Promising Practices for Achieving Patient-centered Hospital Care: A National Study of High-performing US Hospitals

Quality and Safety in Nursing: Recommendations From a Systematic Review

ABSTRACT

As a consistent 24-hour presence in hospitals, nurses play a pivotal role in ensuring the quality and safety (Q&S) of patient care. However, a comprehensive review of evidence-based recommendations to guide nursing interventions that enhance the Q&S of patient care is lacking. Therefore, the purpose of our systematic review was to create evidence-based recommendations for the Q&S component of a nursing professional practice model for military hospitals. To accomplish this, a triservice military nursing team used Covidence software to conduct a systematic review of the literature across five databases. Two hundred forty-nine articles met inclusion criteria. From these articles, we created 94 recommendations for practice and identified eight focus areas from the literature: (1) communication; (2) adverse events; (3) leadership; (4) patient experience; (5) quality improvement; (6) safety culture/committees; (7) staffing/workload/work environment; and (8) technology/electronic health record. These findings provide suggestions for implementing Q&S practices that could be adapted to many healthcare delivery systems.

Fostering Patient-Centered Equitable Care in Radiology: AJR Expert Panel Narrative Review

Patient-centered care (PCC) and equity are two of the six core domains of quality health care, according to the Institute of Medicine. Exceptional imaging care requires radiology practices to provide patient-centered (i.e., respectful and responsive to individual patient preferences, needs, and values) and equitable (i.e., does not vary in quality on the basis of gender, ethnicity, geographic location, or socioeconomic status) care. Specific barriers that prevent the delivery of patient-centered equitable care include information gaps, breaches of trust, organizational medical culture, and financial incentives. Information gaps limit practitioners in understanding the lived experience of patients. Breaches of trust prevent patients from seeking needed medical care. Organizational medical cultures may not be centered around patient experiences. Financial incentives can impede practitioners' ability to spend the time and resources required to meet patient goals and needs. Intentional approaches that integrate core principles in both PCC and health equity are required to deliver high-quality patient-centered imaging care for diverse patient populations. The purpose of this AJR Expert Panel Narrative Review is to review the origins of the PCC movement in radiology, characterize connections between the PCC and health equity movements, and describe concrete examples of ways to foster patient-centered equitable care in radiology.

Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

How health systems facilitate patient-centered care and care coordination: a case series analysis to identify best practices

Large- and small-scale transformation of healthcare delivery toward improved patient experience through promotion of patient-centered and coordinated care continues to be at the forefront of health system efforts in the United States. As part of a Quality Improvement (QI) project at a large, midwestern health system, a case series of high-performing organizations was explored with the goal of identifying best practices in patient-centered care and/or care coordination (PCC/CC). Identification of best practices was done through rapid realist review of peer-reviewed literature supporting three PCC/CC interventions per case. Mechanisms responsible for successful intervention outcomes and associated institutional-level facilitators were evaluated, and cross-case analysis produced high-level focus items for health system leadership, including (1) institutional values surrounding PCC/CC, (2) optimization of IT infrastructure to enhance performance and communication, (3) pay structures and employment models that enhance accountability, and (4) organizing bodies to support implementation efforts. Health systems may use this review to gain insight into how institutional-level factors may facilitate small-scale PCC/CC behaviors, or to conduct similar assessments in their own QI projects. Based on our analysis, we recommend health systems seeking to improve PCC/CC at any level or scale to evaluate how IT infrastructure affects provider-provider and provider-patient communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings. Ideally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically devoted to PCC/CC implementation work.

The Implementation of Improvement Interventions for "Low Performing" and "High Performing" Organisations in Health, Education and Local Government: A Phased Literature Review

BACKGROUND

There is limited understanding about whether and how improvement interventions are effective in supporting failing healthcare organisations and improving the quality of care in high-performing organisations. The aim of this review was to examine the underlying concepts guiding the design of interventions aimed at low and high performing healthcare organisations, processes of implementation, unintended consequences, and their impact on costs and quality of care. The review includes articles in the healthcare sector and other sectors such as education and local government.

METHODS

We carried out a phased rapid systematic review of the literature. Phase one was used to develop a theoretical framework of organisational failure and turnaround, and the types of interventions implemented to improve quality. The framework was used to inform phase 2, which was targeted and focused on organisational failure and turnaround in healthcare, education and local government settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to guide the reporting of the methods and findings and the Mixed Methods Appraisal Tool (MMAT) as a quality assessment tool. The review protocol was registered with PROSPERO (CRD: 42019131024).

RESULTS

Failure is frequently defined as the inability of organisations to meet pre-established performance standards and turnaround as a linear process. Improvement interventions are designed accordingly and are focused on the organisation, with limited system-level thinking. Successful interventions included restructuring senior leadership teams, inspections, and organisational restructuring by external organisations. Limited attention was paid to the potential negative consequences of the interventions and their costs.

CONCLUSION

Dominant definitions of success/failure and turnaround have led to the reduced scope of improvement interventions, the linear perception of turnaround, and lack of consideration of organisations within the wider system in which they operate. Future areas of research include an analysis of the costs of delivering these interventions in relation to their impact on quality of care.

