate can be accomplished by emphasizing the important role that weight management may have in reducing incidence and severity of obesity-related chronic conditions. Coalescing highly functioning multi-disciplinary teams was an essential step for more effective implementation of MOVE!. In some situations, local champions can overcome challenging barriers in facilities that lack sufficient management support.

CONCLUSIONS

Key organizational factors at local VA medical centers were strongly associated with MOVE! implementation. Results pointed to recommendations that can help accelerate large-scale dissemination of complex weight management programs.

Building collaborative capacity: promoting interdisciplinary teamwork in the absence of formal teams

BACKGROUND

Contradictory findings about the effectiveness of health care teams may relate to the actual structure of teams-loose rather than formal-and the nature of decision making-hierarchical rather than egalitarian. We introduce the concept of collaborative capacity-the likelihood that providers, no matter how brief their exchange, will collaborate as if they were members of an egalitarian team even in the absence of a formal team structure.

OBJECTIVE

To examine aspects and determinants of collaborative capacity, namely task interdependence, norms of working together, and egalitarian collaboration among interdisciplinary providers on health care units.

RESEARCH DESIGN

We collected survey data from unit-based staff in 45 units across 9 hospitals and 7 health systems in upstate New York. One thousand five hundred twenty-seven surveys were returned for an overall response rate of 68.5%.

RESULTS

Measures for team structure and collaboration do not vary significantly between hospitals, only by unit and occupational group, with higher status providers reporting greater interdependence, higher quality of interactions, and more collaborative influence in decision making. Clear task direction, namely an emphasis on patient-centered care, and organizational contexts supportive of work are both significantly associated with higher levels of task interdependence, quality of staff interactions, and collaborative influence.

CONCLUSIONS

Collaborative capacity is somewhat constrained by a rigid hierarchy of health care occupations and division of labor that make teamwork more similar than different across hospitals. At the unit level, collaborative capacity may be improved, however, by an emphasis on patient-centered care and a context that supports providers' work.

Organisational characteristics associated with the use of daily interruption of sedation in US hospitals: a national study

OBJECTIVE

Daily interruption of sedation (DIS) has multiple proven benefits, but implementation is erratic. Past research on sedative interruption utilisation focused on individual clinicians, ignoring the role of organisations in shaping practice. The authors test the hypothesis that specific hospital organisational characteristics are associated with routine use of DIS.

DESIGN AND SETTING

National, mailed survey to a stratified random sample of US hospitals in 2009. Respondents were the lead infection control professionals at each institution.

METHODS

Survey items enquired about DIS use, institutional structure, and organisational culture. Multivariable analysis was used to evaluate the independent association of these factors with DIS use.

RESULTS

A total of 386 hospitals formed our final analytic sample; the response rate was 69.4%. Hospitals ranged in size from 25 to 1359 beds. 26% of hospitals were associated with a medical school. Almost 80% reported regular use of DIS for ventilated patients. While 75.4% of hospitals reported having leadership focus on safety culture, only 42.7% reported that their staff were receptive to changes in practice. In a multivariable logistic regression model, structural characteristics such as size and academic affiliation were not associated with use of DIS. However, leadership emphasis on safety culture (p=0.04), staff receptivity to change (p=0.02) and involvement in an infection prevention collaborative (p=0.04) were significantly associated with regular DIS use.

CONCLUSIONS

Several elements of hospital organisational culture were associated with regular use of DIS in US hospitals. These findings emphasise the importance of combining specific administrative approaches with strategies to encourage receptivity to change among bedside clinicians in order to successfully implement complex evidence-based practices in the intensive care setting.

Helping hands: a cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses

Background

Hand hygiene prescriptions are the most important measure in the prevention of hospital-acquired infections. Yet, compliance rates are generally below 50% of all opportunities for hand hygiene. This study aims at evaluating the short- and long-term effects of two different strategies for promoting hand hygiene in hospital nurses.

Methods/design

This study is a cluster randomised controlled trial with inpatient wards as the unit of randomisation. Guidelines for hand hygiene will be implemented in this study. Two strategies will be used to improve the adherence to guidelines for hand hygiene. The state-of-the-art strategy is derived from the literature and includes education, reminders, feedback, and targeting adequate products and facilities. The extended strategy also contains activities aimed at influencing social influence in groups and enhancing leadership. The unique contribution of the extended strategy is built upon relevant behavioural science theories. The extended strategy includes all elements of the state-of-the-art strategy supplemented with gaining active commitment and initiative of ward management, modelling by informal leaders at the ward, and setting norms and targets within the team. Data will be collected at four points in time, with six-month intervals. An average of 3,000 opportunities for hand hygiene in approximately 900 nurses will be observed at each time point.

Discussion

Performing and evaluating an implementation strategy that also targets the social context of teams may considerably add to the general body of knowledge in this field. Results from our study will allow us to draw conclusions on the effects of different strategies for the implementation of hand hygiene guidelines, and based on these results we will be able to define a preferred implementation strategy for hospital based nursing.

Trial registration

The study is registered as a Clinical Trial in ClinicalTrials.gov, dossier number: NCT00548015.

SCOPE: Safer care for older persons (in residential) environments: a study protocol

BACKGROUND

The current profile of residents living in Canadian nursing homes includes elder persons with complex physical and social needs. High resident acuity can result in increased staff workload and decreased quality of work life.

