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Thille P, Tobin A, Evans JM, Katz A, Russell GM. Evolving through multiple, co-existing pressures to change: a case study of self-organization in primary care during the COVID-19 pandemic in Canada. BMC PRIMARY CARE 2024; 25:285. [PMID: 39103760 DOI: 10.1186/s12875-024-02520-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 07/10/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Primary care is often described as slow to change. But conceptualized through complexity theory, primary care is continually changing in unpredictable, non-linear ways through self-organization processes. Self-organization has proven hard to study directly. We aimed to develop a methodology to study self-organization and describe how a primary care clinic self-organizes over time. METHODOLOGY We completed a virtual case study of an urban primary care clinic from May-Nov 2021, applying methodological insights from actor-network theory to examine the complexity theory concept of self-organization. We chose to focus our attention on self-organization activities that alter organizational routines. Data included fieldnotes of observed team meetings, document collection, interviews with clinic members, and notes from brief weekly discussions to detect actions to change clinical and administrative routines. Adapting schema analysis, we described changes to different organizational routines chronologically, then explored intersecting changes. We sought feedback on results from the participating clinic. FINDINGS Re-establishing equilibrium remained challenging well into the COVID-19 pandemic. The primary care clinic continued to self-organize in response to changing health policies, unintended consequences of earlier adaptations, staff changes, and clinical care initiatives. Physical space, technologies, external and internal policies, guidelines, and clinic members all influenced self-organization. Changing one created ripple effects, sometimes generating new, unanticipated problems. Member checking confirmed we captured most of the changes to organizational routines during the case study period. CONCLUSIONS Through insights from actor-network theory, applied to studying actions taken that alter organizational routines, it is possible to operationalize the theoretical construct of self-organization. Our methodology illuminates the primary care clinic as a continually changing entity with co-existing and intersecting processes of self-organization in response to varied change pressures.
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Affiliation(s)
- Patricia Thille
- Department of Physical Therapy, College of Rehabilitation Sciences, University of Manitoba, R106-771 McDermot Ave, Winnipeg, MB, R3E 0T6, Canada.
| | - Anastasia Tobin
- Department of Physical Therapy, College of Rehabilitation Sciences, University of Manitoba, R106-771 McDermot Ave, Winnipeg, MB, R3E 0T6, Canada
| | - Jenna M Evans
- DeGroote School of Business, McMaster University, 1280 Main Street West, L8S 4L8, Hamilton, ON, Canada
| | - Alan Katz
- Manitoba Centre for Health Policy & Departments of Community Health Sciences and Family Medicine, University of Manitoba, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada
| | - Grant M Russell
- Department of General Practice, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
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Holtrop JS, Gurfinkel D, Nederveld A, Reedy J, Rubinson C, Kwan BM. What works in implementing shared medical appointments for patients with diabetes in primary care to enhance reach: a qualitative comparative analysis from the Invested in Diabetes study. Implement Sci Commun 2024; 5:82. [PMID: 39049078 PMCID: PMC11267890 DOI: 10.1186/s43058-024-00608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Diabetes is a serious public health problem affecting 37.3 million Americans. Diabetes shared medical appointments (SMAs) are an effective strategy for providing diabetes self-management support and education in primary care. However, practices delivering SMAs experience implementation challenges. This analysis examined conditions associated with successful practice implementation of diabetes SMAs in the context of participation in a pragmatic trial. METHODS Mixed methods study using qualitative and quantitative data collected from interviews, observations, surveys, and practice-reported data, guided by the practical, robust implementation and sustainability model (PRISM). Data were analyzed using qualitative comparative analysis (QCA). Successful implementation was defined as meeting patient recruitment targets (Reach) during the study period. Participants were clinicians and staff members from 22 primary care practices in Colorado and Missouri, USA. RESULTS The first necessary condition identified from the QCA was the presence of additional resources for patients with diabetes in the practice. Within practices that had these additional resources, we found that a sufficiency condition was the presence of an effective key person to make things happen with the SMAs. A second QCA was conducted to determine conditions underlying the presence of the effective key person (often performing functions of an implementation champion), which revealed factors including low or managed employee turnover, a strong baseline practice culture, and previous experience delivering SMAs. CONCLUSIONS Identification of key factors necessary and sufficient for implementation of new care processes is important to enhance patient access to evidence-based interventions. This study suggests that practice features and resources have important implications for implementation of diabetes SMAs. There may be opportunities to support practices with SMA implementation by enabling the presence of skilled implementation champions. TRIAL REGISTRATION Registered at clinicaltrials.gov under trial ID NCT03590041, registered on July 18, 2018.
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Aurora, CO, 80045, USA.
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA.
| | - Dennis Gurfinkel
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA
| | - Andrea Nederveld
- Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Aurora, CO, 80045, USA
| | - Julia Reedy
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA
| | - Claude Rubinson
- Department of Social Sciences, University of Houston-Downtown, 1 Main Street, Houston, TX, 77009, USA
| | - Bethany Matthews Kwan
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Aurora, CO, 80045, USA
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Jimenez EE, Rosland AM, Stockdale SE, Reddy A, Wong MS, Torrence N, Huynh A, Chang ET. Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial. Implement Sci Commun 2024; 5:75. [PMID: 39010160 PMCID: PMC11251253 DOI: 10.1186/s43058-024-00613-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/08/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Patients with significant multimorbidity and other factors that make healthcare challenging to access and coordinate are at high risk for poor health outcomes. Although most (93%) of Veterans' Health Administration (VHA) patients at high risk for hospitalization or death ("high-risk Veterans") are primarily managed by primary care teams, few of these teams have implemented evidence-based practices (EBPs) known to improve outcomes for the high-risk patient population's complex healthcare issues. Effective implementation strategies could increase adoption of these EBPs in primary care; however, the most effective implementation strategies to increase evidence-based care for high-risk patients are unknown. The high-RIsk VETerans (RIVET) Quality Enhancement Research Initiative (QUERI) will compare two variants of Evidence-Based Quality Improvement (EBQI) strategies to implement two distinct EBPs for high-risk Veterans: individual coaching (EBQI-IC; tailored training with individual implementation sites to meet site-specific needs) versus learning collaborative (EBQI-LC; implementation sites trained in groups to encourage collaboration among sites). One EBP, Comprehensive Assessment and Care Planning (CACP), guides teams in addressing patients' cognitive, functional, and social needs through a comprehensive care plan. The other EBP, Medication Adherence Assessment (MAA), addresses common challenges to medication adherence using a patient-centered approach. METHODS We will recruit and randomize 16 sites to either EBQI-IC or EBQI-LC to implement one of the EBPs, chosen by the site. Each site will have a site champion (front-line staff) who will participate in 18 months of EBQI facilitation. ANALYSIS We will use a mixed-methods type 3 hybrid Effectiveness-Implementation trial to test EBQI-IC versus EBQI-LC versus usual care using a Concurrent Stepped Wedge design. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the maintenance/sustainment and spread of both EBPs in primary care after the 18-month implementation period. Our primary outcome will be Reach, measured by the percentage of eligible high-risk patients who received the EBP. DISCUSSION Our study will identify which implementation strategy is most effective overall, and under various contexts, accounting for unique barriers, facilitators, EBP characteristics, and adaptations. Ultimately this study will identify ways for primary care clinics and teams to choose implementation strategies that can improve care and outcomes for patients with complex healthcare needs. TRIAL REGISTRATION ClinicalTrials.gov, NCT05050643. Registered September 9th, 2021, https://clinicaltrials.gov/study/NCT05050643 PROTOCOL VERSION: This protocol is Version 1.0 which was created on 6/3/2020.
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Affiliation(s)
- Elvira E Jimenez
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA.