Examining Factors Associated with Utilization of Chaplains in the Acute Care Setting

Hospitalized persons want their spiritual needs addressed and discussed by the healthcare team, but medical providers and nurses lack the necessary training. Patients want chaplaincy care, but very few receive it, and little is known about utilization factors. To identify the population characteristics associated with the utilization of chaplaincy services, hospitalization data from March 2012 to July 2017 were analyzed (N = 15,242 patients). Religiously affiliated individuals and those with the most acute health needs were more likely to receive chaplaincy care and received more total care. Patient-centered healthcare models may need to evaluate strategic integration of spiritual care beyond reactive spiritual care provision.

Overcoming language barriers, enhancing collaboration with interpreters - an interprofessional learning intervention (Interpret2Improve)

BACKGROUND

Language barriers (LB) are common in patient care. They can negatively impact the quality of care, and increase costs. LB can be overcome by using interpreters. However, collaboration with interpreters is a professional activity which can and needs to be learnt. Interpret2Improve is an innovative educational intervention where medical and nursing students learn together how to address LB and effectively collaborate with interpreters.

METHODS

The three-hour course has two parts: After a short introduction on the relevance of LB and resulting issues of patient safety etc., students in interprofessional teams of two practice conversations with non-German-speaking simulated patients and professional interpreters. The course is evaluated in a pre-post format with the Freiburg Questionnaire for Interprofessional Learning Evaluation which has been validated in prior studies.

RESULTS

Fifty-one students (thirty of the participants were medical students, 21 participants were students in nursing care) participated from 11/2016-07/2018. Overall, the course was very well received (mean 1.73 (SD 0.85) on a five point scale: 1 = very good, 5 = insufficient). The evaluation by medical and nursing students differed significantly. Fourteen out of twenty-one items show a self-assessed increase in interprofessional knowledge or skills.

CONCLUSIONS

Students felt that their skills in addressing LB by effectively collaborating with interpreters increased during this interprofessional format. Further studies are needed to obtain further evidence beyond self-assessment and regarding the long-term outcomes.

Improving the Discharge Experience of Hospital Patients Through Standard Tools and Methods of Education

ABSTRACT

Discharge education is essential to patient health and care coordination. Patient satisfaction with discharge education reveals a hospital's ability to provide reliable, quality experiences that engage and prepare patients for recovery in the community. The purpose of this study was to examine and improve patient satisfaction with discharge preparation by providing timely, standardized methods of educating patients about their medical condition, discharge needs, and follow-up care. This project provided nursing and the care team with training in effective techniques such as the teach-back method as well as new tools like a discharge folder to be successful. Provider workflows were redesigned, and the discharge education document was changed to ensure appropriate information was provided to patients. Patient perspective and satisfaction with their degree of preparedness for discharge were measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. After intervention, an improvement in the HCAHPS survey top box percent score for the domains of Care Transitions, 52.41%-54.49% (p < .0001) and Discharge Information, 87.38-90.12% (p < .0001), was noted. Increasing scores for HCAHPS questions pertinent to discharge suggest the intervention improved patient satisfaction with discharge information and preparation for recovery outside the hospital.

From a View of the Hospital as a System to a View of the Suffering Patient

Purpose: Hospitals aspire to provide patient-centered care but are far from achieving it. This qualitative mixed methods study explored the capacity of hospital directors to shift from a hospital systemic-view to a suffering patient-view applying the Salutogenic theory.

Methods: Following IRB, we conducted in-depth narrative interviews with six directors of the six Israeli academic tertiary public hospitals, focusing on their managerial role. In a second meeting we conducted vignette interviews in which we presented each director with a narrative of a suffering young patient who died at 33 due to medical misconduct, allowing self-introspection. Provisional coding was performed for data analysis to identify categories and themes by the three dimensions of the sense-of-coherence, an anchor of Salutogenics: comprehensibility, manageability, and meaningfulness.

Results: While at the system level, directors reported high comprehensibility and manageability in coping with complexity, at the patient level, when confronted with the vignette, directors acknowledged their poor comprehensibility of patients' needs and patient's experience during hospitalizations. They acknowledged their poor capacity to provide patient-centered care. Meaningfulness in the narrative interview focused on the system while meaningfulness in the vignette interview focused on providing patient care.

Conclusions: The evident gaps between the system level and the patient level create lack of coherence, hindering the ability to cope with complexity, and are barriers to providing patient-centered care. To improve the delivery of patient-centered care, we suggest ways to consolidate the views, enabling the shift from a systemic-view to a patient-view.

Comparison of Patient Satisfaction in Inpatient Care Provided by Hospitalists and Nonhospitalists in South Korea

Background: A Korean hospitalist is a medical doctor in charge of inpatient care during hospital stays. The purpose of this study is to examine the patient satisfaction of hospitalist patients compared to non-hospitalist patients. Patient satisfaction is closely related to the outcome, quality, safety, and cost of care. Thus, seeking to achieve high patient satisfaction is essential in the inpatient care setting. Design, setting, and participants: This is a case-control study based on patient satisfaction survey by the Korean Health Insurance Review and Assessment Service. We measured patients’ satisfaction in physician accessibility, consultation and care service skills, and overall satisfaction through logistic regression analyses. A total of 3871 patients from 18 facilities responded to 18 questionnaires and had health insurance claim data. Results: Hospitalist patients presented higher satisfaction during the hospital stay compared to non-hospitalist patients. For example, as per accessibility, hospitalist patients could meet their attending physician more than twice a day (OR: 3.46, 95% CI: 2.82–4.24). Concerning consultation and care service skills, hospitalists’ explanations on the condition and care plans were easy to understand (OR: 2.33, 95% CI: 1.89–2.88). Moreover, overall satisfaction was significantly higher (β: 0.431, p < 0.0001). Subgroup analyses were conducted by medical division and region. Hospitalist patients in the surgical department and the rural area had greater patient satisfaction in all aspects of the survey than non-hospitalist patients. Conclusions: Hospitalists’ patients showed higher satisfaction during the hospital stay. Our study discovered that hospitalists could provide high-quality care as they provide onsite care continuously from admission to discharge.

