1
|
Schneiders J, Telo GH, Lavinsky D, Dos Reis MA, Corrêa BG, Schaan BD. Organizational intervention to improve access to retinopathy screening for patients with diabetes mellitus: health care service improvement project in a tertiary public hospital. Prim Care Diabetes 2023:S1751-9918(23)00101-8. [PMID: 37328386 DOI: 10.1016/j.pcd.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 03/27/2023] [Accepted: 05/28/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The aim of this study was to improve the access to diabetic retinopathy (DR) screening with retinographies in a tertiary care center through a process conducted by an interdisciplinary group driven by a nurse. MATERIALS AND METHODS This is a quality improvement study that evaluated the flow for DR screening conducted by an interdisciplinary group using the Plan-Do-Study-Act methodology. As a result measure, we assessed the quantity of retinographies performed after the project implementation, the proportion of patients who presented abnormal retinographies, and the proportion of patients referred to a specialist. RESULTS The new patient screening flow and the reinforcement of available human resources led to an increase in the number of retinographies performed and screened patients. A total of 1184 retinographies were conducted, and it was possible to observe DR alterations in 37.8 % patients, of which only 6 % needed to be referred to the DR reference center. CONCLUSIONS This study showed a significant increase in the number of retinographies performed. The Plan-Do-Study-Act methodology was an important tool to improve the flow of patient access to fundus images, helping to consistently and continuously improve these processes.
Collapse
Affiliation(s)
| | - Gabriela H Telo
- Graduate Program, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Internal Medicine Department, Hospital São Lucas, Porto Alegre, Brazil
| | - Daniel Lavinsky
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - Beatriz D Schaan
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil; Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| |
Collapse
|
2
|
Slocum JD, Holl JL, Love R, Shi M, Mackersie R, Alam H, Loftus TM, Andersen R, Bilimoria KY, Stey AM. Defining obstacles to emergency transfer of trauma patients: An evaluation of retriage processes from nontrauma and lower-level Illinois trauma centers. Surgery 2022; 172:1860-1865. [PMID: 36192213 PMCID: PMC10111878 DOI: 10.1016/j.surg.2022.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/15/2022] [Accepted: 08/24/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Retriage is the emergency transfer of severely injured patients from nontrauma and lower-level trauma centers to higher-level trauma centers. We identified the barriers to retriage at sending centers in a single health system. METHODS We conducted a failure modes effects and criticality analysis at 4 nontrauma centers and 5 lower-level trauma centers in a single health system. Clinicians from each center described the steps in the trauma assessment and retriage process to create a process map. We used standardized scoring to characterize each failure based on frequency, impact on retriage, and prevention safeguards. We ranked each failure using the scores to calculate a risk priority number. RESULTS We identified 26 steps and 93 failures. The highest-risk failure was refusal by higher-level trauma centers (receiving hospitals) to accept a patient. The most critical failures in the retriage process based on total risk, frequency, and safeguard scores were (1) refusal from a receiving higher-level trauma center to accept a patient (risk priority number = 191), (2) delay in a sending center's consultant examination of a patient in the emergency department (risk priority number = 177), and (3) delay in receiving hospital's consultant calling back (risk priority number = 177). CONCLUSION We identified (1) addressing obstacles to determining clinical indications for retriage and (2) identifying receiving level I trauma centers who would accept the patient as opportunities to increase timely retriage. Establishing clear clinical indications for retriage that sending and receiving hospitals agree on represents an opportunity for intervention that could improve the retriage of injured patients.
Collapse
Affiliation(s)
- John D Slocum
- Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL
| | - Jane L Holl
- Department of Neurology, Center for Healthcare Delivery Science and Innovation, University of Chicago, IL
| | - Remi Love
- Surgical Outcomes and Quality Improvement Center, Northwestern University, Chicago, IL
| | - Meilynn Shi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Robert Mackersie
- Department of Surgery, School of Medicine, University of California-San Francisco, CA
| | - Hasan Alam
- Department of Surgery, School of Medicine, University of California-San Francisco, CA
| | - Timothy M Loftus
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rebecca Andersen
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Karl Y Bilimoria
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Anne M Stey
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| |
Collapse
|
3
|
Joshi T, Budhathoki P, Adhikari A, Poudel A, Raut S, Shrestha DB. Improving Medical Education: A Narrative Review. Cureus 2021; 13:e18773. [PMID: 34804650 PMCID: PMC8592289 DOI: 10.7759/cureus.18773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 12/05/2022] Open
Abstract
With the advancement in basic and clinical sciences, medical education is also constantly evolving. The Accreditation Council for Graduate Medical Education (ACGME) has endorsed six core competencies to improve teaching and learning. This narrative review was conducted after searching the article databases (PubMed, PubMed Central, Embase, and Scopus) about the core competencies such as medical knowledge (problem-based learning), interpersonal communication, patient care, professionalism, practice-based learning and improvement, and system-based care endorsed by ACGME. We included randomized and quasi-experimental trials, cohorts, and case-control studies in this narrative review. In a problem-based learning modality, a real-life scenario is allocated to a group of students. Studies have shown that it is more effectively demonstrated by a better post-test score, improved concentration, and application of knowledge. Interpersonal communication skills promote collaboration with interdisciplinary teams, work quality, and patient adherence to treatment. Professionalism is a human attribute that creates a pleasant work environment and is an essential trait that improves patients' adherence to treatment. In system-based care, patients are benefitted through a well-structured plan of care. Finally, in practice-based learning, medical trainees learn to systematically evaluate the pattern of care and practice the best modality to improve the overall patient care and physician satisfaction. These core competencies need to be incorporated into all levels of medical training.