AIMS

Safer Care for Older Persons [in residential] Environments is a two year (2010 to 2012) proof-of-principle pilot study conducted in seven nursing homes in western Canada. The purpose of the study is to evaluate the feasibility of engaging front line staff to use quality improvement methods to integrate best practices into resident care. The goals of the study are to improve the quality of work life for staff, in particular healthcare aides, and to improve residents' quality of life.

METHODS/DESIGN

The study has parallel research and quality improvement intervention arms. It includes an education and support intervention for direct caregivers to improve the safety and quality of their care delivery. We hypothesize that this intervention will improve not only the care provided to residents but also the quality of work life for healthcare aides. The study employs tools adapted from the Institute for Healthcare Improvement's Breakthrough Series: Collaborative Model and Canada's Safer Healthcare Now! improvement campaign. Local improvement teams in each nursing home (1 to 2 per facility) are led by healthcare aides (non-regulated caregivers) and focus on the management of specific areas of resident care. Critical elements of the program include local measurement, virtual and face-to-face learning sessions involving change management, quality improvement methods and clinical expertise, ongoing virtual and in person support, and networking.

DISCUSSION

There are two sustainability challenges in this study: ongoing staff and leadership engagement, and organizational infrastructure. Addressing these challenges will require strategic planning with input from key stakeholders for sustaining quality improvement initiatives in the long-term care sector.

Patient Care Teams in treatment of diabetes and chronic heart failure in primary care: an observational networks study

Background

Patient care teams have an important role in providing medical care to patients with chronic disease, but insight into how to improve their performance is limited. Two potentially relevant determinants are the presence of a central care provider with a coordinating role and an active role of the patient in the network of care providers. In this study, we aimed to develop and test measures of these factors related to the network of care providers of an individual patient.

Methods

We performed an observational study in patients with type 2 diabetes or chronic heart failure, who were recruited from three primary care practices in The Netherlands. The study focused on medical treatment, advice on physical activity, and disease monitoring. We used patient questionnaires and chart review to measure connections between the patient and care providers, and a written survey among care providers to measure their connections. Data on clinical performance were extracted from the medical records. We used network analysis to compute degree centrality coefficients for the patient and to identify the most central health professional in each network. A range of other network characteristics were computed including network centralization, density, size, diversity of disciplines, and overlap among activity-specific networks. Differences across the two chronic conditions and associations with disease monitoring were explored.

Results

Approximately 50% of the invited patients participated. Participation rates of health professionals were close to 100%. We identified 63 networks of 25 patients: 22 for medical treatment, 16 for physical exercise advice, and 25 for disease monitoring. General practitioners (GPs) were the most central care providers for the three clinical activities in both chronic conditions. The GP's degree centrality coefficient varied substantially, and higher scores seemed to be associated with receiving more comprehensive disease monitoring. The degree centrality coefficient of patients also varied substantially but did not seem to be associated with disease monitoring.

Conclusions

Our method can be used to measure connections between care providers of an individual patient, and to examine the association between specific network parameters and healthcare received. Further research is needed to refine the measurement method and to test the association of specific network parameters with quality and outcomes of healthcare.

Structured diabetes care leads to differences in organization of care in general practices: the healthcare professional and patient perspective

Background

Care for patients with chronic diseases is challenging and requires multifaceted interventions to appropriately coordinate the entire treatment process. The effect of such interventions on clinical outcomes has been assessed, but evidence of the effect on organization of care is scarce.

The aim is to assess the effect of structured diabetes care on organization of care from the perspective of patients and healthcare professionals in routine practice, and to ascertain whether this effect persists

Methods

In a quasi-experimental study the effect of structured care (SC) was compared with care-as-usual (CAU). Questionnaires were sent to healthcare professionals (SC n = 31; CAU n = 11) and to patients (SC n = 301; CAU n = 102). A follow-up questionnaire was sent after formal support of the intervention ended (2007).

Results

SC does have an effect on the organization of care. More cooperation between healthcare professionals, less referrals to secondary care and more education were reported in the SC group as compared to the CAU group. These changes were found both at the healthcare professional and at the patient level. Organizational changes remained after formal support for the intervention support had ended.

Conclusion

According to patients and healthcare professionals, structured care does have a positive effect on the organization of care. The use of these two sources of information is important, not only to assess the value of changes in care for the patient and the healthcare provider but also to ascertain the validity of the results found.

Perceptions of team workers in youth care of what makes teamwork effective

In youth care, little is known about what makes teamwork effective. What is known mostly reflects the view of managers in care organisations, as objective outcome measures are lacking. The objective of this article was to explore the views of youth care workers in different types of teams on the relative importance of characteristics of teamwork for its effectiveness. Q methodology was used. Fifty-one respondents rank-order 34 opinion statements regarding characteristics of teamwork. Individual Q sorts were analysed using by-person factor analysis. The resulting factors, which represented team workers' views of what is important for effective teamwork, were interpreted and described using composite rankings of the statements for each factor and corresponding team workers' explanations. We found three views of what makes teamwork effective. One view emphasised interaction between team members as most important for team effectiveness. A second view pointed to team characteristics that help sustain communication within teams as being most important. In the third view, the team characteristics that facilitate individuals to perform as a team member were put forward as most important for teamwork to be effective. In conclusion, different views exist on what makes a team effective in youth care. These views correspond with the different types of teams active in youth care as well as in other social care settings.