Identifying contextually relevant improvement measures, illustrated by a case of executive walkrounds

PURPOSE

A method to engage salient organisational stakeholders in identifying and ranking measures of healthcare improvement programs is described. The method is illustrated using Executive WalkRounds (EWRs) in a multi-site Australian Health District.

DESIGN/METHODOLOGY/APPROACH

Subject matter experts (SMEs) conducted document analysis, identified potential EWRs measures, created driver diagrams and then eliminated weak measures. Next, a panel of executives skilled in EWRs ranked and ratified the potential measures using a modified Delphi technique.

FINDINGS

EWRs measurement selection demonstrated the feasibility of the method. Of the total time to complete the method 79% was contributed by SMEs, 14% by administration personnel and 7% by executives. Document analysis revealed three main EWRs aims. Ten of 28 potential measures were eliminated by the SME review. After repeated Delphi rounds the executive panel achieved consensus (75% cut-off) on seven measures. One outcome, one process and one implementation fidelity metric were selected to measure and monitor the impact of EWRs in the health district.

PRACTICAL IMPLICATIONS

Perceptions of weak relationships between measures and intended improvements can lead to practitioner scepticism. This work offers a structured method to combine the technical expertise of SMEs with the practical knowledge of healthcare staff in selecting improvement measures.

ORIGINALITY/VALUE

This research describes and demonstrates a novel method to systematically leverage formal and practical types of expertise to select measures that are strongly linked to local quality improvement goals. The method can be applied in diverse healthcare settings.

Six years of measuring patient experiences in Belgium: Limited improvement and lack of association with improvement strategies

OBJECTIVE

To examine trends in patient experiences in the period 2014-2019, describe improvement strategies implemented by hospitals in the same period, and study associations between patient experiences and implemented strategies.

DESIGN

Multi-center retrospective region-wide observational design.

SETTING

Flanders, Belgium.

PARTICIPANTS

44 out of 46 Flemish acute-care hospitals publicly reporting patient experiences via the Flemish Patient Survey (FPS).

MAIN OUTCOME MEASURE(S)

Primary outcomes were the two global FPS ratings: percentage of patients rating the hospital 9 or 10 and percentage of patients definitely recommending the hospital. Secondary outcomes were the average top-box score percentages for each of the 8 remaining dimensions of the FPS.

RESULTS

Between 2014 and 2019, there was a significant improvement in patients scoring the hospital 9 or 10 (56% to 61%) and patients definitely recommending (67% to 70%) the hospital. Significant increases in patient experiences over time were also observed in other dimensions, except for the dimension discharge. Hospital key informants reported various improvement strategies related to patient experiences with care and the FPS. Feedback to nursing wards (n = 44, 100%) and clinicians (n = 39, 89%) were most common. Overall, most improvement strategies were not or only weakly associated with patient experience ratings in 2019 and changes in ratings over time. Still, positive associations were discovered between the strategies 'nursing ward interventions' and 'hospital wide education' and recommendation of the hospital.

CONCLUSIONS

Patient experiences have improved modestly in Flemish acute-care hospitals. Hospitals report to have invested in patient experience improvement strategies but positive associations between such strategies and FPS scores are weak, although there is potential in further exploring nursing ward interventions and hospital wide education. Hospitals should continue their efforts to improve the patient's experience, but with a more targeted approach, taking the lessons learned on the efficacy of strategies into consideration.

Patient feedback to improve quality of patient-centred care in public hospitals: a systematic review of the evidence

Background

To review systematically the published literature relating to interventions informed by patient feedback for improvement to quality of care in hospital settings.

Methods

A systematic search was performed in the CINAHL, EMBASE, PsyInfo, MEDLINE, Cochrane Libraries, SCOPUS and Web of Science databases for English-language publications from January 2008 till October 2018 using a combination of MeSH-terms and keywords related to patient feedback, quality of health care, patient-centred care, program evaluation and public hospitals. The quality appraisal of the studies was conducted with the MMAT and the review protocol was published on PROSPERO. Narrative synthesis was used for evaluation of the effectiveness of the interventions on patient-centred quality of care.

Results

Twenty papers reporting 20 studies met the inclusion criteria, of these, there was one cluster RCT, three before and after studies, four cross-sectional studies and 12 organisational case studies. In the quality appraisal, 11 studies were rated low, five medium and only two of high methodological quality. Two studies could not be appraised because insufficient information was provided. The papers reported on interventions to improve communication with patients, professional practices in continuity of care and care transitions, responsiveness to patients, patient education, the physical hospital environment, use of patient feedback by staff and on quality improvement projects. However, quantitative outcomes were only provided for interventions in the areas of communication, professional practices in continuity of care and care transitions and responsiveness to patients. Multi-component interventions which targeted both individual and organisational levels were more effective than single interventions. Outcome measures reported in the studies were patient experiences across various diverse dimensions including, communication, responsiveness, coordination of and access to care, or patient satisfaction with waiting times, physical environment and staff courtesy.