Collapse
Affiliation(s)
- Tilak Joshi
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | | | - Anurag Adhikari
- Intensive Care Unit, Nepal Korea Friendship Municipality Hospital, Madhyapur Thimi, NPL
| | - Ayusha Poudel
- Department of Emergency Medicine, Alka Hospital Pvt. Ltd., Kathmandu, NPL
| | - Sumit Raut
- Department of Internal Medicine, Kathmandu Medical College, Kathmandu, NPL
| | - Dhan B Shrestha
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, USA
| |
Collapse
|
4
|
Raval MV, Wymore E, Ingram MCE, Tian Y, Johnson JK, Holl JL. Assessing effectiveness and implementation of a perioperative enhanced recovery protocol for children undergoing surgery: study protocol for a prospective, stepped-wedge, cluster, randomized, controlled clinical trial. Trials 2020; 21:926. [PMID: 33198767 PMCID: PMC7667817 DOI: 10.1186/s13063-020-04851-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perioperative enhanced recovery protocols (ERPs) have been found to decrease hospital length of stay, in-hospital costs, and complications among adult surgical populations but evidence for pediatric populations is lacking. The study is designed to evaluate the adoption, effectiveness, and generalizability of a 21-element ERP, adapted for pediatric surgery. METHODS The multicenter study is a stepped-wedge, cluster-randomized, pragmatic clinical trial that will evaluate the effectiveness of the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) intervention while also assessing site-specific adaptations, implementation fidelity, and sustainability. The target patient population is pediatric patients, between 10 and 18 years old, who undergo elective gastrointestinal surgery. Eighteen (N = 18) participating sites will be randomly assigned to one of three clusters with each cluster, in turn, being randomly assigned to an intervention start period (stepped-wedge). Each cluster will participate in a Learning Collaborative, using the National Implementation Research Network's five Active Implementation Frameworks (AIFs) (competency, organization, and leadership), as drivers of facilitation of rapid-cycle adaptations and implementation. The primary study outcome is hospital length of stay, with implementation metrics being used to evaluate adoption, fidelity, and sustainability. Additional clinical outcomes include opioid use, post-surgical complications, and post-discharge healthcare utilization (clinic/emergency room visits, telephone calls to clinic, and re-hospitalizations), as well as, assess patient- and parent-reported health-related quality of life outcomes. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist. DISCUSSION The study provides a unique opportunity to accelerate the adoption of ERPs across 18 US pediatric surgical centers and to evaluate, for the first time, the effect of a pediatric-specific ENRICH-US intervention on clinical and implementation outcomes. The study design and methods can serve as a model for future pediatric surgical quality improvement implementation efforts. TRIAL REGISTRATION ClinicalTrials.gov NCT04060303 . Registered on 07 August 2019.
Collapse
Affiliation(s)
- Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA. .,Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Erin Wymore
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA.,Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA
| | - Julie K Johnson
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, 633 N. St. Clair, 20th Floor, Chicago, IL, 60611, USA
| | - Jane L Holl
- Biological Science Division, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| |
Collapse
|
5
|
Stulberg JJ, Schäfer WLA, Shallcross ML, Lambert BL, Huang R, Holl JL, Bilimoria KY, Johnson JK. Evaluating the implementation and effectiveness of a multi-component intervention to reduce post-surgical opioid prescribing: study protocol of a mixed-methods design. BMJ Open 2019; 9:e030404. [PMID: 31164370 PMCID: PMC6561445 DOI: 10.1136/bmjopen-2019-030404] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Opioids prescribed after surgery accounted for 5% of the 191 million opioid prescriptions filled in 2017. Approximately 80% of the opioid pills prescribed by surgical care providers remain unused, leaving a substantial number of opioids available for non-medical use. We developed a multi-component intervention to address surgical providers' role in the overprescribing of opioids. Our study will determine effective strategies for reducing post-surgical prescribing while ensuring adequate post-surgery patient-reported pain-related outcomes, and will assess implementation of the strategies. METHODS AND ANALYSIS The Minimising Opioid Prescribing in Surgery study will implement a multi-component intervention, in an Illinois network of six hospitals (one academical, two large community and three small community hospitals), to decrease opioid analgesics prescribed after surgery. The multi-component intervention involves four domains: (1) patient expectation setting, (2) baseline assessment of opioid use, (3) perioperative pain control optimisation and (4) post-surgical opioid minimisation. Four surgical specialities (general, orthopaedics, urology and gynaecology) at the six hospitals will implement the intervention. A mixed-methods approach will be used to assess the implementation and effectiveness of the intervention. Data from the network's enterprise data warehouse will be used to evaluate the intervention's effect on post-surgical prescriptions and a survey will collect pain-related patient-reported outcomes. Intervention effectiveness will be determined using a triangulation design, mixed-methods approach with staggered speciality-specific implementation for contemporaneous control of opioid prescribing changes over time. The Consolidated Framework for Implementation Research will be used to evaluate the site-specific contextual factors and adaptations to achieve implementation at each site. ETHICS AND DISSEMINATION The study aims to identify the most effective hospital-type and speciality-specific intervention bundles for rapid dissemination into our 56-hospital learning collaborative and in hospitals throughout the USA. All study activities have been approved by the Northwestern University Institutional Review Board (ID STU00205053).
Collapse
Affiliation(s)
- Jonah J Stulberg
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Willemijn L A Schäfer
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Meagan L Shallcross
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Bruce L Lambert
- Centre for Communication and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Reiping Huang
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Jane L Holl
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Karl Y Bilimoria
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Julie K Johnson
- Surgical Outcomes & Quality Improvement Centre (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
- Centre for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| |
Collapse
|
6
|
O'Leary KJ, Johnson JK, Manojlovich M, Goldstein JD, Lee J, Williams MV. Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems. BMC Health Serv Res 2019; 19:293. [PMID: 31068161 PMCID: PMC6505207 DOI: 10.1186/s12913-019-4116-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 04/22/2019] [Indexed: 11/25/2022] Open
Abstract
Background A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality. Methods The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes. Discussion The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions. Trial registration NCT03745677. Retrospectively registered on November 19, 2018. Electronic supplementary material The online version of this article (10.1186/s12913-019-4116-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kevin J O'Leary
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario Street, Suite 700, Chicago, IL, 60611, USA.