- Department of Neurology, David Gefen School of Medicine, University of California Los Angeles (UCLA), 760 Westwood Plaza, Los Angeles, CA, 90095, USA.
| | - Ann-Marie Rosland
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, 1 University Dr, Pittsburgh, PA, 15240, USA
- Caring for Complex Chronic Conditions Research Center & Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles (UCLA), 760 Westwood Plaza, Los Angeles, CA, 90095, USA
| | - Ashok Reddy
- Department of Medicine, Division of General Internal Medicine, Harborview Medical Center, University of Washington, 325 Ninth Ave, Box 359780, Seattle, WA, 98104, USA
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA, 98108, USA
| | - Michelle S Wong
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Natasha Torrence
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, 1 University Dr, Pittsburgh, PA, 15240, USA
- Caring for Complex Chronic Conditions Research Center & Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 3550 Terrace St, Pittsburgh, PA, 15213, USA
| | - Alexis Huynh
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA
- Division of General Internal Medicine, Department of Medicine, David Gefen School of Medicine, UCLA, 740 Charles E Young Dr S, Los Angeles, CA, 90095, USA
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Bilaver LA, Ariza AJ, Binns HJ, Jiang J, Cohn R, Sansweet S, Hultquist H, Laurienzo Panza J, Togias A, Gupta R. Design of the Intervention to Reduce Early Peanut Allergy in Children (iREACH): A practice-based clinical trial. Pediatr Allergy Immunol 2024; 35:e14115. [PMID: 38566365 PMCID: PMC11268822 DOI: 10.1111/pai.14115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Introducing peanut products early can prevent peanut allergy (PA). The "Addendum guidelines for the prevention of PA in the United States" (PPA guidelines) recommend early introduction of peanut products to low and moderate risk infants and evaluation prior to starting peanut products for infants at high risk for PA (those with severe eczema and/or egg allergy). Rapid adoption of guidelines could aid in lowering the prevalence of PA. The Intervention to Reduce Early (Peanut) Allergy in Children (iREACH) trial was designed to promote PPA guideline adherence by pediatric clinicians. METHODS A two-arm, cluster-randomized, controlled clinical trial was designed to measure the effectiveness of an intervention that included clinician education and accompanying clinical decision support tools integrated in electronic health records (EHR) versus standard care. Randomization was at the practice level (n = 30). Primary aims evaluated over an 18-month trial period assess adherence to the PPA guidelines using EHR documentation at 4- and 6-month well-child care visits aided by natural language processing. A secondary aim will evaluate the effectiveness in decreasing the incidence of PA by age 2.5 years using EHR documentation and caregiver surveys. The unit of observation for evaluations are individual children with clustering at the practice level. CONCLUSION Application of this intervention has the potential to inform the development of strategies to speed implementation of PPA guidelines.
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Affiliation(s)
- Lucy A Bilaver
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Adolfo J. Ariza
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Helen J. Binns
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
| | - Jialing Jiang
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Rich Cohn
- Not Applicable – Independent Consultant
| | - Samantha Sansweet
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Haley Hultquist
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Joy Laurienzo Panza
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, MD, United States
| | - Ruchi Gupta
- Northwestern University Feinberg School of Medicine, Chicago, IL, United States
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
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Tsui J, Shin M, Sloan K, Martinez B, Palinkas LA, Baezconde-Garbanati L, Cantor JC, Hudson SV, Crabtree BF. Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2024; 25:147-162. [PMID: 37368117 PMCID: PMC11133176 DOI: 10.1007/s11121-023-01568-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.
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Affiliation(s)
- Jennifer Tsui
- University of Southern California, Los Angeles, CA, USA.
| | | | - Kylie Sloan
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Joel C Cantor
- Rutgers the State University of New Jersey, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Rutgers the State University of New Jersey, New Brunswick, NJ, USA
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Sideman AB, Razon N. Extra/ordinary medicine: Toward an anthropology of primary care. Soc Sci Med 2024; 346:116707. [PMID: 38430873 PMCID: PMC10978222 DOI: 10.1016/j.socscimed.2024.116707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 02/07/2024] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Primary care is at the forefront of healthcare delivery. It is the site of disease prevention and health management and serves as the bridge between communities and the health care system As ethnographers of primary care, in this article we discuss what is gained by situating anthropological inquiry within primary care. We articulate how anthropologists can contribute to a better understanding of the issues that emerge in primary care. We provide a review of anthropological work in primary care and offer empirical data from two ethnographic case studies based in the United States, one focused on social risk screening in primary care and the other examining the diagnosis and care of people with dementia in primary care. Through these cases, we demonstrate how research of and within primary care can open important avenues for the study of the multidimensionality of primary care. This multidimensionality is apparent in the ways the medical field addresses the social and structural experiences of patients, scope of practice and disciplinary boundaries, and the intersection of ordinary and extraordinary medicine that emerge in the care of patients in primary care.
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Affiliation(s)
- Alissa Bernstein Sideman
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA; Global Brain Health Institute, Department of Neurology, University of California, San Francisco, USA; Department of Humanities & Social Sciences, University of California, San Francisco, USA.
| | - Na'amah Razon
- Department of Family and Community Medicine, University of California, Davis, USA
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Cullen J, Childerhouse P, Jayamaha N, McBain L. Developing a model for primary care quality improvement success: a comparative case study in rural, urban and Kaupapa Māori organisations. J Prim Health Care 2023; 15:333-342. [PMID: 38112700 DOI: 10.1071/hc23046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/10/2023] [Indexed: 12/21/2023] Open
Abstract
Introduction Primary care is under pressure to achieve accessible, equitable, quality health care, while being increasingly under resourced. There is a need to understand factors that influence quality improvement (QI) to support a high-performing primary care system. Literature highlights the impact of context on QI but there is little primary care research on this topic. Aim This qualitative case study research seeks to discover the contextual factors influencing QI in primary care, and how the relationships between contextual factors, the QI initiative, and the implementation process influence outcomes. Methods The Consolidated Framework for Implementation Research was used to frame this qualitative study exploring primary care experiences in depth. Six sites were selected to provide a sample of rural, urban and Kaupapa Māori settings. Qualitative data was collected via semi-structured interviews and compared and contrasted with the organisational documents and data provided by participants. Results Cases reported success in achieving improved outcomes for patients, practices, and staff. Strong internal cultures of 'Clan' and 'Adhocracy' typologies supported teamwork, distributed leadership, and a learning climate to facilitate iterative sensemaking activities. To varying degrees, external network relationships provided resources, knowledge, and support. Discussion Organisations were motivated by a combination of patient/community need and organisational culture. Network relationships assisted to varying degrees depending on need. Engaged and distributed leadership based on teamwork was observed, where leadership was shared and emerged at different levels and times as the need arose. A learning climate was supported to enable iterative sensemaking activities to achieve success.
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Affiliation(s)
- Jane Cullen
- Massey University, Palmerston North, New Zealand
| | | | | | - Lynn McBain
- Department of Primary Care, University of Otago, Wellington, New Zealand
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Mehta J, Williams C, Holden RJ, Taylor B, Fowler NR, Boustani M. The methodology of the Agile Nudge University. FRONTIERS IN HEALTH SERVICES 2023; 3:1212787. [PMID: 38093811 PMCID: PMC10716213 DOI: 10.3389/frhs.2023.1212787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/10/2023] [Indexed: 02/01/2024]
Abstract
Introduction The Agile Nudge University is a National Institute on Aging-funded initiative to engineer a diverse, interdisciplinary network of scientists trained in Agile processes. Methods Members of the network are trained and mentored in rapid, iterative, and adaptive problem-solving techniques to develop, implement, and disseminate evidence-based nudges capable of addressing health disparities and improving the care of people living with Alzheimer's disease and other related dementias (ADRD). Results Each Agile Nudge University cohort completes a year-long online program, biweekly coaching and mentoring sessions, monthly group-based problem-solving sessions, and receives access to a five-day Bootcamp and the Agile Nudge Resource Library. Discussion The Agile Nudge University is evaluated through participant feedback, competency surveys, and tracking of the funding, research awards, and promotions of participating scholars. The Agile Nudge University is compounding national innovation efforts in overcoming the gaps in the ADRD discovery-to-delivery translational cycle.