Up close and (inter)personal: insights from a primary care practice's efforts to improve office relationships over time, 2003-2009

A growing body of literature suggests that interpersonal relationships between personnel in health care organizations can have an impact on the quality of care provided. Some research recommends that the fundamental practice transformation that is being urged in this current climate of health care reform may be aided by strong interpersonal practice relationships and communication. There is much to be learned, however, about what is involved in the process of addressing and improving interpersonal relationships in primary care practices. This case study offers insights into this process by examining 1 primary care practice's efforts to address interpersonal office issues over the course of its participation in 2 back-to-back quality improvement (QI) intervention studies. Our analysis is based on extensive qualitative data on this practice (observational data, interviews, and audio-recorded QI meetings) from 2003 to 2009. By tracing common themes and patterns of interaction over an extended period of time, we identify a variety of facilitators of and barriers to addressing interpersonal issues in the practice setting. We conclude by suggesting some implications from this case for future QI research.

The influence of context on quality improvement success in health care: a systematic review of the literature

CONTEXT

The mixed results of success among QI initiatives may be due to differences in the context of these initiatives.

METHODS

The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field.

FINDINGS

Forty-seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well-specified measures.

CONCLUSIONS

Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.

The influence of context on quality improvement success in health care: a systematic review of the literature

CONTEXT

The mixed results of success among QI initiatives may be due to differences in the context of these initiatives.

METHODS

The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field.

FINDINGS

Forty-seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well-specified measures.

CONCLUSIONS

Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.

Making sense of health information technology implementation: A qualitative study protocol

Background

Implementing new practices, such as health information technology (HIT), is often difficult due to the disruption of the highly coordinated, interdependent processes (e.g., information exchange, communication, relationships) of providing care in hospitals. Thus, HIT implementation may occur slowly as staff members observe and make sense of unexpected disruptions in care. As a critical organizational function, sensemaking, defined as the social process of searching for answers and meaning which drive action, leads to unified understanding, learning, and effective problem solving -- strategies that studies have linked to successful change. Project teamwork is a change strategy increasingly used by hospitals that facilitates sensemaking by providing a formal mechanism for team members to share ideas, construct the meaning of events, and take next actions.

Methods

In this longitudinal case study, we aim to examine project teams' sensemaking and action as the team prepares to implement new information technology in a tiertiary care hospital. Based on management and healthcare literature on HIT implementation and project teamwork, we chose sensemaking as an alternative to traditional models for understanding organizational change and teamwork. Our methods choices are derived from this conceptual framework. Data on project team interactions will be prospectively collected through direct observation and organizational document review. Through qualitative methods, we will identify sensemaking patterns and explore variation in sensemaking across teams. Participant demographics will be used to explore variation in sensemaking patterns.

Discussion

Outcomes of this research will be new knowledge about sensemaking patterns of project teams, such as: the antecedents and consequences of the ongoing, evolutionary, social process of implementing HIT; the internal and external factors that influence the project team, including team composition, team member interaction, and interaction between the project team and the larger organization; the ways in which internal and external factors influence project team processes; and the ways in which project team processes facilitate team task accomplishment. These findings will lead to new methods of implementing HIT in hospitals.

Effective cooperation influencing performance: a study in Dutch hospitals

OBJECTIVE

This study focuses on cooperation between physicians and managers and aspects of that cooperation that can provide leads for interventions aimed at enhancing hospital performance.

DESIGN

We performed a qualitative study on cooperation between physicians and managers and the influence of that cooperation on hospital performance, and structured the resulting data according to the conditions of Allport's theory on intergroup conflicts.

SETTING

General hospitals in the Netherlands.

PARTICIPANTS

Thirty physicians (surgical and internal) and managers (strategic, tactic and operational) working in five different hospitals.

INTERVENTIONS

In-depth interviews exploring the influence of cooperation between physicians and managers on hospital performance.

MAIN OUTCOME MEASURES

Respondents confirmed the complexity of the relationship between physicians and managers and the link between their cooperation and hospital performance. Mentioned aspects such as power and status differences, clarity in decision-making and personal click, are important in determining the effectiveness of the cooperation between physicians and managers.

RESULTS

Our study suggests that the effectiveness of cooperation between physicians and managers is related to the uptake of quality initiatives and hospital performance.

CONCLUSIONS

The complex relationship between physicians and managers can be referred to as an intergroup conflict situation. We combined Allport's Contact theory conditions with aspects found in our study leading to the following facilitating conditions: address common goals; create interdependent tasks; arrange the support of authorities and respect the medical domain. They will enhance intra-hospital cooperation and therewith hospital performance.

Adoption of policies to treat tobacco dependence in U.S. medical groups

BACKGROUND

There remains an ongoing need to reduce tobacco use in the U.S. Physician organizations, such as medical groups, can support healthcare providers to be more effective in their delivery of tobacco cessation by adopting practices recommended in the Public Health Service Clinical Practice Guideline for Treating Tobacco Use and Dependence (PHS Guideline).