| | - Julie K Johnson
- Department of Surgery and the Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Milisa Manojlovich
- Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA
| | - Jenna D Goldstein
- Center for Hospital Innovation and Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Jungwha Lee
- Department of Preventative Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark V Williams
- Center for Health Services Research, University of Kentucky College of Medicine, Lexington, KY, USA
| |
Collapse
|
7
|
Moeenuddin Z, Kim-Kupfer C, Owchar E, Baker J, Duffield A, Santoro T. The Influence of Care Coordination on Patients With Special Health Care Needs in a Pediatric Residency Continuity Clinic. Glob Pediatr Health 2019; 6:2333794X19848677. [PMID: 31106252 PMCID: PMC6507326 DOI: 10.1177/2333794x19848677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022] Open
Abstract
This study evaluates the influence of comprehensive health care coordination for children with special health care needs (CSHCN) in a resident continuity clinic. CSHCN patients were identified from 2 resident continuity panels. Patients were eligible with a score of 2 or greater on the CSHCN screener. Interventions included extended appointment times, a binder, and direct phone access to the social worker who facilitated follow-up appointment scheduling. Data measured included completed and no-show visits for primary care and subspecialty appointments, hospitalization and emergency department visits, use of binders, and parent satisfaction surveys. Patients with a baseline CSHCN screener score ≥4 were 15.6 times more likely to keep their appointment after enrollment (P = .0035). Mental health no-show visits decreased significantly (P < .0001). The utilization of components of comprehensive team-based care coordination, even with limited resources, can improve the delivery of health care for children with complex medical needs and mental health disorders in a resident-based clinic.
Collapse
|
8
|
Adams D. Quality improvement; part 1: introduction and overview. BJA Educ 2018; 18:89-94. [PMID: 33456816 PMCID: PMC7807853 DOI: 10.1016/j.bjae.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
- D. Adams
- Derriford Hospital, Plymouth, United Kingdom
| |
Collapse
|
9
|
Coury J, Schneider JL, Rivelli JS, Petrik AF, Seibel E, D'Agostini B, Taplin SH, Green BB, Coronado GD. Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Serv Res 2017. [PMID: 28629348 PMCID: PMC5477281 DOI: 10.1186/s12913-017-2364-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The Plan-Do-Study-Act (PDSA) cycle is a commonly used improvement process in health care settings, although its documented use in pragmatic clinical research is rare. A recent pragmatic clinical research study, called the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), used this process to optimize the research implementation of an automated colon cancer screening outreach program in intervention clinics. We describe the process of using this PDSA approach, the selection of PDSA topics by clinic leaders, and project leaders’ reactions to using PDSA in pragmatic research. Methods STOP CRC is a cluster-randomized pragmatic study that aims to test the effectiveness of a direct-mail fecal immunochemical testing (FIT) program involving eight Federally Qualified Health Centers in Oregon and California. We and a practice improvement specialist trained in the PDSA process delivered structured presentations to leaders of these centers; the presentations addressed how to apply the PDSA process to improve implementation of a mailed outreach program offering colorectal cancer screening through FIT tests. Center leaders submitted PDSA plans and delivered reports via webinar at quarterly meetings of the project’s advisory board. Project staff conducted one-on-one, 45-min interviews with project leads from each health center to assess the reaction to and value of the PDSA process in supporting the implementation of STOP CRC. Results Clinic-selected PDSA activities included refining the intervention staffing model, improving outreach materials, and changing workflow steps. Common benefits of using PDSA cycles in pragmatic research were that it provided a structure for staff to focus on improving the program and it allowed staff to test the change they wanted to see. A commonly reported challenge was measuring the success of the PDSA process with the available electronic medical record tools. Conclusion Understanding how the PDSA process can be applied to pragmatic trials and the reaction of clinic staff to their use may help clinics integrate evidence-based interventions into their everyday care processes. Trial registration Clinicaltrials.gov NCT01742065. Registered October 31, 2013.
Collapse
Affiliation(s)
- Jennifer Coury
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - Jennifer L Schneider
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Jennifer S Rivelli
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Evelyn Seibel
- Lean HealthCare West, 315 SW 5th Avenue, Suite 900, Portland, OR, 97204, USA
| | - Brieshon D'Agostini
- Multnomah County Health Department, 426 SW Stark St, 8th Floor, Portland, OR, 97204, USA
| | - Stephen H Taplin
- Process of Care Research Branch, Behavioral Research Program, National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, MD, USA
| | - Beverly B Green
- Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA
| | - Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| |
Collapse
|
10
|
Pinnock H, Barwick M, Carpenter CR, Eldridge S, Grandes G, Griffiths CJ, Rycroft-Malone J, Meissner P, Murray E, Patel A, Sheikh A, Taylor SJC. Standards for Reporting Implementation Studies (StaRI): explanation and elaboration document. BMJ Open 2017; 7:e013318. [PMID: 28373250 PMCID: PMC5387970 DOI: 10.1136/bmjopen-2016-013318] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 01/09/2017] [Accepted: 01/11/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Implementation studies are often poorly reported and indexed, reducing their potential to inform the provision of healthcare services. The Standards for Reporting Implementation Studies (StaRI) initiative aims to develop guidelines for transparent and accurate reporting of implementation studies. METHODS An international working group developed the StaRI guideline informed by a systematic literature review and e-Delphi prioritisation exercise. Following a face-to-face meeting, the checklist was developed iteratively by email discussion and critical review by international experts. RESULTS The 27 items of the checklist are applicable to the broad range of study designs employed in implementation science. A key concept is the dual strands, represented as 2 columns in the checklist, describing, on the one hand, the implementation strategy and, on the other, the clinical, healthcare or public health intervention being implemented. This explanation and elaboration document details each of the items, explains the rationale and provides examples of good reporting practice. CONCLUSIONS Previously published reporting statements have been instrumental in improving reporting standards; adoption by journals and authors may achieve a similar improvement in the reporting of implementation strategies that will facilitate translation of effective interventions into routine practice.
