1
|
Connell NB, Zupanc SN, Lorenz KA, Bhatnagar S, Fereydooni S, Gamboa RC, Ganesh A, Satija A, Singh N, Spruijt O, Giannitrapani KF. Facilitators of palliative care quality improvement team cohesion: Lessons from a seven-site implementation project in India. Health Care Manage Rev 2023; 48:219-228. [PMID: 37158411 DOI: 10.1097/hmr.0000000000000368] [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] [Indexed: 05/10/2023]
Abstract
BACKGROUND The Palliative Care: Promoting Access and Improvement of the Cancer Experience (PC-PAICE) initiative is a team-based, palliative care (PC) quality improvement (QI) project working to promote high-quality PC in India. As a PC QI initiative, PC-PAICE implementation relied upon building interdisciplinary teams, providing the ideal context for understanding facilitators of team cohesion that compelled clinical, organizational, and administrative team members to work together. There is an opportunity to leverage the intersection between QI implementation and organizational theory to inform and improve implementation science. PURPOSE As a subaim of a larger implementation evaluation, we aimed to identify facilitators of team cohesion within QI implementation context. METHODOLOGY A quota sampling approach captured the perspectives of 44 stakeholders across three strata (organizational leaders, clinical leaders, and clinical team members) from all seven sites through a semistructured interview guide informed by the Consolidated Framework for Implementation Research (CFIR). We used a combination of inductive and deductive approaches informed by organizational theory to identify facilitators. RESULT We identified three facilitators of PC team cohesion: (a) balancing formalization and flexibility around team roles, (b) establishing widespread awareness of the QI project, and (c) prioritizing a nonhierarchical organizational culture. PRACTICE IMPLICATIONS Leveraging CFIR to analyze PC-PAICE stakeholder interviews created a data set conducive to understanding complex multisite implementation. Layering role and team theory to our implementation analysis helped us identify facilitators of team cohesion across levels within the team (bounded team), beyond the team (teaming), and surrounding the team (culture). These insights demonstrate the value of team and role theories in implementation evaluation efforts.
Collapse
|
2
|
Satija A, Lorenz KA, Spruijt O, Ganesh A, Singh N, Connell NB, Gamboa RC, Fereydooni S, Chandrashekaran S, Hennings T, Giannitrapani KF, Bhatnagar S. Quality Improvement in Itself Changes Your Thinking: Lessons From Disseminating Quality Improvement Methods Through a Multisite International Collaborative Palliative Care Project in India. JCO Glob Oncol 2022; 8:e2200147. [PMID: 36252162 PMCID: PMC9812511 DOI: 10.1200/go.22.00147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/12/2022] [Accepted: 09/01/2022] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Seven major palliative care (PC) centers in India were mentored through the Palliative Care-Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India. METHODS A quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches. RESULTS We interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture. CONCLUSION Engaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.
Collapse
Affiliation(s)
- Aanchal Satija
- Department of Onco-Anesthesia and Palliative Medicine, Dr B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - Karl A. Lorenz
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Odette Spruijt
- Peter MacCallum Cancer Center, University of Melbourne, Melbourne, VIC, Australia
| | - Archana Ganesh
- Department of Onco-Anesthesia and Palliative Medicine, Dr B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - Nainwant Singh
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Natalie B. Connell
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Raziel C. Gamboa
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | | | | | - Tayler Hennings
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA
| | - Karleen F. Giannitrapani
- VA HSR&D Center for Innovation to Implementation (Ci2i), Menlo Park, CA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, CA
| | - Sushma Bhatnagar
- Department of Onco-Anesthesia and Palliative Medicine, Dr B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| |
Collapse
|
3
|
Singh N, Giannitrapani KF, Satija A, Ganesh A, Gamboa R, Fereydooni S, Hennings T, Chandrashekaran S, Spruijt O, Bhatnagar S, Lorenz KA. Considerations for Fostering Palliative Care Awareness in Developing Contexts: Strategies From Locally Initiated Projects in India. J Pain Symptom Manage 2022; 64:370-376. [PMID: 35764200 DOI: 10.1016/j.jpainsymman.2022.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
CONTEXT Lack of palliative care (PC) awareness is a barrier to its utilization in developing contexts. OBJECTIVES To identify and understand strategies that changed awareness of the concepts and value of palliative care in a multi-site quality improvement project in India. METHODS The Palliative Care - Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) evaluation team conducted 44 semi-structured interviews with clinician and organization stakeholders at seven geographically dispersed sites. We used inductive and deductive approaches in this secondary analysis to identify emerging themes. RESULTS We identified the following strategies to improve awareness of concepts and value of palliative care. Strategy 1: Educate medical trainees, staff, and the community about palliative care and its concepts. Sub-strategies: Participate in community events. Integrate PC concepts into early medical education. Standardize training for practitioners. Strategy 2: Design and disseminate India-specific research to reinforce awareness of the value of palliative care. Sub-strategies: Publish and use India-specific palliative care research. Strategy 3: Facilitate communication between providers and departments to improve awareness of palliative care services and its concepts. Sub-strategies: Create referral frameworks and network with providers referring to palliative care to change awareness of available services and palliative care concepts. CONCLUSION To increase palliative care utilization, program development can include community and provider-focused efforts on awareness of the concepts and value of palliative care. These three strategies held salience across sites representing diverse Indian geographic and cultural settings; as such, they may be applicable to other contexts.