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Affiliation(s)
- Jade Mehta
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
| | - Christopher Williams
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, United States
- Department of Health and Wellness Design, School of Public Health - Bloomington, Indiana University, Bloomington, IN, United States
| | - Richard J. Holden
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Department of Health and Wellness Design, School of Public Health - Bloomington, Indiana University, Bloomington, IN, United States
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Britain Taylor
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Nicole R. Fowler
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, United States
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Malaz Boustani
- Center for Health Innovation and Implementation Science, School of Medicine, Indiana University, Indianapolis, IN, United States
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN, United States
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, IN, United States
- Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, United States
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Schütz Leuthold M, El-Hakmaoui F, Senn N, Cohidon C. General Practitioner's Experience of Public-Private Partnerships to Develop Team-Based Care: A Qualitative Study. Int J Public Health 2023; 68:1606453. [PMID: 38033765 PMCID: PMC10681929 DOI: 10.3389/ijph.2023.1606453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives: A tripartite public-private partnership was established between GPs' practices, public health authorities and a university department of family medicine, to develop multidisciplinary teams and integrate nurses into GPs' practices. The present paper describes the points of view of the GPs involved in this collaboration. Methods: We conducted a qualitative study, with data coming from eight interviews with GPs, one from each practice. We also used the facilitator's project diary to complete the discussion. Results: The principal issue discussed was the financial aspects of the collaboration. GPs are generally satisfied, but time spent coordinating with nurses and transferring activities made them fear financial losses. Secondly, the partnership with public health authorities was well appreciated, but not clear enough. Some aspects of the partnership, such as referring patient to the nurse should have been better defined et controlled. The last aspect was the academic support. It allowed reducing GPs' workload in training nurses and supporting the project implementation within the GPs' practice. Conclusion: GPs have a positive point of view of such public-private partnership and saw an opportunity to be involved in developing public health policies.
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Affiliation(s)
- Muriel Schütz Leuthold
- Department of Family Medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Fatima El-Hakmaoui
- Department of Family Medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Nicolas Senn
- Department of Family Medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Christine Cohidon
- Department of Family Medicine, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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Farooq MS, Abdullah M, Riaz S, Alvi A, Rustam F, Flores MAL, Galán JC, Samad MA, Ashraf I. A Survey on the Role of Industrial IoT in Manufacturing for Implementation of Smart Industry. SENSORS (BASEL, SWITZERLAND) 2023; 23:8958. [PMID: 37960657 PMCID: PMC10650216 DOI: 10.3390/s23218958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 10/24/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023]
Abstract
The Internet of Things (IoT) is an innovative technology that presents effective and attractive solutions to revolutionize various domains. Numerous solutions based on the IoT have been designed to automate industries, manufacturing units, and production houses to mitigate human involvement in hazardous operations. Owing to the large number of publications in the IoT paradigm, in particular those focusing on industrial IoT (IIoT), a comprehensive survey is significantly important to provide insights into recent developments. This survey presents the workings of the IoT-based smart industry and its major components and proposes the state-of-the-art network infrastructure, including structured layers of IIoT architecture, IIoT network topologies, protocols, and devices. Furthermore, the relationship between IoT-based industries and key technologies is analyzed, including big data storage, cloud computing, and data analytics. A detailed discussion of IIoT-based application domains, smartphone application solutions, and sensor- and device-based IIoT applications developed for the management of the smart industry is also presented. Consequently, IIoT-based security attacks and their relevant countermeasures are highlighted. By analyzing the essential components, their security risks, and available solutions, future research directions regarding the implementation of IIoT are outlined. Finally, a comprehensive discussion of open research challenges and issues related to the smart industry is also presented.
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Affiliation(s)
- Muhammad Shoaib Farooq
- Department of Computer Science, University of Management and Technology, Lahore 54000, Pakistan; (M.S.F.); (M.A.); (S.R.); (A.A.)
| | - Muhammad Abdullah
- Department of Computer Science, University of Management and Technology, Lahore 54000, Pakistan; (M.S.F.); (M.A.); (S.R.); (A.A.)
| | - Shamyla Riaz
- Department of Computer Science, University of Management and Technology, Lahore 54000, Pakistan; (M.S.F.); (M.A.); (S.R.); (A.A.)
| | - Atif Alvi
- Department of Computer Science, University of Management and Technology, Lahore 54000, Pakistan; (M.S.F.); (M.A.); (S.R.); (A.A.)
| | - Furqan Rustam
- School of Computer Science, University College Dublin, D04 V1W8 Dublin, Ireland;
| | - Miguel Angel López Flores
- Research Group on Foods, Universidad Europea del Atlantico, Isabel Torres 21, 39011 Santander, Spain; (M.A.L.F.); (J.C.G.)
- Research Group on Foods, Universidad Internacional Iberoamericana, Campeche 24560, Mexico
- Instituto Politécnico Nacional, UPIICSA, Ciudad de México 04510, Mexico
| | - Juan Castanedo Galán
- Research Group on Foods, Universidad Europea del Atlantico, Isabel Torres 21, 39011 Santander, Spain; (M.A.L.F.); (J.C.G.)
- Universidad Internacional Iberoamericana, Arecibo, PR 00613, USA
- Department of Projects, Universidade Internacional do Cuanza, Cuito EN250, Bie, Angola
| | - Md Abdus Samad
- Department of Information and Communication Engineering, Yeungnam University, Gyeongsan 38541, Republic of Korea
| | - Imran Ashraf
- Department of Information and Communication Engineering, Yeungnam University, Gyeongsan 38541, Republic of Korea
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11
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Hancock C, Johnson A, Sladky M, Lawton Chen L, Shushan S, Parchman ML. Integrating MOUD and Primary Care: Outcomes of a Multicenter Learning Collaborative. Fam Med 2023; 55:452-459. [PMID: 37450845 PMCID: PMC10622073 DOI: 10.22454/fammed.2023.643371] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Opioid use and overdose remain a central and worsening public health emergency in the United States and abroad. Efforts to expand treatment have struggled to match the rising incidence of opioid use disorder (OUD), and treating patients in primary care settings represents one of the most promising opportunities to meet this need. Learning collaboratives (LCs) are one evidence-based strategy to improve implementation of medication treatment for opioid use disorder (MOUD) in primary care. METHODS We developed and studied a multidisciplinary MOUD learning collaborative involving six underserved primary care clinics. We used a mixed-methods approach to assess needs, develop curriculum, and evaluate outcomes from these clinics. RESULTS We recruited six clinics to participate in the collaborative. Half had an established MOUD program. Approximately 80% of participants achieved their organizational quality improvement goals for the collaborative. After the collaborative, participants also reported a significant increase in their perceived competence to implement/improve a MOUD program (pre-LC competence=2.80, post-LC competence=6.33/10, P=.02). The most consistent barrier we identified was stigma around OUD and its effects on patients' ability to access services and staff/provider ability to provide services. The most frequent enablers of program success were trainee interest, organizational leadership support, and a dedicated MOUD care team. CONCLUSIONS Organizations used clinical and systems improvement knowledge to enhance their existing programs or to take steps to create new programs. All participants identified the need for additional staff/clinician training, especially to overcome stigma around OUD. The outcomes demonstrated the crucial importance of long-term organizational support for program success.
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Affiliation(s)
| | - Ashley Johnson
- Department of Family Medicine, University of WashingtonSeattle, WA
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12
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Kilbourne AM, Geng E, Eshun-Wilson I, Sweeney S, Shelley D, Cohen DJ, Kirchner JE, Fernandez ME, Parchman ML. How does facilitation in healthcare work? Using mechanism mapping to illuminate the black box of a meta-implementation strategy. Implement Sci Commun 2023; 4:53. [PMID: 37194084 PMCID: PMC10190070 DOI: 10.1186/s43058-023-00435-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 05/06/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Healthcare facilitation, an implementation strategy designed to improve the uptake of effective clinical innovations in routine practice, has produced promising yet mixed results in randomized implementation trials and has not been fully researched across different contexts. OBJECTIVE Using mechanism mapping, which applies directed acyclic graphs that decompose an effect of interest into hypothesized causal steps and mechanisms, we propose a more concrete description of how healthcare facilitation works to inform its further study as a meta-implementation strategy. METHODS Using a modified Delphi consensus process, co-authors developed the mechanistic map based on a three-step process. First, they developed an initial logic model by collectively reviewing the literature and identifying the most relevant studies of healthcare facilitation components and mechanisms to date. Second, they applied the logic model to write vignettes describing how facilitation worked (or did not) based on recent empirical trials that were selected via consensus for inclusion and diversity in contextual settings (US, international sites). Finally, the mechanistic map was created based on the collective findings from the vignettes. FINDINGS Theory-based healthcare facilitation components informing the mechanistic map included staff engagement, role clarification, coalition-building through peer experiences and identifying champions, capacity-building through problem solving barriers, and organizational ownership of the implementation process. Across the vignettes, engagement of leaders and practitioners led to increased socialization of the facilitator's role in the organization. This in turn led to clarifying of roles and responsibilities among practitioners and identifying peer experiences led to increased coherence and sense-making of the value of adopting effective innovations. Increased trust develops across leadership and practitioners through expanded capacity in adoption of the effective innovation by identifying opportunities that mitigated barriers to practice change. Finally, these mechanisms led to eventual normalization and ownership of the effective innovation and healthcare facilitation process. IMPACT Mapping methodology provides a novel perspective of mechanisms of healthcare facilitation, notably how sensemaking, trust, and normalization contribute to quality improvement. This method may also enable more efficient and impactful hypothesis-testing and application of complex implementation strategies, with high relevance for lower-resourced settings, to inform effective innovation uptake.