Collapse
Affiliation(s)
- Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Melanie Barwick
- Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Psychiatry and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Christopher R Carpenter
- Division of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, USA
| | - Sandra Eldridge
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gonzalo Grandes
- Primary Care Research Unit of Bizkaia, Basque Health Service, Bilbao, Spain
| | - Chris J Griffiths
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jo Rycroft-Malone
- Bangor Institute for Health and Medical Research, Bangor University, Bangor, UK
| | - Paul Meissner
- Montefiore Medical Center, The University Hospital for Albert Einstein College of Medicine, New York, USA
| | - Elizabeth Murray
- Department of Primary Care and Population Health, University College London, London, UK
| | - Anita Patel
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Stephanie J C Taylor
- Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
11
|
Abstract
The Texas Medicaid 1115 Transformation Waiver reforms the state's safety net systems by creating a Delivery System Reform Incentive Payment incentive pool for innovative healthcare delivery. The Waiver supports the design and implementation of transformative projects. As part of the Waiver requirements, regions created Learning Collaboratives to collaborate on project implementation and outcomes. This paper describes the experience of one region in adapting the Institute for Healthcare Improvement Breakthrough Series (IHI BTS) model, as a framework for their Learning Collaborative. Implementation of the Learning Collaborative was systematic, multidimensional, and regularly evaluated. Some features of the IHI model were adapted, specifically longer Plan-Do-Check-Act cycles and the lack of a single clinical focus. This experience demonstrates the ability of a region to improve health from a more diverse perspective than the traditional IHI BTS Collaboratives. Within the region, organizations are connecting, agencies are building continuums of care, and stakeholders are involved in healthcare delivery. The initial stages show a remarkable increase in communication and enhanced relationships between providers. At the end of the 5-year Waiver, evaluation of the impact of the regional and cohort Learning Collaboratives will determine how well the adapted IHI BTS model facilitated improvements in the community's health.
Collapse
|
12
|
Francis MD, Julian KA, Wininger DA, Drake S, Bollman K, Nabors C, Pereira A, Rosenblum M, Zelenski AB, Sweet D, Thomas K, Varney A, Warm E, Francis ML. Continuity Clinic Model and Diabetic Outcomes in Internal Medicine Residencies: Findings of the Educational Innovations Project Ambulatory Collaborative. J Grad Med Educ 2016; 8:27-32. [PMID: 26913099 PMCID: PMC4763392 DOI: 10.4300/jgme-d-15-00073.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes. METHODS This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size. RESULTS No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001). CONCLUSIONS While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.
Collapse
Affiliation(s)
- Maureen D. Francis
- Corresponding author: Maureen D. Francis, MD, FACP, Texas Tech University Health Sciences Center El Paso, Department of Medical Education, 5001 El Paso Drive, El Paso, TX 79905, 915.215.4333, fax 915.783.1715,
| | | | | | | | | | | | | | | | | | | | | | | | | | - Mark L. Francis
- Corresponding author: Maureen D. Francis, MD, FACP, Texas Tech University Health Sciences Center El Paso, Department of Medical Education, 5001 El Paso Drive, El Paso, TX 79905, 915.215.4333, fax 915.783.1715,
| |
Collapse
|
13
|
Bogetz JF, Rassbach CE, Bereknyei S, Mendoza FS, Sanders LM, Braddock CH. Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2015; 90:1561-1572. [PMID: 26039140 DOI: 10.1097/acm.0000000000000773] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care. METHOD A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention. RESULTS A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives. CONCLUSIONS The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.
Collapse
Affiliation(s)
- Jori F Bogetz
- J.F. Bogetz is postdoctoral fellow and clinical instructor, Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. C.E. Rassbach is associate residency program director, pediatric hospitalist, and clinical assistant professor, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. S. Bereknyei is a research scholar, Stanford Center for Medical Education Research and Innovation (SCeMERI), Stanford University School of Medicine, Palo Alto, California. F.S. Mendoza is professor of pediatrics and chief, Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. L.M. Sanders is associate professor of pediatrics, Division of General Pediatrics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California. C.H. Braddock III is professor of medicine and vice dean for education, University of California, Los Angeles David Geffen School of Medicine, Los Angeles, California
| | | | | | | | | | | |
Collapse
|
14
|
Jones AC, Shipman SA, Ogrinc G. Republished: Key characteristics of successful quality improvement curricula in physician education: a realist review. Postgrad Med J 2015; 91:102-13. [PMID: 25655253 DOI: 10.1136/postgradmedj-2014-002846rep] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE Quality improvement (QI) is a common competency that must be taught in all physician training programmes, yet, there is no clear best approach to teach this content in clinical settings. We conducted a realist systematic review of the existing literature in QI curricula within the clinical setting, highlighting examples of trainees learning QI by doing QI. METHOD Candidate theories describing successful QI curricula were articulated a priori. We searched MEDLINE (1 January 2000 to 12 March 2013), the Cochrane Library (2013) and Web of Science (15 March 2013) and reviewed references of prior systematic reviews. Inclusion criteria included study design, setting, population, interventions, clinical and educational outcomes. The data abstraction tool included categories for setting, population, intervention, outcomes and qualitative comments. Themes were iteratively developed and synthesised using realist review methodology. A methodological quality tool assessed the biases, confounders, secular trends, reporting and study quality. RESULTS Among 39 studies, most were before-after design with resident physicians as the primary population. Twenty-one described clinical interventions and 18 described educational interventions with a mean intervention length of 6.58 (SD=9.16) months. Twenty-eight reported successful clinical improvements; no studies reported clinical outcomes that worsened. Characteristics of successful clinical QI curricula include attention to the interface of educational and clinical systems, careful choice of QI work for the trainees and appropriately trained local faculty. CONCLUSIONS This realist review identified success characteristics to guide training programmes, medical schools, faculty, trainees, accrediting organisations and funders to further develop educational and improvement resources in QI educational programmes.