PURPOSE

To document the extent to which activities to reduce tobacco use, as recommended in the PHS Guideline as system-level interventions, are provided within large medical groups in the U.S.

METHODS

During 2006-2007, data were collected on 339 medical groups operating in the U.S., with 20 or more physicians treating at least one of four chronic conditions. Organizations were surveyed regarding activities to reduce tobacco use as recommended in the PHS Guideline as system-level interventions (i.e., tobacco-use status documentation, policies to promote provider interventions, and staff dedicated to treating tobacco dependence). Between 2008 and 2009, bivariate associations and multivariate logistic regression models assessed the relationship of organizational characteristics and external incentives with adoption of systems strategies for treating tobacco dependence.

RESULTS

Nearly 83% of medical groups with 20 or more physicians operating in the U.S. in 2006-2007 have adopted one or more strategies recommended as effective to support the treatment of tobacco dependence. However, only 5.6% of medical groups engage in all eight tobacco control activities examined in this study. The two factors that were associated most consistently with medical group policies to treat tobacco dependence were the patient-centeredness of the organization and participation in a quality demonstration program.

CONCLUSIONS

There is much room for improvement in increasing medical group adoption of systems strategies to reduce tobacco use. The findings in this paper suggest recommendations to achieve these improvements.

Why is better mental health care so elusive?

PURPOSE

There are numerous barriers to improving healthcare delivery. This article summarizes contemporary theories and research evidence to focus on ways to motivate change within the hospital system to provide better health care.

CONCLUSIONS

Understanding multidisciplinary team processes, recognizing hospitals as systems, and ascertaining the unit culture is a prerequisite for leaders and policy makers to improve mental health practices.

PRACTICE IMPLICATIONS

Finding ways to deliver better health care to people with a mental illness is a high priority, and nurses have a central role to play in this pursuit of excellence.

Culture and quality care perceptions in a Pakistani hospital

PURPOSE

Organizational culture is a determinant for quality improvement. This paper aims to assess organizational culture in a hospital setting, understand its relationship with perceptions about quality of care and identify areas for improvement.

DESIGN/METHODOLOGY/APPROACH

The paper is based on a cross-sectional survey in a large clinical department that used two validated questionnaires. The first contained 20 items addressing perceptions of cultural typology (64 respondents). The second one assessed staff views on quality improvement implementation (48 faculty) in three domains: leadership, information and analysis and human resource utilization (employee satisfaction).

FINDINGS

All four cultural types received scoring, from a mean of 17.5 (group), 13.7 (developmental), 31.2 (rational) to 37.2 (hierarchical). The latter was the dominant cultural type. Group (participatory) and developmental (open) culture types had significant positive correlation with optimistic perceptions about leadership (r = 0.48 and 0.55 respectively, p < 0.00). Hierarchical (bureaucratic) culture was significantly negatively correlated with domains; leadership (r = -0.61,p < 0.00), information and analysis (-0.50, p < 0.00) and employee satisfaction (r = -0.55, p < 0.00). Responses reveal a need for leadership to better utilize suggestions for improving quality of care, strengthening the process of information analysis and encouraging reward and recognition for employees.

RESEARCH LIMITATIONS/IMPLICATIONS

It is likely that, by adopting a participatory and open culture, staff views about organizational leadership will improve and employee satisfaction will be enhanced. This finding has implications for quality care implementation in other hospital settings.

ORIGINALITY/VALUE

The paper bridges an important gap in the literature by addressing the relationship between culture and quality care perceptions in a Pakistani hospital. As such a new and informative perspective is added.

An evaluation of the influence of primary care team functioning on the health of Medicare beneficiaries

In service industries other than health care, unit employees who report a favorable service climate--characterized by commitment to a team concept and intrateam interactions that are supportive, collegial, and collaborative--have high levels of consumer satisfaction and work unit productivity. The authors evaluated whether similar primary care team (PCT) functioning influenced the short-term future health (SF-36) of elderly Medicare beneficiaries (N = 991) in a group model managed care organization (MCO). PCT functioning was assessed by surveys of practitioners and support staff on the MCO's 14 primary care practices and included measures of perceived task delegation, role collaboration, patient orientation, and team ownership. On average, patient physical and emotional health declined over 2 years. Medicare beneficiaries empanelled to relatively high functioning PCTs had significantly better physical and emotional health at 2 years following baseline assessment than those empanelled to relatively low functioning PCTs.

The organization of multidisciplinary care teams: modeling internal and external influences on cancer care quality

Quality cancer treatment depends upon careful coordination between multiple treatments and treatment providers, the exchange of technical information, and regular communication between all providers and physician disciplines involved in treatment. This article will examine a particular type of organizational structure purported to regularize and streamline the communication between multiple specialists and support services involved in cancer treatment: the multidisciplinary treatment care (MDC) team. We present a targeted review of what is known about various types of MDC team structures and their impact on the quality of treatment care, and we outline a conceptual model of the connections between team context, structure, process, and performance and their subsequent effects on cancer treatment care processes and patient outcomes. Finally, we will discuss future research directions to understand how MDC teams improve patient outcomes and how characteristics of team structure, culture, leadership, and context (organizational setting and local environment) contribute to optimal multidisciplinary cancer care.