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Affiliation(s)
- Amy M. Kilbourne
- Health Services Research & Development, VA Office of Research and Development, US Department of Veterans Affairs and University of Michigan, 810 Vermont Ave, NW, Washington, D.C., 20420 USA
| | - Elvin Geng
- Washington University at St. Louis, St. Louis, MO USA
| | | | | | - Donna Shelley
- New York University School of Global Public Health, New York, New York USA
| | | | - JoAnn E. Kirchner
- Central Arkansas VA Healthcare System and University of Arkansas for Medical Sciences, North Little Rock, AR USA
| | - Maria E. Fernandez
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX USA
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13
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Breton M, Gaboury I, Martin E, Green ME, Kiran T, Laberge M, Kaczorowski J, Ivers N, Deville-Stoetzel N, Bordeleau F, Beaulieu C, Descoteaux S. Impact of externally facilitated continuous quality improvement cohorts on Advanced Access to support primary healthcare teams: protocol for a quasi-randomized cluster trial. BMC PRIMARY CARE 2023; 24:97. [PMID: 37038126 PMCID: PMC10088119 DOI: 10.1186/s12875-023-02048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Improving access to primary health care is among top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results. The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes. METHODS Cluster-controlled trial allowing for a comprehensive and rigorous evaluation of the proposed intervention 48 multidisciplinary primary care clinics will be recruited to participate. 24 Clinics from the intervention regions will receive the CQI intervention for 18 months including three activities carried out iteratively until the clinic's improvement objectives are achieved: 1) reflective sessions and problem priorisation; 2) plan-do-study-act cycles; and 3) group mentoring. Clinics located in the control regions will receive an audit-feedback report on access. Complementary qualitative and quantitative data reflecting the quintuple aim will be collected over a period of 36 months. RESULTS This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients' experiences of care. CONCLUSION This mixed-method approach offers a unique opportunity to contribute to the scientific literature on large-scale CQI cohorts to improve AA in primary care teams and to better understand the processes of CQI. TRIAL REGISTRATION Clinical Trials: NCT05715151.
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Affiliation(s)
- Mylaine Breton
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada.
| | - Isabelle Gaboury
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Elisabeth Martin
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | | | - Tara Kiran
- University of Toronto, Toronto, ON, Canada
| | | | | | - Noah Ivers
- University of Toronto, Toronto, ON, Canada
| | - Nadia Deville-Stoetzel
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Francois Bordeleau
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Christine Beaulieu
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Sarah Descoteaux
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
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14
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Kirkegaard A, Ball L, Mitchell L, Williams LT. A novel perspective of Australian primary care dietetics: Insights from an exploratory study using complex adaptive systems theory. Nutr Diet 2022; 79:469-480. [PMID: 35692187 PMCID: PMC9545103 DOI: 10.1111/1747-0080.12742] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/29/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
Aims Effective quality improvement strategies are essential to enhancing outcomes of dietetic care. Interventions informed by complex adaptive systems theory have demonstrated effectiveness in other healthcare settings. This study aimed to explore primary care dietetics practice using complex adaptive systems theory and to identify factors that individuals across the healthcare system can examine and address to improve the quality of dietetic care. Methods Qualitative analysis of semi‐structured interviews of healthcare consumers and professionals involved in the provision of dietetic care. Data collection and analysis was guided by a complexity‐informed conceptual framework. The Framework Method was used to code transcripts and identify themes describing primary care dietetics. Results Twenty‐three consumers and 26 primary care professionals participated. Participants described dietetic care as being delivered by individuals organised into formal and informal systems that were influenced by the wider environment, including legal, economic, and socio‐cultural systems. Dietitians described interactions with consumers as a learning opportunity and sought education, mentoring, or supervision to address knowledge and skill gaps. Relationships underpinned transfer of information between individuals. Conclusion Complex adaptive systems theory proved to be a useful conceptual framework for primary care dietetics. Factors identified at the macro (e.g., funding), meso (e.g., professional networks), and micro (e.g., consumer education) levels should be examined and addressed to improve the quality of dietetic care.
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Affiliation(s)
- Amy Kirkegaard
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
| | - Lauren Ball
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
| | - Lana Mitchell
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
| | - Lauren T Williams
- Menzies Health Institute of Queensland, Griffith University, Southport, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Southport, QLD, Australia
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15
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Garbutt J, Dodd S, Rook S, Graham S, Wang R, Sterkel R, Plax K. Improving Follow-Up for Adolescents With Depression in Primary Care. Pediatrics 2022; 149:e2021051107. [PMID: 35641468 PMCID: PMC9647579 DOI: 10.1542/peds.2021-051107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Few adolescents with depression receive treatment in accordance with national guidelines. This quality improvement project took place in 11 primary care practices with the primary aim of increasing the percentage of teens with depression who received follow-up care within 6 weeks of diagnosis and within 3 months, once stable. METHODS The primary strategy was external practice facilitation for 12 months. The change process used goal setting and plan-do-study-act cycles to identify and implement change ideas. A preanalysis and postanalysis was completed to evaluate process change, provider confidence, and patient improvement. RESULTS Randomly selected samples of 199 and 217 charts of teens newly diagnosed with depression were reviewed before and after the intervention, respectively. Chart data for these measurements was provided by 10 and 9 practices, respectively. The percentage of patients with follow-up care within 6 weeks after diagnosis increased from 40% to 81% (P < .001), the percentage with a follow-up visit within 3 months once stable increased from 30% to 60% (P < .001), and the percentage in remission at 6 months increased from 7% to 21% (P < .001). Providers reported increased confidence to diagnose and manage depression, assess severity, provide pharmacotherapy, and educate families. CONCLUSIONS Practices improved follow-up care for teens with depression. In addition, providers experienced an improvement in their confidence to diagnose and manage depression. Working with a facilitator, each practice implemented standardized systems to provide effective care in the medical home, increase providers' confidence to address this common problem, and improve patient outcomes.
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Affiliation(s)
- Jane Garbutt
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Sherry Dodd
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Shannon Rook
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Sharon Graham
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Ruoyun Wang
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Randall Sterkel
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Katie Plax
- Department of Pediatrics, Washington University, St. Louis, Missouri
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16
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Cullen J, Childerhouse P, McBain L. Contextual antecedents of quality improvement: a comparative case study in rural, urban and Kaupapa Māori general practice. J Prim Health Care 2022; 14:179-186. [PMID: 35771707 DOI: 10.1071/hc22012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/04/2022] [Indexed: 12/20/2022] Open
Abstract
Introduction The impact of contextual factors on primary health-care quality improvement is significant. In-depth research is required to identify the key contextual factors that influence quality improvement initiatives to develop high-performing primary health-care systems. Aim This research seeks to answer two questions; what are the contextual factors influencing primary care improvement initiatives?; and how do contextual factors, the quality improvement initiative and the implementation process influence one another and the overall improvement outcomes? Methods A multi-case study methodology was used to explore the complexities of the phenomena in situ . Three sites where successful quality improvement had occurred were selected by purposeful theoretical sampling to provide a sample of rural, urban and Kaupapa Māori general practice settings typical of the New Zealand environment. Semi-structured interviews were conducted with team members and triangulated with secondary data provided by the organisations. Results The quality improvement topic and the approach taken were intrinsically linked to context. Sites reported success in achieving the desired outcomes benefitting the patients, practice and staff. Teams did not use formal improvement methods, instead relying on established relationships and elements of change management methods. The culture in all three cases was a large component of why and how these initiatives were successful. Discussion Intrinsic motivation was generated by community connections and networks. This combined with a learning climate generated by distributed leadership and teamwork enabled success. Iterative reflection and sensemaking processes were able to deliver quality improvement success in primary care without the use of formal improvement methods.