Collapse
Affiliation(s)
- Anne C Jones
- Veterans Affairs Medical Center, White River Junction, Vermont, USA Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA Gannett Health Services, Cornell University, Ithaca, New York, USA
| | - Scott A Shipman
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA Association of American Medical Colleges, Washington, DC, Washington,USA
| | - Greg Ogrinc
- Veterans Affairs Medical Center, White River Junction, Vermont, USA Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| |
Collapse
|
15
|
Chronic care model as a framework to improve diabetes care at an academic internal medicine faculty-resident practice. J Ambul Care Manage 2015; 37:42-50. [PMID: 24309394 DOI: 10.1097/jac.0000000000000007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
We implemented a quality improvement project for diabetes care in a faculty-resident internal medicine practice, using the Chronic Care Model framework. We created a planned visit clinic, used a stepwise medication algorithm, and self-management support. The intervention was effective for patients with glycohemoglobin A1c levels 10 or above (P = .0075) when compared with usual care after adjusting for all significant predictors. Compliance with foot examinations increased by 72% (P < .0001) and pneumococcal vaccinations by 25% (P = .0115). We believe that the Chronic Care Model can be successfully integrated into faculty-resident practices and provides a model for further exploration into disease management education in academic settings.
Collapse
|
16
|
Abazari P. Diabetes management: Influential paradigms. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2015; 4:31. [PMID: 25884001 PMCID: PMC4392540 DOI: 10.4103/2277-9531.154130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Parvaneh Abazari
- Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran E-mail:
| |
Collapse
|
17
|
Blanchard RD, Pierce-Boggs K, Visintainer PF, Hinchey KT. Integrating Quality Improvement With Graduate Medical Education: Lessons Learned From the AIAMC National Initiatives. Am J Med Qual 2015; 31:240-5. [PMID: 25632049 DOI: 10.1177/1062860615569270] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Quality and safety initiatives (QI) are national priorities for health care, yet the role of residents in QI has not always been clear. In academic medical centers, residents and fellows play a critical role in patient care and, as such, their integration into QI presents a unique opportunity to affect change. The Alliance for Independent Academic Medical Centers (AIAMC) began a national campaign in 2007 to harness the potential of infusing graduate medical education (GME) with QI, through their AIAMC National Initiative: Improving Patient Care Through Medical Education. This article describes the National Initiatives (NIs) and the reflections of NI participants, including their reflections on the goals they set for integrating GME with QI, the barriers they encountered along the way, and their advice to others beginning the challenge. These reflections provide some insight into the pathways of promoting organizational change and offer practical insight and inspiring advice for others embarking on the journey.
Collapse
Affiliation(s)
- Rebecca D Blanchard
- Baystate Health, Springfield, MA Tufts University School of Medicine, Boston, MA
| | | | - Paul F Visintainer
- Baystate Health, Springfield, MA Tufts University School of Medicine, Boston, MA
| | - Kevin T Hinchey
- Baystate Health, Springfield, MA Tufts University School of Medicine, Boston, MA The Alliance of Independent Academic Medical Centers, Chicago, IL
| |
Collapse
|
18
|
Choi YJ, Shin DS, Kang M, Bae SS, Kim J. Evaluating Chronic Care of Public Health Centers in a Metropolitan City. HEALTH POLICY AND MANAGEMENT 2014. [DOI: 10.4332/kjhpa.2014.24.4.312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
19
|
Taylor SJC, Pinnock H, Epiphaniou E, Pearce G, Parke HL, Schwappach A, Purushotham N, Jacob S, Griffiths CJ, Greenhalgh T, Sheikh A. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02530] [Citation(s) in RCA: 191] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BackgroundDespite robust evidence concerning self-management for some long-term conditions (LTCs), others lack research explicitly on self-management and, consequently, some patient groups may be overlooked.AimTo undertake a rapid, systematic overview of the evidence on self-management support for LTCs to inform health-care commissioners and providers about what works, for whom, and in what contexts.MethodsSelf-management is ‘the tasks . . . individuals must undertake to live with one or more chronic conditions . . . [including] . . . having the confidence to deal with medical management, role management and emotional management of their conditions’. We convened an expert workshop and identified characteristics of LTCs potentially of relevance to self-management and 14 diverse exemplar LTCs (stroke, asthma, type 2 diabetes mellitus, depression, chronic obstructive pulmonary disease, chronic kidney disease, dementia, epilepsy, hypertension, inflammatory arthropathies, irritable bowel syndrome, low back pain, progressive neurological disorders and type 1 diabetes mellitus). For each LTC we conducted systematic overviews of systematic reviews of randomised controlled trials (RCTs) of self-management support interventions (‘quantitative meta-reviews’); and systematic overviews of systematic reviews of qualitative studies of patients’ experiences relating to self-management (‘qualitative meta-reviews’). We also conducted an original systematic review of implementation studies of self-management support in the LTCs. We synthesised all our data considering the different characteristics of LTCs. In parallel, we developed a taxonomy of the potential components of self-management support.ResultsWe included 30 qualitative systematic reviews (including 515 unique studies), 102 quantitative systematic reviews (including 969 RCTs), and 61 studies in the implementation systematic review. Effective self-management support interventions are multifaceted, should be tailored to the individual, their culture and beliefs, a specific LTC and position on the disease trajectory, and underpinned by a collaborative/communicative relationship between the patient and health-care professional (HCP) within the context of a health-care organisation that actively promotes self-management. Self-management support is a complex intervention and although many components were described and trialled in the studies no single component stood out as more important than any other. Core components include (1) provision of education about the LTC, recognising the importance of understanding patients’ pre-existing knowledge and beliefs about their LTC; (2) psychological strategies to support adjustment to life with a LTC; (3) strategies specifically to support adherence to treatments; (4) practical support tailored to the specific LTC, including support around activities of daily living for disabling conditions, action plans in conditions subject to marked exacerbations, intensive disease-specific training to enable self-management of specific clinical tasks; and (5) social support as appropriate. Implementation requires a whole-systems approach which intervenes at the level of the patient, the HCP and the organisation. The health-care organisation is responsible for providing the means (both training and time/material resources) to enable HCPs to implement, and patients to benefit from, self-management support, regularly evaluating self-management processes and clinical outcomes. More widely there is a societal need to address public understanding of LTCs. The lack of public story for many conditions impacted on patient help-seeking behaviour and public perceptions of need.ConclusionsSupporting self-management is inseparable from the high-quality care for LTCs. Commissioners and health-care providers should promote a culture of actively supporting self-management as a normal, expected, monitored and rewarded aspect of care. Further research is needed to understand how health service managers and staff can achieve this culture change in their health-care organisations.Study registrationThis study is registered as PROSPERO CRD42012002898.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Stephanie JC Taylor