Collapse
Affiliation(s)
- Nainwant Singh
- Division of Primary Care and Population Health (N.S., K.F.G., T.H., K.A.L.), Stanford University School of Medicine, Palo Alto, California, USA; VA HS R&D Center for Innovation to Implementation (Ci2i) (N.S. K.F.G., R.G., K.A.L.), Menlo Park, California, USA.
| | - Karleen F Giannitrapani
- Division of Primary Care and Population Health (N.S., K.F.G., T.H., K.A.L.), Stanford University School of Medicine, Palo Alto, California, USA; VA HS R&D Center for Innovation to Implementation (Ci2i) (N.S. K.F.G., R.G., K.A.L.), Menlo Park, California, USA
| | - Aanchal Satija
- Department of Onco-Anaesthesia and Palliative Medicine (A.S., A.G., S.B.), Dr. B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - Archana Ganesh
- Department of Onco-Anaesthesia and Palliative Medicine (A.S., A.G., S.B.), Dr. B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - Raziel Gamboa
- VA HS R&D Center for Innovation to Implementation (Ci2i) (N.S. K.F.G., R.G., K.A.L.), Menlo Park, California, USA
| | - Soraya Fereydooni
- Yale University School of Medicine (S.F.), New Haven, Connecticut, USA
| | - Tayler Hennings
- Division of Primary Care and Population Health (N.S., K.F.G., T.H., K.A.L.), Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Odette Spruijt
- Peter MacCallum Cancer Center (O.S.), University of Melbourne, Melbourne, VIC, Australia
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine (A.S., A.G., S.B.), Dr. B. R. Ambedkar, IRCH, AIIMS, New Delhi, India
| | - Karl A Lorenz
- Division of Primary Care and Population Health (N.S., K.F.G., T.H., K.A.L.), Stanford University School of Medicine, Palo Alto, California, USA; VA HS R&D Center for Innovation to Implementation (Ci2i) (N.S. K.F.G., R.G., K.A.L.), Menlo Park, California, USA
| |
Collapse
|
4
|
Fereydooni S, Lorenz KA, Ganesh A, Satija A, Spruijt O, Bhatnagar S, Gamboa RC, Singh N, Giannitrapani KF. Empowering families to take on a palliative caregiver role for patients with cancer in India: Persistent challenges and promising strategies. PLoS One 2022; 17:e0274770. [PMID: 36112593 PMCID: PMC9481001 DOI: 10.1371/journal.pone.0274770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 09/04/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The population of patients with cancer requiring palliative care (PC) is on the rise in India. Family caregivers will be essential members of the care team in the provision of PC. OBJECTIVE We aimed to characterize provider perspectives of the challenges that Indian families face in taking on a palliative caregiving role. METHOD Data for this analysis came from an evaluation of the PC-PAICE project, a series of quality improvement interventions for PC in India. We conducted 44 in-depth semi-structured interviews with organizational leaders and clinical team members at seven geographically and structurally diverse settings. Through thematic content analysis, themes relating to the caregivers' role were identified using a combination of deductive and inductive approaches. RESULT Contextual challenges to taking up the PC caregiving role included family members' limited knowledge about PC and cancer, the necessity of training for caregiving responsibilities, and cultural preferences for pursuing curative treatments over palliative ones. Some logistical challenges include financial, time, and mental health limitations that family caregivers may encounter when navigating the expectations of taking on the caregiving role. Strategies to facilitate family buy-in for PC provision include adopting a family care model, connecting them to services provided by Non-Governmental Organizations, leveraging volunteers and social workers to foster PC awareness and training, and responding specifically to family's requests. CONCLUSION Understanding and addressing the various challenges that families face in adopting the caregiver role are essential steps in the provision and expansion of PC in India. Locally initiated quality improvement projects can be a way to address these challenges based on the context.