Conclusion

Overall, it was found that there is limited evidence on the effectiveness of interventions, because few have been tested in well-designed trials, very few papers described the theoretical basis on which the intervention had been developed. Further research is needed to understand the choice and mechanism of action of the interventions used to improve patient experience.

Factors Associated With Family Experience in Pediatric Inpatient Care

BACKGROUND

Hospitals are rapidly increasing efforts to improve the pediatric inpatient experience. However, hospitals often do not know what to target for improvement. To determine what matters most to families, we assessed which aspects of experience have the strongest relationships with parents' willingness to recommend a hospital.

METHODS

Cross-sectional study of 17 727 surveys completed from November 2012 to January 2014 by parents of children hospitalized at 69 hospitals in 34 states using the Child Hospital Consumer Assessment of Healthcare Providers and Systems Survey. Hierarchical logistic regressions predicted the "top box" for willingness to recommend from measures of specific care dimensions (nurse-parent communication, doctor-parent communication, communication about medicines, keeping parents informed about the child's care, privacy with providers, preparing to leave the hospital, mistakes and concerns, child comfort, cleanliness, and quietness), adjusting for parent-child characteristics. Relative importance was assessed by using partially standardized adjusted odds ratios (aORs).

RESULTS

Child comfort (aOR 1.50; 95% confidence interval 1.41-1.60) and nurse-parent communication (aOR 1.50; 95% confidence interval 1.42-1.58) showed the strongest relationships with willingness to recommend, followed by preparing to leave the hospital, doctor-parent communication, and keeping parents informed. Privacy and quietness were not significantly associated with willingness to recommend in multivariate analysis.

CONCLUSIONS

Our study uncovered highly valued dimensions that are distinct to pediatric care. Hospitals that care for children should consider using dedicated pediatric instruments to measure and track their performance. Improvement efforts should focus on creating an age-appropriate environment, improving the effectiveness of provider interactions, and engaging parents to share their values and concerns.

Factors that influence patient empowerment in inpatient chronic care: early thoughts on a diabetes care intervention in South Africa

BACKGROUND

The burden of non-communicable diseases is growing rapidly in low- and middle-income countries. Research suggests that health interventions that aim to improve patient self-management and empower patients to care actively for their disease will improve health outcomes over the long-term. There is, however, a gap in the literature about the potential role of the inpatient setting in supporting chronic care. This is particularly important in low-and-middle income countries where hospitals may be a rare prolonged point of contact between patient and health provider. The aim of this small scale, exploratory study was to understand what factors within the inpatient setting may affect patients' feelings of empowerment in relation to their chronic disease care and provides recommendations for future inpatient-based interventions to support self-management of disease.

METHODS

This study was based in a public, academic hospital in South Africa. Eighteen qualitative, semi-structured interviews were conducted with multiple participants with experience of diabetes care: inpatients and health professionals such as nurses, endocrinologists, and dieticians. Findings were analysed using a broad, exploratory, thematic approach, guided by self-management and chronic care literature.

RESULTS

Interviews with both patients and providers suggest that patients living in low socio-economic contexts are likely to struggle to access appropriate healthcare information and services, and may often have financial and emotional priorities that take precedence over their chronic illness. Younger people may also be more dependent on their family and community, giving them less ability to take control of their disease care and lifestyle. In addition, hospital care remains bound by an acute care model; and the inpatient setting of focus is characterised by perceived staff shortages and ineffective communication that undermine the implementation of patient empowerment-focused interventions.

CONCLUSIONS

Patient and provider contexts are likely to make supporting patient engagement in long-term chronic care difficult in lower income settings. However, knowledge of these factors can be harnessed to improve chronic care interventions in South Africa and other similar countries.

Patient perspectives on a harm reduction-oriented addiction medicine consultation team implemented in a large acute care hospital

BACKGROUND

Addiction medicine consultation teams [AMCTs] are a promising strategy for improving hospital care for patients with substance use disorders. Yet very little research has examined AMCT implementation in acute care settings. To address this gap, we conducted a process evaluation of a novel harm reduction-oriented AMCT. Our specific aims included examining patients' perspectives on factors that facilitated or hindered AMCT delivery, and its impact on their hospital care and outcomes.

METHODS

The AMCT provided integrated addiction medicine, harm reduction services, and wraparound health and social supports for patients of a large, urban acute care hospital in Western Canada. We adopted a focused ethnographic design and recruited 21 patients into semi-structured interviews eliciting their views on the care they received from the team.

RESULTS

Participants highlighted the AMCT's harm reduction approach; reputation amongst peers; and specialized training as especially important intervention facilitators. Key barriers that constrained the impact of the team included unmet expectations; difficulty accessing follow-up care; and residual conflicts between the AMCT's harm reduction approach and the abstinence-only orientation of some hospital staff. For a few participants these conflicts led to negative experiences. Despite this, participants reported that the AMCT had positive impacts overall, including declines in substance use, enhanced mental and emotional wellbeing, and improved socio-economic circumstances.

CONCLUSIONS

A novel harm reduction-oriented AMCT led to better hospital experiences and perceived outcomes for patients. However, further efforts are needed to ensure adequate post-discharge follow-up, and a consistent approach to substance use disorder care amongst all hospital staff.