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Hilary Pinnock
- Centre for Population Health Science, University of Edinburgh, Edinburgh, UK
| | - Eleni Epiphaniou
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gemma Pearce
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Hannah L Parke
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Anna Schwappach
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Neetha Purushotham
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Sadhana Jacob
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Chris J Griffiths
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Trisha Greenhalgh
- Centre for Primary Care and Public Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Aziz Sheikh
- Centre for Population Health Science, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
20
|
Jones AC, Shipman SA, Ogrinc G. Key characteristics of successful quality improvement curricula in physician education: a realist review. BMJ Qual Saf 2014; 24:77-88. [DOI: 10.1136/bmjqs-2014-002846] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
21
|
Callahan KE, Rogers MT, Lovato JF, Fernandez HM. A longitudinal, experiential quality improvement curriculum meeting ACGME competencies for geriatrics fellows: lessons learned. GERONTOLOGY & GERIATRICS EDUCATION 2013; 34:372-392. [PMID: 23972275 PMCID: PMC7880204 DOI: 10.1080/02701960.2013.815179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Quality improvement (QI) initiatives are critical in the care of older adults who are more vulnerable to substandard care. QI education meets aspects of core Accreditation Council of Graduate Medical Education competencies and prepares learners for the rising focus on performance measurement in health care. The authors developed, implemented, and evaluated a QI curriculum for geriatrics fellows. The evidence-based curriculum included didactics and a fellow-led QI intervention based on audit and feedback through the Practice Improvement Module in Care of the Vulnerable Elderly. QI knowledge, attitudes, and behaviors were assessed before and after the improvement project. Fellows' knowledge of QI improved (p = .0156), but behavior did not change significantly across a short-term improvement project. A structured focus group with fellows revealed themes of accountability and the importance of interprofessional teamwork in QI. QI education for geriatrics fellows can be feasible, well received, and prepare future physician leaders for patient-centered care, performance measurement, and effecting systems change.
Collapse
Affiliation(s)
- Kathryn E. Callahan
- Section on Gerontology and Geriatric Medicine, Department of Internal Medicine; and Clinical Geriatrics Fellowship , Sticht Center on Aging, Wake Forest School of Medicine , Winston-Salem , North Carolina , USA
| | | | - James F. Lovato
- Department of Public Health Sciences , Wake Forest University Health Sciences , Winston-Salem , North Carolina , USA
| | - Helen M. Fernandez
- Department of Geriatrics and Palliative Medicine; and Geriatrics Fellowship , Mount Sinai School of Medicine , New York , New York , USA
| |
Collapse
|
22
|
Transforming primary care training--patient-centered medical home entrustable professional activities for internal medicine residents. J Gen Intern Med 2013; 28:801-9. [PMID: 22997002 PMCID: PMC3663955 DOI: 10.1007/s11606-012-2193-3] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 07/02/2012] [Accepted: 07/23/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The U.S. faces a critical gap between residency training and clinical practice that affects the recruitment and preparation of internal medicine residents for primary care careers. The patient-centered medical home (PCMH) represents a new clinical microsystem that is being widely promoted and implemented to improve access, quality, and sustainability in primary care practice. AIM We address two key questions regarding the training of internal medicine residents for practice in PCMHs. First, what are the educational implications of practice transformations to primary care home models? Second, what must we do differently to prepare internal medicine residents for their futures in PCMHs? PROGRAM DESCRIPTION The 2011 Society of General Internal Medicine (SGIM) PCMH Education Summit established seven work groups to address the following topics: resident workplace competencies, teamwork, continuity of care, assessment, faculty development, 'medical home builder' tools, and policy. The output from the competency work group was foundational for the work of other groups. The work group considered several educational frameworks, including developmental milestones, competencies, and entrustable professional activities (EPAs). RESULTS The competency work group defined 25 internal medicine resident PCMH EPAs. The 2011 National Committee for Quality Assurance (NCQA) PCMH standards served as an organizing framework for EPAs. DISCUSSION The list of PCMH EPAs has the potential to begin to transform the education of internal medicine residents for practice and leadership in the PCMH. It will guide curriculum development, learner assessment, and clinical practice redesign for academic health centers.
Collapse
|
23
|
Kalanithi L, Coffey CE, Mourad M, Vidyarthi AR, Hollander H, Ranji SR. The Effect of a Resident-Led Quality Improvement Project on Improving Communication Between Hospital-Based and Outpatient Physicians. Am J Med Qual 2013; 28:472-9. [DOI: 10.1177/1062860613478976] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Arpana R. Vidyarthi
- Duke University–National University of Singapore Graduate School of Medicine, Singapore
| | | | | |
Collapse
|
24
|
Health districts as quality improvement collaboratives and multijurisdictional entities. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2013; 18:561-70. [PMID: 23023281 DOI: 10.1097/phh.0b013e31825b89fd] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Local health departments are increasingly challenged to meet emerging health problems at the same time that they are being challenged with dwindling resources and the demands of accreditation. OBJECTIVE To assess the capacity of Multicounty health districts to serve as "Quality Improvement Collaboratives" and support local health departments to meet accreditation standards. DESIGN The study used an online survey tool and follow-up phone calls with key informants in health districts and county health departments in Georgia. Data collection was primarily based on an instrument to measure Quality Improvement Collaboratives that was adapted and tested for use with public health agencies in Georgia. SETTING The Georgia PBRN conducted this study of health districts and county health departments. The Georgia Department of Public Health supports 18 health districts and 159 county health departments (GA DPH, 2011). The health districts range in county composition from 1 to 16 counties in each district. PARTICIPANTS Key informants comprised district and county health department staff and county health department board members were identified by 13 participating health district offices. RESULTS Key opinion leaders from both the rural and nonrural counties agreed that the Districts were important for providing essential services and supporting quality improvement collaboration. Psychometric testing of the Quality Improvement Collaborative assessment public health instrument yielded high scores for validity and reliability. CONCLUSIONS AND IMPLICATIONS Regionalization of local public health capacity is a critical emerging issue for public health accreditation and quality improvement. This study demonstrated the utility of regionalization across traditional local geopolitical boundaries.