The relationship between organizational culture of nursing staff and quality of care for residents with dementia: questionnaire surveys and systematic observations in nursing homes

BACKGROUND

Since the 1990s, several studies have shown that organizational culture is an important characteristic in long-term care. However, at the moment little is known about organizational culture and its relationship with quality of care.

OBJECTIVES

In this study, the relationship between organizational culture and quality of care in long-term care was investigated using the competing values framework. Thereto, two independent measurements of quality of care were applied: the perceived quality of care by nursing staff of dementia units and the observed quality of care on the units by researchers.

DESIGN

The study used a cross-sectional design.

SETTINGS

Data were collected on 11 dementia units in 11 Dutch nursing homes.

PARTICIPANTS

All nursing staff on the units were asked to complete a questionnaire, of whom 248 staff members responded. The average response rate on the 11 units was 63%.

METHODS

Data were collected during two days of field-work on each unit. Systematic observations were performed, and questionnaires were distributed among nursing staff. Data were analyzed using multilevel analyses.

RESULTS

Organizational culture was related to both perceived and observed quality of care on the units. Units that are characterized by a clan culture provide better quality of care, both in the eyes of the nursing staff as in the eyes of outsiders. Market culture, compared to clan culture, is negatively related to quality of care in this sample.

CONCLUSIONS

The results indicate that organizational culture in long-term dementia care is important for organizational performance.

Quantifying culture gaps between physicians and managers in Dutch hospitals: a survey

Background

The demands in hospitals for safety and quality, combined with limitations in financing health care require effective cooperation between physicians and managers. The complex relationship between both groups has been described in literature. We aim to add a perspective to literature, by developing a questionnaire which provides an opportunity to quantitatively report and elaborate on the size and content of differences between physicians and managers. Insight gained from use of the questionnaire might enable us to reflect on these differences and could provide practical tools to improve cooperation between physicians and managers, with an aim to enhance hospital performance.

Methods

The CG-Questionnaire was developed by adjusting, pre-testing, and shortening Kralewski's questionnaire, and appeared suitable to measure culture gaps. It was shortened by exploratory factor analysis, using principal-axis factoring extraction with Varimax rotation. The CG-Questionnaire was sent to all physicians and managers within 37 Dutch general hospitals. ANOVA and paired sample T-tests were used to determine significant differences between perceptions of daily work practices based in both professional cultures; culture gaps. The size and content of culture gaps were determined with descriptive statistics.

Results

The total response (27%) consisted of 929 physicians and 310 managers. The Cronbachs alpha's were 0.70 - 0.79. Statistical analyses showed many differences; culture gaps were found in the present situation; they were even larger in the preferred situation. Differences between both groups can be classified into three categories: (1) culture gaps in the present situation and not in the preferred, (2) culture gaps in the preferred situation and not in the present, and (3) culture gaps in both situations.

Conclusions

With data from the CG-Questionnaire it is now possible to measure the size and content of culture gaps between physicians and managers in hospitals. Results gained with the CG-Questionnaire enables hospitals to reflect on these differences. Combining the results, we distinguished three categories of increasing complexity. We linked these three categories to three methods from intergroup literature (enhanced information, contact and ultimately meta cognition) which could help to improve the cooperation between physicians and managers.

The chronic care model: which physician practice organizations adapt best?

Chronic diseases remain among the major causes of death and disability in Canada as well as in other western industrialized nations. The episodic, punctuated, acute care model of health service delivery that describes the organization and orientation of care delivery is ill prepared to meet the needs of society burdened by chronic illness. The chronic care model (CCM) has been advanced as a way by which primary care practices can be transformed to meet the challenge of chronic illness. The objective of this research is to examine how well primary care physician practices, including walk-in clinics, solo family practices, group family practices, community health centres and physicians practicing in primary care networks, are succeeding at implementing the components of the CCM. Results suggest that physician primary care practices have considerable way to go in implementing the model, with walk-in clinics and solo family practices showing the least progress in inculcating its components.

Improving chronic illness care: findings from a national study of care management processes in large physician practices

The use of evidence-based care management processes (CMPs) in physician practice is an important component of delivery-system reform.The authors used data from a 2006-2007 national study of large physician organizations-medical groups and independent practice associations (IPAs) to determine the extent to which organizations use CMPs, and to identify external (market) influences and organizational capabilities associated with CMP use. The study found that physician organizations use about half of recommended CMPs, most commonly disease registries, specially trained patient educators, and performance feedback to physicians. Physician organizations that reported participating in quality improvement programs, having a patient-centered focus, and being owned by a hospital or health maintenance organization used more CMPs. IPAs and very large medical groups used more CMPs than smaller groups. Organizations externally evaluated on quality measures used more CMPs than other organizations. These findings can inform efforts to stimulate the adoption of best practices for chronic illness care.

Practice changes associated with the Department of Veterans Affairs' Family Care Collaborative

BACKGROUND

The Department of Veterans Affairs (VA) provides rehabilitation for veterans with moderate to severe war injuries through four regional Polytrauma Rehabilitation Centers (PRCs). To standardize and improve care provided to these veterans' family members, health services researchers partnered with program leaders and rehabilitation specialists to implement a family care quality improvement collaborative.