Improving the patient experience through a comprehensive performance framework to evaluate excellence in person-centred care

BACKGROUND

Person-centred care (PCC) is now recognised as an important component of healthcare quality. However, a lack of consensus of its most critical elements and absence of a global measure of person-centredness has limited the ability to evaluate the impact of implementation.

AIM

Introduce a measurable construct for PCC that yields improvement in quality, patient loyalty and staff engagement.

METHODS

Informed by scientific evidence and the voices of patients, families and healthcare professionals, the Person-Centered Care Certification Programme was developed as a comprehensive measure of PCC (Person-Centered Care Certification is a registered trademark of Planetree Registered in the US Patent and Trademark Office). Ten years after its development, the programme was redesigned to offer a more complete evaluative framework to focus organisations' PCC efforts and better understand their impact. Drawing on the National Academy of Medicine's Guiding Framework for Patient and Family Engaged Care, five drivers for excellence were identified that delineate the critical inputs required to create and maintain a culture of PCC. Aligned within the drivers are 26 interventions that connect staff to purpose, promote partnership with patients and families, engage individuals in care and promote continuous learning. A multimethod evaluation approach assesses how effectively these PCC strategies have been executed within the organisation and to understand their impact on the human experience of care.

RESULTS

The Person-Centered Care Certification Programme is associated with improvements in patient experience, patient loyalty and staff engagement.

CONCLUSION

The structured Certification framework can help organisations identify PCC improvement opportunities, guide their implementation efforts, and better understand the impact on patient and staff outcomes. Tested in cultures around the world and across the care continuum, the framework has proven effective in converting PCC into a definable, measurable and attainable goal. This paper outlines how the programme was designed, the measurable benefits derived by organisations and lessons learnt through the process.

Empowering Patients during Hospitalization: Perspectives on Inpatient Portal Use

BACKGROUND

Patients have demonstrated an eagerness to use portals to access their health information and connect with care providers. While outpatient portals have been extensively studied, there is a recognized need for research that examines inpatient portals.

OBJECTIVE

We conducted this study to improve our understanding about the role of a portal in the context of inpatient care. Our study focused on a large sample of the general adult inpatient population and obtained perspectives from both patients and care team members about inpatient portal use.

METHODS

We interviewed patients (n = 120) who used an inpatient portal during their hospitalization at 15 days or 6 months after discharge to learn about their portal use. We also interviewed care team members (n = 331) 4 weeks, 6 months, and 12 months after inpatient portal implementation to collect information about their ongoing perspectives about patients' use of the portal.

RESULTS

The perspectives of patients and care team members generally converged on their views of the inpatient portal. Three features-(1) ordering meals, (2) looking up health information, and (3) viewing the care team-were most commonly used; the secure messaging feature was less commonly used and of some concern to care team members. The inpatient portal benefited patients in four main ways: (1) promoted independence, (2) reduced anxiety, (3) informed families, and (4) increased empowerment.

CONCLUSION

Inpatient portals are recognized as a tool that can enhance the delivery of patient-centered care. In addition to empowering patients by increasing their sense of control, inpatient portals can support family members and caregivers throughout the hospital stay. Given the consistency of perspectives about portal use across patients and care team members, our findings suggest that inpatient portals may facilitate shifts in organizational culture that increase the patient centeredness of care and improve patient experience in the hospital context.

Satisfaction of surgical patients with perioperative nursing care in a Spanish tertiary care hospital

OBJECTIVE

Although numerous studies have assessed patient satisfaction in diverse settings, in the realm of nursing surgical care, standardization of measurement for patient experience and satisfaction is lacking. Therefore, the aim of this study was to assess the satisfaction of surgical patients with perioperative nursing care.

METHOD

A descriptive cross-sectional survey was conducted. Sociodemographic characteristics and clinical data were recorded. Patient satisfaction was measured with a modified version of the La Monica-Oberst Patient Satisfaction Scale (LOPSS-12).

RESULTS

150 patients (73 women, 49% and 77 men; 51%) completed the survey. The mean age was 63 years (standard deviation, 16 years). The mean overall satisfaction score on the La Monica-Oberst Patient Satisfaction Scale was 3.17 (standard deviation, 0.21). The scale showed adequate content validity (Lawshe's Content Validity Index was 0.76) and moderate reliability (Cronbach's alpha = 0.70). Two variables-patient sex and the presence of comorbidities-were significantly associated with overall satisfaction: men and patients with comorbidities were more satisfied with the care received. Patients with university studies were significantly more likely than patients with less education to consider nurses "impatient," but also considered the nurses' advice to be "useful." Patients with hospital-acquired complications were more likely to perceive nurses to be "more interested in completing tasks than in listening," although they also felt that nurses worked "conscientiously."

CONCLUSION

Overall, patient satisfaction with perioperative nursing care was good. This study identified several areas of nursing care in need of improvement, particularly the need to spend more time with patients and to keep them better informed about the perioperative process. The modified La Monica-Oberst Patient Satisfaction Scale is suitable for measuring surgical patient satisfaction with perioperative nursing care. The findings presented here may be of value to nursing administrators, educators, and nursing care providers to improve patient satisfaction and to develop strategies to prevent patient dissatisfaction.

Effectiveness of structured multidisciplinary rounding in acute care units on length of stay and satisfaction of patients and staff: a quantitative systematic review

BACKGROUND

Consistent, concise and timely communication between a multidisciplinary team of healthcare providers, patients and families is necessary for the delivery of quality care. Structured multidisciplinary rounding (MDR) using a structured communication tool may positively impact length of stay (LOS) and satisfaction of patients and staff by improving communication, coordination and collaboration among the healthcare team.