Collapse
|
25
|
Yank V, Laurent D, Plant K, Lorig K. Web-based self-management support training for health professionals: a pilot study. PATIENT EDUCATION AND COUNSELING 2013; 90:29-37. [PMID: 23031610 DOI: 10.1016/j.pec.2012.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 08/31/2012] [Accepted: 09/07/2012] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate a web-based self-management training for health professionals. Patients spend 99% of their time outside the healthcare system. Thus self-management support from health professionals is central to optimal care. Our objective was to teach health professionals the skills to provide this support. METHODS Primary care residents and practicing providers enrolled in six groups. Each group received four web-based interactive training sessions derived from self-efficacy theory. Retrospective-pre/post assessed changes in self-management beliefs and confidence. Wilcoxon signed-rank tests with Bonferroni correction compared responses. Focus groups solicited qualitative feedback. RESULTS Fifty-seven residents and providers across the United States enrolled. Residents demonstrated positive changes on all belief questions (P 0.001-0.012). Practicing providers had a non-significant positive change on one and significant changes on the remainder (P 0.001-0.018). Both types of participants demonstrated significant increases on confidence questions regarding their ability to support self-management (P<0.01 for all). Participants described learned techniques as being useful, reducing burnout, and increasing acceptance of patient involvement in care planning. CONCLUSION The web-based self-management support training for health professionals was feasible and changed beliefs and confidence. PRACTICE IMPLICATIONS The program may maximize patient self-management by increasing provider self-efficacy and skill for self-management support.
Collapse
Affiliation(s)
- Veronica Yank
- Division of General Medical Disciplines, Stanford University, Stanford, CA 94304-5411, USA.
| | | | | | | |
Collapse
|
26
|
Houle J, Beaulieu MD, Lussier MT, Del Grande C, Pellerin JP, Authier M, Duplain R, Tran TM, Allison F. Patients' experience of chronic illness care in a network of teaching settings. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2012; 58:1366-73. [PMID: 23242897 PMCID: PMC3520666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate chronic illness care delivery from the patient's perspective and to examine its main correlates. DESIGN Cross-sectional, descriptive study using questionnaires and medical chart review. SETTING Nine teaching family practices in Quebec. PARTICIPANTS A total of 364 patients with diabetes, hypertension, or chronic obstructive pulmonary disease. MAIN OUTCOMES MEASURES Score on the Patient Assessment of Chronic Illness Care (PACIC) questionnaire, which evaluates the patient's perspective on the care received based on the chronic care model (CCM); patients characteristics (sex, level of education, number of chronic illnesses); patient-physician relationship (relational continuity, interpersonal communication assessed from the patient's perspective); and interdisciplinary care and technical quality of care abstracted from patients' medical charts. RESULTS The mean PACIC score obtained (2.8 out of 5) indicates that, on average, CCM-concordant care "generally did not occur" or occurred only "sometimes" in this network of teaching practices. However, with a mean technical quality-of-care score of nearly 80%, physicians in this network showed a high degree of adherence to clinical guidelines for the chronic illnesses under study. Patient education level lower than high school was negatively associated with PACIC scores, while positive associations were found with male sex, number of chronic illnesses, relational continuity, interpersonal communication, interdisciplinary care, and technical quality of care. CONCLUSION Patients with less education reported receiving less CCM-concordant care. The patient-physician relationship was the strongest correlate of PACIC scores, while interdisciplinary care and technical quality of care had modest contributions.
Collapse
Affiliation(s)
- Janie Houle
- Department of Psychology, Université du Québec à Montréal, PO Box 8888, Station Centre-ville, Montreal, QC H3C 3P8.
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Conn DL, Pan Y, Easley KA, Comeau DL, Carlone JP, Culler SD, Tiliakos A. The effect of the Arthritis Self-Management Program on outcome in African Americans with rheumatoid arthritis served by a public hospital. Clin Rheumatol 2012; 32:49-59. [DOI: 10.1007/s10067-012-2090-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 08/30/2012] [Accepted: 09/10/2012] [Indexed: 01/18/2023]
|
28
|
Fellner AN, Pettit RC, Sorscher J, Stephens L, Drake B, Welling RE. Chronic disease management: a residency-led intervention to improve outcomes in diabetic patients. Ochsner J 2012; 12:323-330. [PMID: 23267258 PMCID: PMC3527859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND When quality improvement processes are integrated into resident education, many opportunities are created for improved outcomes in patient care. For Bethesda Family Medicine (BFM), integrating quality improvement into resident education is paramount in fulfilling the Accreditation Council for Graduate Medical Education Practice-Based Learning and Improvement core competency requirements. METHODS A resident-developed diabetes management treatment protocol that targeted 11 evidence-based measures recommended for successful diabetes management was implemented within the BFM residency and all physician practices under its parent healthcare system. This study compares diabetes management at BFM and at 2 other family medicine practices at timepoints before and after protocol implementation. We measured hemoglobin A1c (HbA1c), low-density lipoprotein (LDL) cholesterol, and systolic blood pressure (SBP) in adult diabetics and compared patient outcomes for these measures for the first and third quarters of 2009 and 2010. RESULTS In BFM patients, HbA1c, LDL, and SBP levels decreased, but only HbA1c improvement persisted long term. For the comparison groups, in general levels were lower than those of BFM patients but not significantly so after the first measurement period. CONCLUSIONS A resident-led treatment protocol can improve HbA1c outcomes among residents' diabetic patients. Periodic educational interventions can enhance residents' focus on diabetes management. Residents in graduate medical education can initiate treatment protocols to improve patient care in a large healthcare system.