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Affiliation(s)
- Jane Cullen
- Massey University, Palmerston North, New Zealand
| | - Paul Childerhouse
- Massey University, Palmerston North, New Zealand; and Department of Supply Chain Management, College of Business and Law, RMIT, Melbourne, Australia
| | - Lynn McBain
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
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17
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Fu N, Singh P, Dale S, Orzol S, Peikes D, Ghosh A, Brown R, Day TJ. Long-Term Effects of the Comprehensive Primary Care Model on Health Care Spending and Utilization. J Gen Intern Med 2022; 37:1713-1721. [PMID: 34236603 PMCID: PMC9130381 DOI: 10.1007/s11606-021-06952-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services launched the 4-year Comprehensive Primary Care Initiative (CPC Classic) in 2012 and its 5-year successor, CPC Plus (CPC+), in 2017 to test whether improving primary care delivery in five areas-and providing practices with financial and technical support-reduced spending and improved quality. This is the first study to examine long-term effects of a primary care practice transformation model. OBJECTIVE To test whether long-term primary care transformation-the 4-year CPC Classic and the first 2 years of its successor, CPC+-reduced hospitalizations, emergency department (ED) visits, and spending over 6 years. DESIGN We used a difference-in-differences analysis to compare outcomes for beneficiaries attributed to CPC Classic practices with outcomes for beneficiaries attributed to comparison practices during the year before and 6 years after CPC Classic began. PARTICIPANTS The study involved 565,674 Medicare fee-for-service beneficiaries attributed to 502 CPC Classic practices and 1,165,284 beneficiaries attributed to 908 comparison practices, with similar beneficiary-, practice-, and market-level characteristics as the CPC Classic practices. INTERVENTIONS The interventions required primary care practices to improve 5 care areas and supported their transformation with substantially enhanced payment, data feedback, and learning support and, for CPC+, added health information technology support. MAIN MEASURES Hospitalizations (all-cause), ED visits (outpatient and total), and Medicare Part A and B expenditures. KEY RESULTS Relative to comparison practices, beneficiaries in intervention practices experienced slower growth in hospitalizations-3.1% less in year 5 and 3.5% less in year 6 (P < 0.01) and roughly 2% (P < 0.1) slower growth each year in total ED visits during years 3 through 6. Medicare Part A and B expenditures (excluding care management fees) did not change appreciably. CONCLUSIONS The emergence of favorable effects on hospitalizations in years 5 and 6 suggests primary care transformation takes time to translate into lower hospitalizations. Longer tests of models are needed.
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Affiliation(s)
- Ning Fu
- Mathematica, Cambridge, MA, USA.
| | | | | | | | | | | | | | - Timothy J Day
- Center for Medicare and Medicaid Innovation, Baltimore, MA, USA
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18
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Implementation and Qualitative Evaluation of a Primary Care Redesign Model with Expanded Scope of Work for Medical Assistants. J Gen Intern Med 2022; 37:1129-1137. [PMID: 34997393 PMCID: PMC8971214 DOI: 10.1007/s11606-021-07246-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 10/22/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implementation of primary care models involving expanded scope of work and redesigned workflows for medical assistants (MAs) as primary care team members can be challenging. Implementation strategies and participatory evaluation informed by implementation science frameworks may inform organizational decisions about model scale-up and sustainment. OBJECTIVE This paper reports implementation strategies and qualitative evaluation of a primary care redesign (PCR) model implementation that included an expanded scope of work for MAs. DESIGN Qualitative evaluation of implementation strategies and clinician and staff experience with implementation of PCR using semi-structured key informant interviews. The evaluation was guided by the RE-AIM framework and the Consolidated Framework for Implementation Research. PARTICIPANTS Sixty-nine clinicians, staff, practice leaders, and administrators from 7 primary care practices (4 general internal medicine, 3 family medicine) implementing PCR. INTERVENTIONS The PCR model included enhanced rooming and documentation support. The health system used multiple strategies to implement PCR, including rapid improvement events, changing clinic space configurations, developing electronic health record templates and performance dashboards, and practice coaching. APPROACH The Consolidated Framework for Implementation Research and the RE-AIM evaluation and planning framework guided development of semi-structured interview guides. A deductive, structural coding approach was used for analysis. KEY RESULTS PCR implementation was facilitated by clear communication about the intervention source, mechanisms for feedback about model goals, and physical environments and electronic health record (EHR) systems that supported the added staff and modified clinic workflow. Clinicians and staff benefited from the ability to see the model in action prior to go-live and opportunities for consistent provider-MA pairings. CONCLUSIONS The PCR model can support achieving the Quadruple Aim when fully implemented with paired MAs and clinicians who are well prepared to follow redesigned workflows and function as a team. Implementation can be effectively supported by a participatory evaluation guided by implementation science frameworks.
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19
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Kilbourne AM, Garrido MM, Brown A. Translating Research into Policy and Action. Health Serv Res 2022; 57 Suppl 1:5-8. [PMID: 35362119 PMCID: PMC9108221 DOI: 10.1111/1475-6773.13980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/29/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Amy M Kilbourne
- Quality Enhancement Research Initiative, U.S. Department of Veterans Affairs.,Department of Learning Health Sciences, University of Michigan
| | - Melissa M Garrido
- Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System.,Department of Health Law, Policy and Management, Boston University School of Public Health
| | - Arleen Brown
- Division of General Internal Medicine and Health Services Research, UCLA School of Medicine.,Olive View-UCLA Medical Center
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20
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Schiavoni KH, Lawrence J, Xue J, Kotelchuck M, Boudreau AA. Pediatric Practice Transformation and Long-Acting Reversible Contraception (LARC) Use in Adolescents. Acad Pediatr 2022; 22:296-304. [PMID: 34758402 DOI: 10.1016/j.acap.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Long acting reversible contraceptives (LARCs) are recommended as highly effective for adolescents. Although the uptake of LARCs has increased, overall use remains low due to barriers for both providers and patients. We evaluate whether pediatric medical home transformation, including implant placement in pediatrics, may increase LARC use or decrease adolescent pregnancy rates. METHODS Retrospective interrupted time-series analysis of adolescents ages 11 to 19 years at 2 pediatric practices in academically affiliated community health centers during 2005-2015. The intervention practice underwent medical home transformation including team-based care with family planning and health coaching, youth-friendly policies, and contraceptive implant placement. The control practice continued usual care. Differential changes in population event rates were evaluated using a segmented longitudinal regression model. RESULTS The study population included 4946 adolescent females at the intervention practice and 1992 at the control practice. Following practice transformation, LARC use increased significantly more at the intervention practice compared to the control (1.73 versus 0.28 events per 1000 patients quarterly P = 0.004). Pregnancy rate declined at both practices without temporal correlation to the LARC intervention. During the medical home transformation period, the intervention practice showed a greater decline in pregnancy rate, though this difference did not reach statistical significance (2.01 versus 0.81 events per 1000 patients quarterly P = 0.090). CONCLUSIONS Adolescents had higher LARC use where implant placement was offered within the pediatric practice as part of medical home transformation. Although LARC did not impact pregnancy rate, the process of practice transformation may have accelerated its decline through heightened adolescent health focus.