OBJECTIVES

To evaluate the effectiveness of structured MDR using a structured communication tool in acute care units on LOS and satisfaction of patients and staff.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult patients admitted to acute care units and healthcare providers who provide direct care for adult patients hospitalized in in-patient acute care units.

TYPE OF INTERVENTION

The implementation of structured MDR utilizing a structured communication tool to enhance and/or guide communication.

TYPES OF STUDIES

Quasi-experimental studies and descriptive studies.

OUTCOMES

Length of stay, patient satisfaction and staff satisfaction.

SEARCH STRATEGY

The comprehensive search strategy aimed to find relevant published and unpublished quantitative English language studies from the inception of each database searched through June 30, 2015. Databases searched include Cumulative Index to Nursing and Allied Health Literature, PubMed, Excerpta Medica Database, Health Source, Cochrane Central Register of Controlled Trials and Scopus. A search of gray literature was also performed.

METHODOLOGICAL QUALITY

All reviewers independently evaluated the included studies for methodological quality using critical appraisal tools from the Joanna Briggs Institute (JBI).

DATA EXTRACTION

Data related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from the JBI.

DATA SYNTHESIS

Due to clinical and methodological heterogeneity in the interventions and outcome measures of the included studies, statistical meta-analysis was not possible. Results are presented in narrative form.

RESULTS

Eight studies were included, three quasi-experimental studies and five descriptive studies of quality improvement projects. In the three quasi-experimental studies, one had a statistically significant decrease (p = 0.01), one no change (p = 0.1) and one had an increase (p = 0.03) in LOS; in the two descriptive studies, one had a statistically significant decrease (p = 0.02) and the other reported a trend toward reduced LOS. Two studies evaluated patient satisfaction, one showed no change (p = 0.76) and one showed a trend toward increased patient satisfaction at 12 months. Six studies demonstrated an improvement in staff satisfaction (p < 0.05) after implementation of structured MDR.

CONCLUSION

The evidence suggests that MDR utilizing a structured communication tool may have contributed to an improvement in staff satisfaction. There was inconclusive evidence to support the use of structured MDR to improve LOS or patient satisfaction. The use of a structured communication tool during MDR is one means to facilitate communication and collaboration, thus improving satisfaction among the multidisciplinary team. More rigorous research using higher level study designs on larger samples of diverse patient populations is needed to further evaluate the effectiveness of structured MDR on patient care outcomes and satisfaction of patients and providers.

Patient-identified information and communication needs in the context of major trauma

Background

Navigating complex health care systems during the multiple phases of recovery following major trauma entails many challenges for injured patients. Patients’ experiences communicating with health professionals are of particular importance in this context. The aim of this study was to explore seriously injured patients’ perceptions of communication with and information provided by health professionals in their first 3-years following injury.

Methods

A qualitative study designed was used, nested within a population-based longitudinal cohort study. Semi-structured telephone interviews were undertaken with 65 major trauma patients, aged 17 years and older at the time of injury, identified through purposive sampling from the Victorian State Trauma Registry. A detailed thematic analysis was undertaken using a framework approach.

Results

Many seriously injured patients faced barriers to communication with health professionals in the hospital, rehabilitation and in the community settings. Key themes related to limited contact with health professionals, insufficient information provision, and challenges with information coordination. Communication difficulties were particularly apparent when many health professionals were involved in patient care, or when patients transitioned from hospital to rehabilitation or to the community. Difficulties in patient-health professional engagement compromised communication and exchange of information particularly at transitions of care, e.g., discharge from hospital. Conversely, positive attributes displayed by health professionals such as active discussion, clear language, listening and an empathetic manner, all facilitated effective communication. Most patients preferred communication consistent with patient-centred approaches, and the use of multiple modes to communicate information.

Conclusions

The communication and information needs of seriously injured patients were inconsistently met over the course of their recovery continuum. To assist patients along their recovery trajectories, patient-centred communication approaches and considerations for environmental and patients’ health literacy are recommended. Additionally, assistance with information coordination and comprehensive multimodal information provision should be available for injured patients.

How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation

BACKGROUND

Healthcare organizations increasingly are focused on providing care which is patient-centered rather than disease-focused. Yet little is known about how best to transform the culture of care in these organizations. We sought to understand key organizational factors for implementing patient-centered care cultural transformation through an examination of efforts in the US Department of Veterans Affairs.

METHODS

We conducted multi-day site visits at four US Department of Veterans Affairs medical centers designated as leaders in providing patient-centered care. We conducted qualitative semi-structured interviews with 108 employees (22 senior leaders, 42 middle managers, 37 front-line providers and 7 staff). Transcripts of audio recordings were analyzed using a priori codes based on the Consolidated Framework for Implementation Research. We used constant comparison analysis to synthesize codes into meaningful domains.

RESULTS

Sites described actions taken to foster patient-centered care in seven domains: 1) leadership; 2) patient and family engagement; 3) staff engagement; 4) focus on innovations; 5) alignment of staff roles and priorities; 6) organizational structures and processes; 7) environment of care. Within each domain, we identified multi-faceted strategies for implementing change. These included efforts by all levels of organizational leaders who modeled patient-centered care in their interactions and fostered willingness to try novel approaches to care amongst staff. Alignment and integration of patient centered care within the organization, particularly surrounding roles, priorities and bureaucratic rules, remained major challenges.