Collapse
Affiliation(s)
- Soraya Fereydooni
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, United States of America
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Karl A. Lorenz
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, United States of America
- Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Archana Ganesh
- All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Anchal Satija
- All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Odette Spruijt
- Peter MacCallum Cancer Center, Melbourne, Victoria, Australia
| | - Sushma Bhatnagar
- All India Institute of Medical Science (AIIMS), New Delhi, India
| | - Raziel C. Gamboa
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Nainwant Singh
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, United States of America
| | - Karleen F. Giannitrapani
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, California, United States of America
- Stanford University School of Medicine, Palo Alto, California, United States of America
| |
Collapse
|
5
|
Pramesh CS, Badwe RA, Bhoo-Pathy N, Booth CM, Chinnaswamy G, Dare AJ, de Andrade VP, Hunter DJ, Gopal S, Gospodarowicz M, Gunasekera S, Ilbawi A, Kapambwe S, Kingham P, Kutluk T, Lamichhane N, Mutebi M, Orem J, Parham G, Ranganathan P, Sengar M, Sullivan R, Swaminathan S, Tannock IF, Tomar V, Vanderpuye V, Varghese C, Weiderpass E. Priorities for cancer research in low- and middle-income countries: a global perspective. Nat Med 2022; 28:649-657. [PMID: 35440716 PMCID: PMC9108683 DOI: 10.1038/s41591-022-01738-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/09/2022] [Indexed: 01/22/2023]
Abstract
Cancer research currently is heavily skewed toward high-income countries (HICs), with little research conducted in, and relevant to, the problems of low- and middle-income countries (LMICs). This regional discordance in cancer knowledge generation and application needs to be rebalanced. Several gaps in the research enterprise of LMICs need to be addressed to promote regionally relevant research, and radical rethinking is needed to address the burning issues in cancer care in these regions. We identified five top priorities in cancer research in LMICs based on current and projected needs: reducing the burden of patients with advanced disease; improving access and affordability, and outcomes of cancer treatment; value-based care and health economics; quality improvement and implementation research; and leveraging technology to improve cancer control. LMICs have an excellent opportunity to address important questions in cancer research that could impact cancer control globally. Success will require collaboration and commitment from governments, policy makers, funding agencies, health care organizations and leaders, researchers and the public.