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Affiliation(s)
- Katherine H Schiavoni
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Mass General Brigham, Population Health Management (KH Schiavoni), Somerville, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass.
| | - Jourdyn Lawrence
- Harvard T. H. Chan School of Public Heath, Department of Social and Behavioral Sciences (J Lawrence), Boston, Mass
| | - Jiayin Xue
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass
| | - Milton Kotelchuck
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass
| | - Alexy Arauz Boudreau
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass
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21
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Kolko DJ, McGuier EA, Turchi R, Thompson E, Iyengar S, Smith SN, Hoagwood K, Liebrecht C, Bennett IM, Powell BJ, Kelleher K, Silva M, Kilbourne AM. Care team and practice-level implementation strategies to optimize pediatric collaborative care: study protocol for a cluster-randomized hybrid type III trial. Implement Sci 2022; 17:20. [PMID: 35193619 PMCID: PMC8862323 DOI: 10.1186/s13012-022-01195-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementation facilitation is an effective strategy to support the implementation of evidence-based practices (EBPs), but our understanding of multilevel strategies and the mechanisms of change within the "black box" of implementation facilitation is limited. This implementation trial seeks to disentangle and evaluate the effects of facilitation strategies that separately target the care team and leadership levels on implementation of a collaborative care model in pediatric primary care. Strategies targeting the provider care team (TEAM) should engage team-level mechanisms, and strategies targeting leaders (LEAD) should engage organizational mechanisms. METHODS We will conduct a hybrid type 3 effectiveness-implementation trial in a 2 × 2 factorial design to evaluate the main and interactive effects of TEAM and LEAD and test for mediation and moderation of effects. Twenty-four pediatric primary care practices will receive standard REP training to implement Doctor-Office Collaborative Care (DOCC) and then be randomized to (1) Standard REP only, (2) TEAM, (3) LEAD, or (4) TEAM + LEAD. Implementation outcomes are DOCC service delivery and change in practice-level care management competencies. Clinical outcomes are child symptom severity and quality of life. DISCUSSION This statewide trial is one of the first to test the unique and synergistic effects of implementation strategies targeting care teams and practice leadership. It will advance our knowledge of effective care team and practice-level implementation strategies and mechanisms of change. Findings will support efforts to improve common child behavioral health conditions by optimizing scale-up and sustainment of CCMs in a pediatric patient-centered medical home. TRIAL REGISTRATION ClinicalTrials.gov, NCT04946253 . Registered June 30, 2021.
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Affiliation(s)
- David J Kolko
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Elizabeth A McGuier
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Renee Turchi
- Department of Pediatrics, Drexel University College of Medicine and St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Eileen Thompson
- PA Medical Home Program, PA Chapter, American Academy of Pediatrics, Media, PA, USA
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shawna N Smith
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Kimberly Hoagwood
- Department of Child and Adolescent Psychiatry, New York University Langone Health, New York, NY, USA
| | - Celeste Liebrecht
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ian M Bennett
- Departments of Family Medicine and Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, One Brookings Drive, St. Louis, MO, 63130, USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Kelly Kelleher
- Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
- Nationwide Children's Hospital Research Institute, Columbus, OH, USA
| | - Maria Silva
- Allegheny Family Network, Pittsburgh, PA, USA
| | - Amy M Kilbourne
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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22
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The Coordination Toolkit and Coaching Project: Cluster-Randomized Quality Improvement Initiative to Improve Patient Experience of Care Coordination. J Gen Intern Med 2022; 37:95-103. [PMID: 34109545 PMCID: PMC8739408 DOI: 10.1007/s11606-021-06926-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 05/11/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Given persistent gaps in coordination of care for medically complex primary care patients, efficient strategies are needed to promote better care coordination. OBJECTIVE The Coordination Toolkit and Coaching project compared two toolkit-based strategies of differing intensity to improve care coordination at VA primary care clinics. DESIGN Multi-site, cluster-randomized QI initiative. PARTICIPANTS Twelve VA primary care clinics matched in 6 pairs. INTERVENTIONS We used a computer-generated allocation sequence to randomize clinics within each pair to two implementation strategies. Active control clinics received an online toolkit with evidence-based tools and QI coaching manual. Intervention clinics received the online toolkit plus weekly assistance from a distance coach for 12 months. MAIN MEASURES We quantified patient experience of general care coordination using the Health Care System Hassles Scale (primary outcome) mailed at baseline and 12-month follow-up to serial cross-sectional patient samples. We measured the difference-in-difference (DiD) in clinic-level-predicted mean counts of hassles between coached and non-coached clinics, adjusting for clustering and patient characteristics using zero-inflated negative binomial regression and bootstrapping to obtain 95% confidence intervals. Other measures included care coordination QI projects attempted, tools adopted, and patient-reported exposure to projects. KEY RESULTS N = 2,484 (49%) patients completed baseline surveys and 2,481 (48%) completed follow-ups. Six coached clinics versus five non-coached clinics attempted QI projects. All coached clinics versus two non-coached clinics attempted more than one project or projects that were multifaceted (i.e., involving multiple components addressing a common goal). Five coached versus three non-coached clinics used 1-2 toolkit tools. Both the coached and non-coached clinics experienced pre-post reductions in hassle counts over the study period (- 0.42 (- 0.76, - 0.08) non-coached; - 0.40 (- 0.75, - 0.06) coached). However, the DiD (0.02 (- 0.47, 0.50)) was not statistically significant; coaching did not improve patient experience of care coordination relative to the toolkit alone. CONCLUSION Although coached clinics attempted more or more complex QI projects and used more tools than non-coached clinics, coaching provided no additional benefit versus the online toolkit alone in patient-reported outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03063294.
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23
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Fakeye OA, Khanna N, Hsu YJ, Marsteller JA. Impact of a Statewide Multi-Payer Patient-Centered Medical Home Program on Antihypertensive Medication Adherence. Popul Health Manag 2021; 25:309-316. [PMID: 34609933 DOI: 10.1089/pop.2021.0172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.
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Affiliation(s)
- Oludolapo A Fakeye
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Niharika Khanna
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jill A Marsteller
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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24
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Epling JW, Rockwell MS, Miller AD, Carver MC. Socializing the evidence for diabetes control to develop "mindlines": a qualitative pilot study. BMC FAMILY PRACTICE 2021; 22:177. [PMID: 34488641 PMCID: PMC8422605 DOI: 10.1186/s12875-021-01521-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Evidence on specific interventions to improve diabetes control in primary care is available, but this evidence is not always well-implemented. The concept of "mindlines" has been proposed to explain how clinicians integrate evidence using specifics of their practices and patients to produce knowledge-in-practice-in-context. The goal of this pilot study was to operationalize this concept by creating a venue for clinician-staff interaction concerning evidence. The research team attempted to hold "mindlines"-producing conversations in primary care practices about evidence to improve diabetes control. METHODS Each of four primary care practices in a single health system held practice-wide conversations about a simple diabetes intervention model over a provided lunch. The conversations were relatively informal and encouraged participation from all. The research team recorded the conversations and took field notes. The team analyzed the data using a framework adapted from the "mindlines" research and noted additional emergent themes. RESULTS While most of the conversation concerned barriers to implementation of the simple diabetes intervention model, there were examples of practices adopting and adapting the evidence to suit their own needs and context. Performance metrics regarding diabetes control for the four practices improved after the intervention. CONCLUSION It appears that the type of conversations that "mindlines" research describes can be generated with facilitation around evidence, but further research is required to better understand the limitations and impact of this intervention.
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Affiliation(s)
- John W Epling
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine and The Carilion Clinic, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA.
| | - Michelle S Rockwell
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine and The Carilion Clinic, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA.,Fralin Life Sciences Institute, Virginia Tech, Blacksburg, VA, USA
| | | | - M Colette Carver
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine and The Carilion Clinic, 1 Riverside Circle, Suite 102, Roanoke, VA, 24016, USA
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25
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Kwan-Gett TS, Albertson EM, Banks J, Revere D, Rogers M, Baseman J, Andris L, Conrad D. Mixed-Methods Evaluation of the Washington State Practice Transformation Support Hub. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2021; 27:484-491. [PMID: 32810069 DOI: 10.1097/phh.0000000000001221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Practice transformation initiatives have the potential to promote collaborations between public health, primary care, and behavioral health, but limited empirical evidence is available on how these programs affect participating clinical practices. OBJECTIVE To report the findings from a mixed-methods program evaluation of the Washington Practice Transformation Support Hub (Hub), a publicly funded, multicomponent practice transformation initiative in Washington State. DESIGN We used quantitative and qualitative methods to evaluate the impact of Hub activities on participating primary care and behavioral health practices. Pre- and posttest survey data were combined with administrative program data to understand the effect of program components. Qualitative interviews contextualized findings. SETTING Urban and rural primary care and behavioral health practices in Washington State. PARTICIPANTS One hundred seventy-five practices that were recruited to receive Hub coaching and facilitation from 8 coaches; of these, 13 practices and all coaches participated in key informant interviews. INTERVENTION Practice coaching and facilitation supported by an online resource portal, from January 2017 through January 2019. MAIN OUTCOME MEASURES Self-reported progress in specific activities in 3 practice-level domains: bidirectional integration of physical and behavioral health care (care integration); alignment with community-based services for whole-person care (clinical-community linkages); and value-based payment. RESULTS Participation in Hub activities was associated with improvements in care integration and clinical-community linkages but not with progress toward value-based payment. Qualitative results indicated that practice progress was influenced by communication with practices, the culture of the practice, resource constraints (particularly in rural areas), and perceptions about sustainability. CONCLUSIONS This statewide practice transformation initiative was successful in strengthening primary care and behavioral health integration and clinical-community linkages among participating practices but not value-based payment. Future practice transformation efforts may benefit from addressing barriers posed by communication, limited application of value-based payment, culture change, competing priorities, and resource limitations, particularly for rural communities.