CONCLUSIONS

Transforming healthcare systems to focus on patient-centered care and better serve the "whole" patient is a complex endeavor. Efforts to transform healthcare culture require robust, multi-pronged efforts at all levels of the organization; leadership is only the beginning. Challenges remain for incorporating patient-centered approaches in the context of competing priorities and regulations. Through actions within each of the domains, organizations may begin to truly transform to patient-driven care.

Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care

BACKGROUND

Patient-centred care is now ubiquitous in health services research, and healthcare systems are moving ahead with patient-centred care implementation. Yet, little is known about how healthcare employees, charged with implementing patient-centred care, conceptualize what they are implementing.

OBJECTIVE

To examine how hospital employees conceptualize patient-centred care.

RESEARCH DESIGN

We conducted qualitative interviews about patient-centred care during site four visits, from January to April 2013.

SUBJECTS

We interviewed 107 employees, including leadership, middle managers, front line providers and staff at four US Veteran Health Administration (VHA) medical centres leading VHA's patient-centred care transformation.

MEASURES

Data were analysed using grounded thematic analysis. Findings were then mapped to established patient-centred care constructs identified in the literature: taking a biopsychosocial perspective; viewing the patient-as-person; sharing power and responsibility; establishing a therapeutic alliance; and viewing the doctor-as-person.

RESULTS

We identified three distinct conceptualizations: (i) those that were well aligned with established patient-centred care constructs surrounding the clinical encounter; (ii) others that extended conceptualizations of patient-centred care into the organizational culture, encompassing the entire patient-experience; and (iii) still others that were poorly aligned with patient-centred care constructs, reflecting more traditional patient care practices.

CONCLUSIONS

Patient-centred care ideals have permeated into healthcare systems. Additionally, patient-centred care has been expanded to encompass a cultural shift in care delivery, beginning with patients' experiences entering a facility. However, some healthcare employees, namely leadership, see patient-centred care so broadly, it encompasses on-going hospital initiatives, while others consider patient-centred care as inherent to specific positions. These latter conceptualizations risk undermining patient-centred care implementation by limiting transformational initiatives to specific providers or simply repackaging existing programmes.

Patient engagement in hospital health service planning and improvement: a scoping review

OBJECTIVES

Patient engagement (PE) improves patient, organisation and health system outcomes, but most research is based on primary care. The primary purpose of this study was to describe the characteristics of published empirical research that evaluated PE in hospital health service improvement.

DESIGN

Scoping review.

METHODS

Five databases were searched from 2006 to September 2016. English language studies that evaluated patient or provider beliefs, participation in PE, influencing factors or impact were eligible. Screening and data extraction were done in triplicate. PE characteristics, influencing factors and impact were extracted and summarised.

RESULTS

From a total of 3939 search results, 227 studies emerged as potentially relevant; of these, 217 were not eligible, and 10 studies were included in the review. None evaluated behavioural interventions to promote or support PE. While most studies examined involvement in standing committees or projects, patient input and influence on decisions were minimal. Lack of skill and negative beliefs among providers were PE barriers. PE facilitators included careful selection and joint training of patients and providers, formalising patient roles, informal interaction to build trust, involving patients early in projects, small team size, frequent meetings, active solicitation of patient input in meetings and debriefing after meetings. Asking patients to provide insight into problems rather than solutions and deploying provider champions may enhance patient influence on hospital services.

CONCLUSIONS

Given the important role of PE in improving hospital services and the paucity of research on this topic, future research should develop and evaluate behavioural interventions for PE directed at patients and providers informed by the PE barriers and facilitators identified here. Future studies should also assess the impact on various individual and organisational outcomes.

Surfacing and addressing hospitalized patients' needs: Proactive nurse rounding as a tool

AIMS

This paper reports on rounding interventions employed at high performing hospitals, and provides three case studies on how proactive nurse rounding was successfully implemented to improve patient-centredness.

BACKGROUND

Proactive nurse rounding is a popular form of rounding that has shown promise for improving patient outcomes, yet, little evidence exists on how to implement it successfully.

METHODS

We identified high-performing hospitals in the domains of staff responsiveness and nurse communications in the Hospital Consumer Assessment of Health Providers and Systems survey nationally, and conducted case studies at three of these hospitals exploring their implementation of proactive nurse rounding. We partnered with leaders from these hospitals to describe the associated challenges and lessons learned.

RESULTS

Twenty-six high performing hospitals in the domains of staff responsiveness and/or nurse communication were identified. The majority of nursing units reported proactive nurse rounding as their main rounding intervention (96%).

CONCLUSIONS

Proactive rounding interventions are a feasible approach to help surface and address hospitalized patients' needs in a timely manner.

IMPLICATIONS FOR NURSING MANAGEMENT

The information and tools provided in this paper build upon the learning from high performing hospitals' experiences and are useful to nurse leaders in their efforts to improve the patient-centeredness in the hospital.