OBJECTIVE

To describe practice changes associated with the Family Care Collaborative's intervention.

DESIGN

Cross-site, mixed-method evaluation.

PARTICIPANTS

Rehabilitation interdisciplinary team members (n = 226) working at the four participating sites.

INTERVENTIONS

The collaborative developed and implemented in a 6-month pilot a web-based tool to standardize and promote family-centered care.

OUTCOMES

Provider survey of family care, satisfaction with family care, and perceived competence in working with families; specific practice changes at each site; provider and facilitator perceptions of the collaborative work; and a validated measure to predict likelihood of success of the selected intervention.

MAIN RESULTS

Family-centered practices and satisfaction improved at sites with lower baseline scores (P < 0.05) and was equivalent across sites after the pilot. Providers initiated specific family-centered practices that often began at one site and spread to the others through the collaborative. Sites standardized family education and collaboration. Providers believed that the collaborative produced a "culture change" from patient-centered to family-centered care and viewed program leadership and health services researchers' involvement as crucial for success. Scores on the measure to predict successful implementation of the intervention beyond the pilot were promising.

CONCLUSIONS

Collaboratives that bring together clinicians, program leaders, and researchers may be useful for fostering complex change involving interdisciplinary teams.

Organizational factors and the cancer screening process

Cancer screening is a process of care consisting of several steps and interfaces. This article reviews what is known about the association between organizational factors and cancer screening rates and examines how organizational strategies can address the steps and interfaces of cancer screening in the context of both intraorganizational and interorganizational processes. We reviewed 79 studies assessing the relationship between organizational factors and cancer screening. Screening rates are largely driven by strategies to 1) limit the number of interfaces across organizational boundaries; 2) recruit patients, promote referrals, and facilitate appointment scheduling; and 3) promote continuous patient care. Optimal screening rates can be achieved when health-care organizations tailor strategies to the steps and interfaces in the cancer screening process that are most critical for their organizations, the providers who work within them, and the patients they serve.

Quality of HIV care provided by non-physician clinicians and physicians in Mozambique: a retrospective cohort study

OBJECTIVES

To compare HIV care quality provided by non-physician clinicians (NPC) and physicians.

DESIGN

Retrospective cohort study assessing the relationship between provider cadre and HIV care quality among non-pregnant adult patients initiating antiretroviral therapy (ART) in the national HIV care programme.

METHODS

Computerized medical records from patients initiating ART between July 2004 and October 2007 at two HIV public HIV clinics in central Mozambique were used to develop multivariate analyses evaluating differences in process and care continuity measures for patients whose initial provider was a NPC or physician.

RESULTS

A total of 5892 patients was included in the study, including 4093 (69.5%) with NPC and 1799 (30.5%) with physicians as initial providers. Those whose initial provider was a NPC were more likely to have a CD4 cell count 90-210 days [risk ratio (RR) 1.13, 1.04<RR<1.23] and 330-390 days (RR 1.12, 0.96<RR<1.31) after initiating ART. A large majority of patients adhered well to care, although patients whose initial provider was a NPC had more frequent clinical visits in the first year post-ART initiation (RR 1.02, 1.00<RR<1.05) and higher levels of adherence to antiretroviral medicines in the first 6 months after initiating ART (RR1.05, 1.02<RR<1.09). Patients of NPC were less likely to be lost to follow-up than those seen by physicians (RR 0.86, 0.73<RR<1.02).

CONCLUSION

NPC performance was similar to or better than that of physicians for the HIV care quality study measures. Our results highlight the important role of NPC in scaling up ART in Mozambique, and argue for using all relevant clinical resources to meet the large demands for care in countries with high HIV burdens.

Using quantitative and qualitative approaches to understand racial disparities in adult vaccination

BACKGROUND

One proposed explanation for the persistence of racial disparities in adult immunizations is that minority patients receive primary care at practices that differ substantively from practices where white patients receive care. This study used both quantitative and qualitative methods to assess physician and practice factors contributing to disparities in a sample of inner-city, urban, and suburban practices in low to moderate income neighborhoods.

METHODS

Pneumococcal polysaccharide vaccine (PPV) and influenza vaccination rates were determined from medical record review in a sample of 2021 elderly (aged > or = 65 years) patients. Their physicians were surveyed about office systems for adult immunizations and structured observations of practice physical features, and operations were conducted. Case studies of practices with lowest and highest rates and the largest racial disparities are presented.

RESULTS

Overall, weighted PPV vaccination rate was 60%, but rates differed significantly by race (65.8% for whites vs 36.5% for minorities, P < .001 by stratified Cochran-Mantel-Haenszel test). Two of 6 minority panels had PPV rates less than 20%. Overall, weighted influenza vaccination rate, as measured by receipt of the vaccine in 3 of the 5 most recent seasons, was 51.9%, but rates also differed significantly by race (55.6% for whites vs 36.2% for minorities, P < .03, by stratified Cochran-Mantel-Haenszel test).

CONCLUSIONS

Low rates in 2 minority panels, racial disparity between minorities and whites in mixed panels, and between-panel variation in rates contributed to the overall differences in vaccination rates by race.