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Affiliation(s)
- Tao Sheng Kwan-Gett
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington (Drs Kwan-Gett, Baseman, and Conrad, Mr Banks, and Mss MLIS, Rogers, and Andris); and Department of Health Policy and Management, University of California Los Angeles Fielding School of Public Health, Los Angeles, California (Ms Albertson)
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26
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DeJonckheere M, McKee MM, Guetterman TC, Schleicher LS, Mulhem E, Panzer K, Bradley K, Plegue MA, Rapai ME, Green LA, Zazove P. Implementation of a Hearing Loss Screening Intervention in Primary Care. Ann Fam Med 2021; 19:388-395. [PMID: 34546945 PMCID: PMC8437567 DOI: 10.1370/afm.2695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/16/2020] [Accepted: 12/03/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Hearing loss (HL) is underdiagnosed and often unaddressed. A recent study of screening for HL using an electronic prompt showed efficacy in increasing appropriate referrals for subsequent testing. We build on the results of this study using a qualitative lens to explore implementation processes through the perspectives of family medicine clinicians. METHODS We collected clinic observations and semistructured interviews of family medicine clinicians and residents who interacted with the HL prompt. All data were analyzed using thematic, framework, and mixed methods integration strategies. RESULTS We interviewed 27 clinicians and conducted 10 observations. Thematic analysis resulted in 6 themes: (1) the prompt was overwhelmingly viewed as easy, simple to use, accurate; (2) clinicians considered prompt as an effective way to increase awareness and conversations with patients about HL; (3) clinician and staff buy-in played a vital role in implementation; (4) clinicians prioritized prompt during annual visits; (5) medical assistant involvement in prompt workflow varied by health system, clinic, and clinician; (6) prompt resulted in more conversations about HL, but uncertain impact on patient outcomes. Themes are presented alongside constructs of normalization process theory and intervention outcomes. CONCLUSION Integration of a HL screening prompt into clinical practice varied by clinician buy-in and beliefs about the impact on patient outcomes, involvement of medical assistants, and prioritization during clinical visits. Further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has sustained impact on HL screening and patient outcomes.
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Affiliation(s)
| | - Michael M McKee
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | | | | | - Elie Mulhem
- Department of Family Medicine and Community Health, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | | | - Kathleen Bradley
- Department of Family Medicine and Community Health, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Melissa A Plegue
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mary E Rapai
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lee A Green
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Philip Zazove
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
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27
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Huybrechts I, Declercq A, Verté E, Raeymaeckers P, Anthierens S. The Building Blocks of Implementation Frameworks and Models in Primary Care: A Narrative Review. Front Public Health 2021; 9:675171. [PMID: 34414155 PMCID: PMC8369196 DOI: 10.3389/fpubh.2021.675171] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/08/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Our aim is to identify the core building blocks of existing implementation frameworks and models, which can be used as a basis to further develop a framework for the implementation of complex interventions within primary care practices. Within the field of implementation science, various frameworks, and models exist to support the uptake of research findings and evidence-based practices. However, these frameworks and models often are not sufficiently actionable or targeted for use by intervention designers. The objective of this research is to map the similarities and differences of various frameworks and models, in order to find key constructs that form the foundation of an implementation framework or model that is to be developed. Methods: A narrative review was conducted, searching for papers that describe a framework or model for implementation by means of various search terms, and a snowball approach. The core phases, components, or other elements of each framework or model are extracted and listed. We analyze the similarities and differences between the frameworks and models and elaborate on their core building blocks. These core building blocks form the basis of an overarching model that we will develop based upon this review and put into practice. Results: A total of 28 implementation frameworks and models are included in our analysis. Throughout 15 process models, a total of 67 phases, steps or requirements are extracted and throughout 17 determinant frameworks a total of 90 components, constructs, or elements are extracted and listed into an Excel file. They are bundled and categorized using NVivo 12© and synthesized into three core phases and three core components of an implementation process as common elements of most implementation frameworks or models. The core phases are a development phase, a translation phase, and a sustainment phase. The core components are the intended change, the context, and implementation strategies. Discussion: We have identified the core building blocks of an implementation framework or model, which can be synthesized in three core phases and three core components. These will be the foundation for further research that aims to develop a new model that will guide and support intervention designers to develop and implement complex interventions, while taking account contextual factors.
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Affiliation(s)
- Ine Huybrechts
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium.,Department of Family Medicine and Chronic Care, Free University of Brussels, Brussels, Belgium
| | - Anja Declercq
- LUCAS - Centre for Care Research and Consultancy & CESO - Centre for Sociological Research, Catholic University of Leuven, Leuven, Belgium
| | - Emily Verté
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium.,Department of Family Medicine and Chronic Care, Free University of Brussels, Brussels, Belgium
| | - Peter Raeymaeckers
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
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28
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Penney LS, Bharath PS, Miake-Lye I, Leng M, Olmos-Ochoa TT, Finley EP, Chawla N, Barnard JM, Ganz DA. Toolkit and distance coaching strategies: a mixed methods evaluation of a trial to implement care coordination quality improvement projects in primary care. BMC Health Serv Res 2021; 21:817. [PMID: 34391443 PMCID: PMC8364700 DOI: 10.1186/s12913-021-06850-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022] Open
Abstract
Background Care coordination tools and toolkits can be challenging to implement. Practice facilitation, an active but expensive strategy, may facilitate toolkit implementation. We evaluated the comparative effectiveness of distance coaching, a form of practice facilitation, for improving the implementation of care coordination quality improvement (QI) projects. Methods We conducted a mixed methods evaluation of the Coordination Toolkit and Coaching (CTAC) initiative. Twelve matched US Veterans Health Administration primary care clinics were randomized to receive coaching and an online care coordination toolkit (“coached”; n = 6) or access to the toolkit only (“non-coached”; n = 6). We did interviews at six, 12, and 18 months. For coached sites, we‘ly collected site visit fieldnotes, prospective coach logs, retrospective coach team debriefs, and project reports. We employed matrix analysis using constructs from the Consolidated Framework for Implementation Research and a taxonomy of outcomes. We assessed each site’s project(s) using an adapted Complexity Assessment Tool for Systematic Reviews. Results Eleven sites implemented a local CTAC project. Eight sites (5 coached, 3 non-coached) used at least one tool from the toolkit. Coached sites implemented significantly more complex projects than non-coached sites (11.5 vs 7.5, 95% confidence interval 1.75–6.25, p < 0.001); engaged in more formal implementation processes (planning, engaging, reflecting and evaluating); and generally had larger, more multidisciplinary QI teams. Regardless of coaching status, sites focused on internal organizational improvement and low-intensity educational projects rather than the full suite of care coordination tools. At 12 months, half the coached and non-coached sites had clinic-wide project implementation; the remaining coached sites had implemented most of their project(s), while the remaining non-coached sites had either not implemented anything or conducted limited pilots. At 18 months, coached sites reported ongoing effort to monitor, adapt, and spread their CTAC projects, while non-coached sites did not report much continuing work. Coached sites accrued benefits like improved clinic relationships and team QI skill building that non-coached sites did not describe. Conclusions Coaching had a positive influence on QI skills of (and relationships among) coached sites’ team members, and the scope and rigor of projects. However, a 12-month project period was potentially too short to ensure full project implementation or to address cross-setting or patient-partnered initiatives. Trial registration NCT03063294. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06850-1.