New Instrument to Measure Hospital Patient Experiences in Flanders

Implementing a standardized patient experience survey may initiate a process to apply pressure on hospitals to attend to improving patient experiences. In Flanders, Belgium, the Flemish Patient Survey was developed between 2011 and 2015. A preliminary version was developed from a scoping review and patient and expert focus groups, and included 27 items for eight hypothesized dimensions: 'preparing for hospital stay', 'information and communication', 'coordination', 'respect', 'privacy', 'safe care', pain management', and 'participation'. Exploratory factor analysis for 1076 patients in 17 hospitals found that the data did not fit the dimensions. Adaptations in item wording and response categories were based on the US Hospital Consumer Assessment of Healthcare Providers and Systems. The revised version showed excellent model fit in 22,143 patients in 37 hospitals. Multiple group analysis pointed to evidence of measurement invariance over time across mode of administration, type of nursing unit, and various patient characteristics. Fostering a collaborative approach thus proved successful in implementing a standardized patient experience survey. The most recent findings (2016) illustrate substandard performance and a need for patient-mix adjustment. The Flemish government developed a dedicated website to make findings publicly available and the federal government currently considers patient experiences in devising a pay-for-quality scheme.

What Defines a High-Performing Health Care Delivery System: A Systematic Review

BACKGROUND

Purchasers, payers, and policy makers are increasingly measuring and rewarding high-performing health systems, which use a variety of definitions of high performance, yet it is unclear if a consistently applied definition exists. A systematic review was conducted to determine if there is a commonly used, agreed-on definition of what constitutes a "high-performing" health care delivery system.

METHODS

Searches were conducted for English-language articles defining high performance with respect to a health care system or organization in PubMed and WorldCat databases from 2005 to 2015 and the New York Academy of Medicine Grey Literature Report from 1999 to 2016. The entity/condition to which the definition was applied was extracted from included articles. The number and type of dimensions used to define high performance within and across articles was tabulated and the number and type of metrics used by performance dimension and by article was calculated.

RESULTS

No consistent definition of a high-performing health care system or organization was identified. High performance was variably defined across different dimensions, including quality (93% of articles), cost (67%), access (35%), equity (26%), patient experience (21%), and patient safety (18%). Most articles used more than one dimension to define high performance (75%), but only five used five or more dimensions. The most commonly paired dimensions were quality and cost (63%).

CONCLUSION

The absence of a consistent definition of what constitutes high performance and how to measure it hinders our ability to compare and reward health care delivery systems on performance, underscoring the need to develop a consistent definition of high performance.

Factors Influencing Patient Experience in Pediatric Neurology

INTRODUCTION

Hospitals have begun to shift toward patient-centered care because of the pay-for-performance system that was established by the Patient Protection and Affordable Care Act. In pediatrics, the needs of both the caregiver and the pediatric patient have to be taken into account. Pediatric practices have been shifting toward a family-centered approach, although the primary drivers have not been well defined. Identifying the key patient experiences that lead to higher patient satisfaction would enable a more meaningful clinical encounter. To better understand patient experience, we examined waiting time and the elements of the physician-patient interaction in pediatric neurology. We predict that the determining factor in patient satisfaction is the physician-patient interaction.

METHODS AND MATERIAL

Patient satisfaction surveys were sent to families via mail or e-mail after their ambulatory pediatric neurology visit. The visits took place between January 1, 2012, and December 31, 2014, at one of multiple locations in a children's health system spanning four states. A Likert scale was used for these surveys, and a top-box method (measuring percent of survey questions were rated 5 out of 5) was used to filter data from this database. Statistical analysis using a Pearson correlation was used for data analysis, with likelihood to recommend practice as the dependent variable.

RESULTS

The five survey questions that correlated most with overall likelihood to recommend the practice were cheerfulness of practice (r = 0.79); staff working together (r = 0.76); cleanliness of practice (r = 0.70); wait time at clinic, from entering to leaving (r = 0.66); and likelihood of recommending care provider (r = 0.65).

CONCLUSION

Pediatric neurologists striving to enhance overall patient satisfaction in their practices should work toward providing an atmosphere that supports office staff cheerfulness, teamwork, and visit efficiency provided in a clean and friendly environment.

Clinical Efficacy, Safety, and Feasibility of Using Video Glasses during Interventional Radiologic Procedures: A Randomized Trial

PURPOSE

To evaluate the clinical efficacy, safety, and feasibility of implementing video glasses in a variety of interventional radiologic (IR) procedures.

MATERIALS AND METHODS

Between August 2012 and August 2013, 83 patients undergoing outpatient IR procedures were randomized to a control group (n = 44) or an experimental group outfitted with video glasses (n = 39). State-Trait Anxiety Inventory (STAI) scores, sedation and analgesia doses, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR), pain scores, and procedure times were obtained. Complications and adverse events related to the use of video glasses were recorded. Postprocedural staff surveys and patient satisfaction surveys were completed.

RESULTS

Women had greater preprocedural anxiety than men (P = .0056), and patients undergoing vascular interventions had greater preprocedural anxiety than those undergoing nonvascular interventions (P = .0396). When assessed after the procedure, patients who wore video glasses had significantly reduced levels of anxiety (-7.7 vs -4.4, respectively; P = .0335) and average MAP (-6.3 vs 2.1, respectively; P = .0486) compared with control patients. There was no significant difference in amount of sedation and analgesia, HR, RR, pain score, or procedure time between groups. No significant adverse events related to the use of video glasses were observed. Postprocedural surveys showed that video glasses were not distracting and did not interfere or pose a safety issue during procedures. Patients enjoyed using the video glasses and would use them again for a future procedure.

CONCLUSIONS

Video glasses can be safely implemented during IR procedures to reduce anxiety and improve a patient's overall experience.