Understanding adult vaccination in urban, lower-socioeconomic settings: influence of physician and prevention systems

PURPOSE

Vaccination rates for pneumococcal polysaccharide vaccine (PPV) and influenza vaccine are relatively low in disadvantaged urban populations. This study was designed to assess which physician and practice characteristics might explain differences in rates across physicians.

METHODS

PPV and influenza vaccination rates were determined for 2,021 patients aged 65 years and older receiving care from 30 physicians in 17 practices surveyed about their office systems for providing adult immunizations. Hierarchical linear modeling (HLM) analyses were used to examine the relationships among vaccination rates, patient-level characteristics, and physician variables.

RESULTS

Overall, the weighted PPV vaccination rate was 60.0% and varied widely across physicians (range, 11%-98%). At the patient level in HLM, patient race (P=.01) and age (P = .02), but not neighborhood income, were associated with PPV status. By linking physician survey data with PPV rates, we found the best pair of physician variables to be "reported time spent with patients for a well visit" (P = .01) and "use of enhanced immunization documentation" (P=.10). The overall influenza vaccination rate was 51.9% (range, 22%-96%). Patient race (P=.003) and age (P = .002) were associated with influenza vaccination. The pair of physician variables with the strongest association with influenza vaccination was "use of standing orders" (P <.001) and "average observed physician examination room time," regardless of visit type (P=.02).

CONCLUSIONS

Vaccination rates vary widely in urban settings and are associated with practice characteristics such as time spent with patients and, for influenza vaccine, use of standing orders.

Consequences of Participating in Multidisciplinary Medical Team Meetings for Surgical, Nonsurgical, and Supporting Specialties

This study examines the consequences for medical specialists of participating in multidisciplinary medical team meetings in terms of perceived clinical autonomy, domain distinctiveness, and professional accountability. These consequences may influence their willingness to cooperate and the quality of teamwork. The authors hypothesized that multidisciplinary medical team meetings would be more of a threat to the professional identity of surgical specialists than to the professional identity of nonsurgical and supporting specialists. A survey among 1,827 Dutch medical specialists supported the authors’ hypotheses. However, a few specific specialties had response patterns that deviated from our expectations. The results are related to specialty choice, to the training of medical specialties, and to having a role in leading team meetings.

Case management for long-term conditions: implementation and processes

This paper presents a structured literature review that focused on comprehensive case management by nurses for adults with long-term conditions living in the community. The emphases of the review are the implementation of case-management approaches, including its roles, core tasks and components, and the coverage and quality of the reported implementation data. Twenty-nine studies were included: the majority were concerned with case management for frail older people, and others focused on people with multiple chronic diseases, high-cost patients, or those at high risk of hospital admissions. All the studies reported that case managers undertook the core tasks of assessment, care planning and the implementation of the care plan, but there was more variation in who carried out case finding, monitoring, review and case closure. Few studies provided adequate implementation information. On the basis of the reviewed evidence, three issues were identified as key to the coherent and sustainable implementation of case management for people with long-term conditions: fidelity to the core elements of case management; size of caseload; and case-management practice, incorporating matters relating to the continuity of care, the intensity and breadth of involvement, and control over resources. It is recommended that future evaluations of case-management interventions include a comprehensive process component or, at the very least, that interventions should be more fully described.

Associations between organizational characteristics and quality improvement activities of clinics participating in a quality improvement collaborative

BACKGROUND

Few studies have rigorously evaluated the associations between organizational characteristics and intervention activities of health care organizations participating in quality improvement collaboratives (QICs).

OBJECTIVE

To examine the relationship between clinic characteristics and intervention activities by primary care clinics that provide HIV care and that participated in a QIC.

DESIGN

Cross-sectional study of Ryan White CARE Act (now called Ryan White HIV/AIDS Treatment Modernization Act) funded clinics that participated in a QIC over 16 months in 2000 and 2001. The QIC was originally planned to be a more typical 12 months long, but was extended to increase the likelihood of success. Data were collected using surveys of clinicians and administrators in participating clinics and monthly reports of clinic improvement activities.

MEASURES

Number of interventions attempted, percent of interventions repeated, percent of interventions evaluated, and organizational characteristics.

RESULTS

Clinics varied significantly in their intervention choices. Organizations with a more open culture and a greater emphasis on quality improvement attempted more interventions (P < 0.01, P < 0.05) and interventions that were more comprehensive (P < 0.01, P < 0.10). Presence of multidisciplinary teams and measurement of progress toward quantifiable goals also were associated with comprehensiveness of interventions (P < 0.01, P < 0.05).

CONCLUSION

Clinic characteristics predicted intervention activities during a QIC. Further research is needed on how these organizational characteristics affect quality of care through their influence on intervention activities.

Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

BACKGROUND

Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.

METHODS

We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.

RESULTS

The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.

CONCLUSION

The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science

BACKGROUND

Many interventions found to be effective in health services research studies fail to translate into meaningful patient care outcomes across multiple contexts. Health services researchers recognize the need to evaluate not only summative outcomes but also formative outcomes to assess the extent to which implementation is effective in a specific setting, prolongs sustainability, and promotes dissemination into other settings. Many implementation theories have been published to help promote effective implementation. However, they overlap considerably in the constructs included in individual theories, and a comparison of theories reveals that each is missing important constructs included in other theories. In addition, terminology and definitions are not consistent across theories. We describe the Consolidated Framework For Implementation Research (CFIR) that offers an overarching typology to promote implementation theory development and verification about what works where and why across multiple contexts.