Collapse
Affiliation(s)
- C S Pramesh
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Rajendra A Badwe
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nirmala Bhoo-Pathy
- Centre for Epidemiology and Evidence-Based Practice, University of Malaya, Kuala Lumpur, Malaysia
| | - Christopher M Booth
- Departments of Oncology and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Anna J Dare
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - David J Hunter
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Satish Gopal
- Centre for Global Health, National Cancer Institute, Rockville, MD, USA
| | - Mary Gospodarowicz
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Peter Kingham
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tezer Kutluk
- Faculty of Medicine and Cancer Institute, Hacettepe University, Ankara, Turkey
| | | | | | | | | | | | - Manju Sengar
- Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Ian F Tannock
- Princess Margaret Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | | | - Verna Vanderpuye
- National Center for Radiotherapy Oncology and Nuclear Medicine and Korle Bu Teaching Hospital, Accra, Ghana
| | | | | |
Collapse
|
6
|
Viswanath V, Digumarti L, Raju NS, Lokanandi URV, Dasu MR, Bolem SKV, Katta N, Vemula SR, Sharma VVLN, Digumarti R. Organising Home-based Palliative Care Services: A Quality Improvement project at the Homi Bhabha Cancer Hospital and Research Centre, Vishakhapatnam. Indian J Palliat Care 2021; 27:197-203. [PMID: 34511784 PMCID: PMC8428891 DOI: 10.25259/ijpc_370_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/21/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives The key component of a comprehensive palliative care (PC) unit is provision of a regular and sustainable home-based PC (HBPC) service. This quality improvement project aimed to plan, organise and sustain a regular HBPC service in a government cancer centre in Southeast India. The aim was to regularise and increase the number of home care visits among the patients identified for HBPC services through sustainable interventions. Materials and Methods The A3 methodology with its team-based, structured problem-solving approach was the tool used. The situational process map at baseline was followed up with a sequential cause and effect analysis and team discussions to create sustainable and reliable interventions. These included creating the electronic data system for data collection in PC, allocation of resources and implementation of systems to coordinate HBPC services. The roles and ownership to maintain improvement were established by designation and this requirement has been included in the job description to ensure reliability and sustainability. Results The regularisation of home care services with a consistent increase in the number of home visits from 2/week to over 6/week helped achieve the Specific, Measurable, Achievable, Relevant and Time bound goal. Better documentation, coordination and accountability were also positive outcomes. Working with different departments and teams along the project helped build trust and understanding along with a sound base for collaborative research. Conclusion The A3 way of problem solving through dialogue and consensus helped to organise HBPC services and this methodology can be extended to other areas in future.
Collapse
Affiliation(s)
- Vidya Viswanath
- Department of Palliative Medicine Homi Bhabha Cancer Hospital and Research Centre, India
| | - Leela Digumarti
- Department of Gynaecologic Oncology, Homi Bhabha Cancer Hospital and Research Centre, India
| | | | | | - Mohana Rao Dasu
- Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh, India
| | | | - Naresh Katta
- Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh, India
| | - Srinivasa Rao Vemula
- Department of Palliative and Geriatric Care, Sneha Sandhya Age Care Foundation, India
| | | | | |
Collapse
|
7
|
Satija A, Lorenz K, DeNatale M, Mickelsen J, Deo SS, Bhatnagar S. Early Referral to Palliative Care for Advanced Oral Cancer Patients: A Quality Improvement Initiative in Oncology Center at All India Institute of Medical Sciences. Indian J Palliat Care 2021; 27:230-234. [PMID: 34511789 PMCID: PMC8428875 DOI: 10.25259/ijpc_367_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/20/2021] [Indexed: 11/04/2022] Open
Abstract
Objectives: Oral cancers have high epidemiologic burden in India, and most oral cancer patients at the All India Institute of Medical Sciences present in advanced stages. Their symptomatic needs are often not adequately addressed and the referrals to palliative medicine clinic are for severe pain or terminal stages. Using quality improvement methods, we aimed to provide early referral to palliative care for advanced oral cancer patients. Materials and Methods: Duration (number of days) between registration at the head-and-neck cancer clinic and referral to palliative medicine clinic at baseline and postinterventions. Interventions: Understanding current perceptions of oncologists for referral to palliative medicine clinic, educating them through departmental meetings, fostering clinician and patient-family awareness through pamphlets, defining process and screening guidelines for referral, including symptom burden charts in head-and-neck cancer clinic notes, soliciting regular feedback from oncologists at review meetings. Results: The number of days for the referral to the palliative medicine clinic decreased from an average of 48 days to 13 days in 6 months. Conclusion: A multicomponent intervention included oncologists and patients and families, education, workflow modification, standardized assessment, documentation, and clinician feedback, and succeeded in improving the timeliness of palliative care referrals of advanced oral cancer patients.
Collapse
Affiliation(s)
- Aanchal Satija
- Departments of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. Ambedkar Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Karl Lorenz
- VA Palo Alto Healthcare System, Palo Alto, California, USA.,Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | | | | | - Sv Suryanarayana Deo
- Surgical Oncology, Dr. B. R. Ambedkar Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Departments of Onco-Anaesthesia and Palliative Medicine, Dr. B. R. Ambedkar Institute Rotary Cancer Hospital, AIIMS, New Delhi, India
| |
Collapse
|