Collapse
Affiliation(s)
| | | | | | | | - Betsy Drake
- Mercy Medical Associates, Mariemont Family Medicine, Cincinnati, OH
| | | |
Collapse
|
29
|
MacLaurin A, McConnell H. Utilizing quality improvement methods to prevent falls and injury from falls: enhancing resident safety in long-term care. JOURNAL OF SAFETY RESEARCH 2011; 42:525-535. [PMID: 22152272 DOI: 10.1016/j.jsr.2011.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 08/31/2011] [Accepted: 10/04/2011] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Internationally, the growing evidence related to preventable adverse events within healthcare settings has resulted in the creation of numerous patient safety and quality improvement initiatives. In Canada, Safer Healthcare Now!, a national patient safety initiative of the Canadian Patient Safety Institute, and the Registered Nurses' Association of Ontario, the professional association representing registered nurses in Ontario, have partnered to combine quality improvement expertise with evidence-based practice expertise to accelerate improvement in the area of falls prevention and injury reduction. The synergistic relationship between Safer Healthcare Now! and the Registered Nurses' Association of Ontario has resulted in the evolution of the Safer Healthcare Now! national Falls Prevention intervention. The ultimate goal of the Falls Prevention intervention is to improve care by translating "what we know" into "what we do," by supporting quality improvement teams to make changes at the local level to enhance the patient experience. METHOD This article provides an overview of Safer Healthcare Now! as a national patient safety initiative, and highlights the results of a National Collaborative on Falls Prevention as a knowledge translation strategy utilized within the long-term care setting. A description of expanding supports for knowledge translation will also be provided.
Collapse
|
30
|
Salem JK, Jones RR, Sweet DB, Hasan S, Torregosa-Arcay H, Clough L. Improving care in a resident practice for patients with diabetes. J Grad Med Educ 2011; 3:196-202. [PMID: 22655142 PMCID: PMC3184903 DOI: 10.4300/jgme-d-10-00113.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Revised: 09/17/2010] [Accepted: 12/21/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Curricular redesign and introduction of the Chronic Care Model in our residency clinic during 2005-2007 achieved limited success in glycemic (glycated hemoglobin level [A(1c)]), lipid (low-density lipoprotein fraction [LDL]), and blood pressure (BP) control for patients with diabetes. INTERVENTION Beginning in January 2008, ancillary staff performed previsit, protocol-driven reviews of medical records of patients with diabetes to identify those not at A(1c), LDL, and BP goals; inserted electronic prompts into the records regarding deficiencies; and obtained samples for A(1c) or lipid panel when needed. Faculty feedback regarding resident-specific panel reviews was added in May 2008, and point-of-care A(1c) testing was implemented in February 2009. METHODS We conducted a 2-year retrospective study of all patients at our facility with diabetes mellitus, who had at least 1 visit during January to June 2008 (baseline) and 1 visit during July to December 2009 (follow-up). Measures included the most current A(1c), LDL, and BP results. Paired outcome results were compared using the McNemar χ(2) test. RESULTS A total of 522 patients with diabetes mellitus were seen during the baseline and follow-up periods, and 456 patients (87.4%) had paired A(1c) results, with A(1c) < 7.0% for 138 of 456 patients (30.3%) at baseline and 166 of 456 patients (36.4%) at follow-up (P = .011). For LDL, 460 patients (88.1%) had paired results, with LDL < 100 mg/dL for 225 of 460 patients (48.9%) at baseline and 262 of 460 patients (57.0%) at follow-up (P = .004). A total of 513 patients (98.3%) had paired BP results in which the BP < 130/80 mm Hg for 124 of 513 patients (24.2%) at baseline and for 188 of 513 patients (36.6%) at follow-up (P < .001). There were 421 patients (80.7%) with paired results for all 3 measures, with 17 of 421 patients (4.0%) at goal at baseline and 41 of 421 patients (9.7%) at goal at follow-up (P = .001). CONCLUSION The interventions resulted in statistically significant improvements in the proportion of patients with diabetes who attained goal for A(1c), LDL, and BP levels. Our redesign elements may be useful in enhancing resident education and in improving patient care.
Collapse
|
31
|
|
32
|
Abstract
Clinician educators-who work at the intersection of patient care and resident education-are well positioned to respond to calls for better, safer patient care and resident education. Explicit lessons that address implementing health care improvement and associated residency training came out of the Academic Chronic Care Collaboratives and include the importance of: (1) redesigning the clinical practice as a core component of the residency curriculum; (2) exploiting the efficiencies of the practice team; (3) replacing "faculty development" with "everyone's a learner;" (4) linking faculty across learning communities to build expertise; and (5) using rigorous methodology to design and evaluate interventions for practice redesign. There has been progress in addressing three thorny academic faculty issues-professional satisfaction, promotion and publication. For example, consensus criteria have been proposed for both faculty promotion as well as the institutional settings that nurture academic health care improvement careers, and the SQUIRE Publication Guidelines have been developed as a general framework for scholarly improvement publications. Extensive curricular resources exist for developing the expert faculty cadre. Curricula from representative training programs include quantitative and qualitative research methods, statistical methodologies appropriate for measuring systems change, organizational culture, management, leadership and scholarly writing for the improvement literature. Clinician educators-particularly those in general internal medicine-bear the principal responsibility for both patient care and resident training in academic departments of internal medicine. The intersection of these activities presents a unique opportunity for their playing a central role in implementing health care improvement and associated residency training. However, this role in academic settings will require an unambiguous development strategy both for faculty and their institutions.
Collapse
Affiliation(s)
- David P Stevens
- Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH 03766, USA.
| | | |
Collapse
|
33
|
Johnson JK, Woods DM, Stevens DP, Bowen JL, Provost LP, Sixta CS, Wagner EH. Joy and challenges in improving chronic illness care: capturing daily experiences of academic primary care teams. J Gen Intern Med 2010; 25 Suppl 4:S581-5. [PMID: 20737233 PMCID: PMC2940446 DOI: 10.1007/s11606-010-1408-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education. OBJECTIVE We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member's experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork. DESIGN The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members' daily work and subsequent outcomes. PARTICIPANTS Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff. APPROACH Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative). KEY RESULTS At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or "Joy in Work". In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments-"lack of professional satisfaction" and awareness of "system failures". CONCLUSIONS The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.
Collapse
Affiliation(s)
- Julie K Johnson
- Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.
| | | | | | | | | | | | | |
Collapse
|