METHODS

We used a snowball sampling approach to identify published theories that were evaluated to identify constructs based on strength of conceptual or empirical support for influence on implementation, consistency in definitions, alignment with our own findings, and potential for measurement. We combined constructs across published theories that had different labels but were redundant or overlapping in definition, and we parsed apart constructs that conflated underlying concepts.

RESULTS

The CFIR is composed of five major domains: intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation. Eight constructs were identified related to the intervention (e.g., evidence strength and quality), four constructs were identified related to outer setting (e.g., patient needs and resources), 12 constructs were identified related to inner setting (e.g., culture, leadership engagement), five constructs were identified related to individual characteristics, and eight constructs were identified related to process (e.g., plan, evaluate, and reflect). We present explicit definitions for each construct.

CONCLUSION

The CFIR provides a pragmatic structure for approaching complex, interacting, multi-level, and transient states of constructs in the real world by embracing, consolidating, and unifying key constructs from published implementation theories. It can be used to guide formative evaluations and build the implementation knowledge base across multiple studies and settings.

An interprofessional team approach to fall prevention for older home care clients 'at risk' of falling: health care providers share their experiences

Background

Providing care for older home care clients ‘at risk’ of falling requires the services of many health care providers due to predisposing chronic, complex conditions. One strategy to ensure that quality care is delivered is described in the integrated care literature; interprofessional collaboration. Engaging in an interprofessional team approach to fall prevention for this group of clients seems to make sense. However, whether or not this approach is feasible and realistic is not well described in the literature. As well, little is known about how teams function in the community when an interprofessional approach is engaged in. The barriers and facilitators of such an approach are also not known.

Purpose

The purpose of this qualitative study was to describe the experiences of five different health care professionals as they participated in an interprofessional team approach to care for the frail older adult living at home and at risk of falling.

Methodology

This study took place in Hamilton, ON, Canada and was part of a randomized controlled trial, the aim of which was to determine the effects and costs of a multifactorial and interdisciplinary team approach to fall prevention for older home care clients ‘at risk’ of falling. The current study utilized an exploratory descriptive design to answer the following research questions: how do interprofessional teams describe their experiences when involved in a research intervention requiring collaboration for a 9-month period of time? What are the barriers and facilitators to teamwork? Four focus groups were conducted with the care-provider teams (n=9) 6 and 9 months following group formation.

Results

This study revealed several themes which included, team capacity, practitioner competencies, perceived outcomes, support and time. Overall, care providers were positive about their experiences and felt that through an interprofessional approach benefits could be experienced by both the provider and the patient and his/her family. Findings from this study suggest that research needs to be conducted to further explore the issues faced by this group of care providers and potential client outcomes.

Cost implications of organizing nursing home workforce in teams

OBJECTIVE

To estimate the costs associated with formal and self-managed daily practice teams in nursing homes.

DATA SOURCES/STUDY SETTING

Medicaid cost reports for 135 nursing homes in New York State in 2006 and survey data for 6,137 direct care workers.

STUDY DESIGN

A retrospective statistical analysis: We estimated hybrid cost functions that include team penetration variables. Inference was based on robust standard errors.

DATA COLLECTION

Formal and self-managed team penetration (i.e., percent of staff working in a team) were calculated from survey responses. Annual variable costs, beds, case mix-adjusted days, admissions, home care visits, outpatient clinic visits, day care days, wages, and ownership were calculated from the cost reports.

PRINCIPAL FINDINGS

Formal team penetration was significantly associated with costs, while self-managed teams penetration was not. Costs declined with increasing penetration up to 13 percent of formal teams, and increased above this level. Formal teams in nursing homes in the upward sloping range of the curve were more diverse, with a larger number of participating disciplines and more likely to include physicians.

CONCLUSIONS

Organization of workforce in formal teams may offer nursing homes a cost-saving strategy. More research is required to understand the relationship between team composition and costs.

Professional commitment to changing chronic illness care: results from disease management programmes

OBJECTIVE

The aim of this exploratory study was to investigate to what extent primary care professionals are able to change their systems for delivering care to chronic obstructive pulmonary disease (COPD) patients and what professional and organizational factors are associated with the degree of process implementation.

DESIGN

Quasi-experimental design with 1 year follow-up after intervention.

SETTING

Three regional COPD management programmes in the Netherlands, in which general practices cooperated with regional hospitals.

PARTICIPANTS

All participating primary care professionals (n = 52).

INTERVENTION

COPD management programme.

MAIN OUTCOME MEASURES

Professional commitment, organizational context and degree of process implementation.

RESULTS

Professionals significantly changed their systems for delivering care to COPD patients, namely self-management support, decision support, delivery system design and clinical information systems. Associations were found between organizational factors, professional commitment and changes in processes of care. Group culture and professional commitment appeared to be, to a moderate degree, predictors of process implementation.

CONCLUSIONS

COPD management was effective; all processes improved significantly. Moreover, theoretically expected associations between organizational context and professional factors with the implementation of COPD management were indeed confirmed to some extent. Group culture and professional commitment are important facilitators.