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Affiliation(s)
- Lauren S Penney
- Elizabeth Dole Center of Excellence for Veteran & Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA. .,Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.
| | - Purnima S Bharath
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.,Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Isomi Miake-Lye
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.,Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mei Leng
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Tanya T Olmos-Ochoa
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Erin P Finley
- Elizabeth Dole Center of Excellence for Veteran & Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX, USA.,Department of Medicine, University of Texas Health San Antonio, San Antonio, TX, USA.,HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Neetu Chawla
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Jenny M Barnard
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - David A Ganz
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.,RAND Corporation, Santa Monica, California, USA
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29
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Gaboury I, Breton M, Perreault K, Bordeleau F, Descôteaux S, Maillet L, Hudon C, Couturier Y, Duhoux A, Vachon B, Cossette B, Rodrigues I, Poitras ME, Loignon C, Vasiliadis HM. Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services. BMC Health Serv Res 2021; 21:812. [PMID: 34388996 PMCID: PMC8361639 DOI: 10.1186/s12913-021-06839-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/30/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.
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Affiliation(s)
- Isabelle Gaboury
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada.
| | - Mylaine Breton
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Kathy Perreault
- GMF-U Saint-Jean-sur-Richelieu, Saint-Jean-sur-Richelieu, Canada
| | - François Bordeleau
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Sarah Descôteaux
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Lara Maillet
- École Nationale d'Administration Publique, Montreal, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Yves Couturier
- School of social work, Faculty of letters and social sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montreal, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Benoit Cossette
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Isabel Rodrigues
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Marie-Eve Poitras
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Christine Loignon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Helen-Maria Vasiliadis
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
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Olmos-Ochoa TT, Ganz DA, Barnard JM, Penney L, Finley EP, Hamilton AB, Chawla N. Sustaining implementation facilitation: a model for facilitator resilience. Implement Sci Commun 2021; 2:65. [PMID: 34154670 PMCID: PMC8218441 DOI: 10.1186/s43058-021-00171-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 06/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Implementation facilitators enable healthcare staff to effectively implement change, yet little is known about their affective (e.g., emotional, mental, physical) experiences of facilitation. We propose an expansion to the Integrated Promoting Action on Research in Health Services (i-PARIHS) framework that introduces facilitation intensity and facilitator resilience to better assess facilitators' affective experiences. METHODS We used an instrumental case study and facilitator data (logged reflections and debrief session notes) from the Coordination Toolkit and Coaching initiative to conceptualize facilitation intensity and facilitator resilience and to better understand the psychological impact of the facilitation process on facilitator effectiveness and implementation success. RESULTS We define facilitation intensity as both the quantitative and/or qualitative measure of the volume of tasks and activities needed to engage and motivate recipients in implementation, and the psychological impact on the facilitator of conducting facilitation tasks and activities. We define facilitator resilience as the ability to cope with and adapt to the complexities of facilitation in order to effectively engage and motivate staff, while nurturing and sustaining hope, self-efficacy, and adaptive coping behaviors in oneself. CONCLUSIONS Facilitators' affective experience may help to identify potential relationships between the facilitation factors we propose (facilitation intensity and facilitator resilience). Future studies should test ways of reliably measuring facilitation intensity and facilitator resilience and specify their relationships in greater detail. By supporting facilitator resilience, healthcare delivery systems may help sustain the skilled facilitator workforce necessary for continued practice improvement. TRIAL REGISTRATION The project was registered with ClinicalTrials.gov ( NCT03063294 ) on February 24, 2017.
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Affiliation(s)
- Tanya T Olmos-Ochoa
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System - Sepulveda, 16111 Plummer Street (152), North Hills, CA, 91343, USA.
| | - David A Ganz
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System - Sepulveda, 16111 Plummer Street (152), North Hills, CA, 91343, USA.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Jenny M Barnard
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System - Sepulveda, 16111 Plummer Street (152), North Hills, CA, 91343, USA
| | - Lauren Penney
- Veterans Evidence-based Research Dissemination and Implementation Center (VERDICT), South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Erin P Finley
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System - Sepulveda, 16111 Plummer Street (152), North Hills, CA, 91343, USA.,Veterans Evidence-based Research Dissemination and Implementation Center (VERDICT), South Texas Veterans Health Care System, San Antonio, TX, USA.,University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System - Sepulveda, 16111 Plummer Street (152), North Hills, CA, 91343, USA.,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Neetu Chawla
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System - Sepulveda, 16111 Plummer Street (152), North Hills, CA, 91343, USA
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Metusela C, Dijkmans-Hadley B, Mullan J, Gow A, Bonney A. Implementation of a patient centred medical home (PCMH) initiative in general practices in New South Wales, Australia. BMC FAMILY PRACTICE 2021; 22:120. [PMID: 34148554 PMCID: PMC8215740 DOI: 10.1186/s12875-021-01485-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/07/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND With an ageing population and an increase in chronic disease burden in Australia, Patient Centred Medical Home (PCMH) models of care have been identified as potential options for primary care reform and improving health care outcomes. Adoption of PCMH models are not well described outside of North America. We examined the experiences of seven general practices in an Australian setting that implemented projects aligned with PCMH values and goals supported by their local Primary Health Network (PHN). METHOD Qualitative and quantitative data were collected over a twelve month period, including semi-structured interviews, participant observation, and practice data to present a detailed examination of a subject of study; the implementation of PCMH projects in seven general practices. We conducted 49 interviews (24 pre and 25 post) with general practitioners, practice managers, practice nurses and PHN staff. Framework analysis deploying the domains of a logic model was used to synthesis and analyse the data. RESULTS Facilitators in implementing successful, sustainable change included the capacity and willingness of practices to undertake change; whole of practice engagement with a shared vision towards PCMH change; engaged leadership; training and support; and structures and processes required to provide team-based, data driven care. Barriers to implementation included change fatigue, challenges of continued engaged leadership and insufficient time to implement PCMH change. CONCLUSIONS Our study examined the experiences of implementing PCMH initiatives in an Australian general practice setting, describing facilitators and barriers to PCMH change. Our findings provide guidance for PHNs and practices within Australia, as well as general practice settings internationally, that are interested in undertaking similar quality improvement projects.
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Affiliation(s)
- Christine Metusela
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
| | | | - Judy Mullan
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
| | - Andrew Gow
- South Eastern New South Wales Primary Health Network, Wollongong, Australia
| | - Andrew Bonney
- General Practice Academic Unit, School of Medicine, University of Wollongong, Wollongong, Australia
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Schuttner L, Coleman K, Ralston J, Parchman M. The role of organizational learning and resilience for change in building quality improvement capacity in primary care. Health Care Manage Rev 2021; 46:E1-E7. [PMID: 33630509 PMCID: PMC7541444 DOI: 10.1097/hmr.0000000000000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The extent that organizational learning and resilience for the change process, that is, adaptive reserve (AR), is a component of building practice capacity for continuous quality improvement (QI) is unknown. PURPOSE The aim of the study was to examine the association of AR and development of QI capacity. METHODOLOGY One hundred forty-two primary care practices were evaluated at baseline and 12 months in a randomized trial to improve care quality. Practice AR was measured by staff survey along with a validated QI capacity assessment (QICA). We assessed the association of baseline QICA with baseline AR and both baseline and change in AR with change in QICA from 0 to 12 months. Effect modification by presence of QI infrastructure in parent organizations and trial arm was examined. RESULTS Mean QICA increased from 6.5 to 8.1 (p < .001), and mean AR increased from 71.8 to 73.9 points (p < .001). At baseline, there was a significant association between AR and QICA scores: The QICA averaged 0.34 points higher (95% CI [0.04, 0.64], p = .03) per 10-point difference in AR. There was a significant association between baseline AR and 12-month QICA-which averaged 0.30 points higher (95% CI [0.02, 0.57], p = .04) per 10 points in baseline AR. There was no association between changes in AR and the QICA from 0 to 12 months and no effect modification by trial arm or external QI infrastructure. CONCLUSIONS Baseline AR was positively associated with both baseline and follow-up QI capacity, but there was no association between change in AR and change in the QICA, suggesting AR may be a precondition to growth in QI capacity. PRACTICE IMPLICATIONS Findings suggest that developing AR may be a valuable step prior to undertaking QI-oriented growth, with implications for sequencing of development strategies, including added gain in QI capacity development from building AR prior to engaging in transformation efforts.
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Walunas TL, Ye J, Bannon J, Wang A, Kho AN, Smith JD, Soulakis N. Does coaching matter? Examining the impact of specific practice facilitation strategies on implementation of quality improvement interventions in the Healthy Hearts in the Heartland study. Implement Sci 2021; 16:33. [PMID: 33789696 PMCID: PMC8011080 DOI: 10.1186/s13012-021-01100-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/18/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Practice facilitation is a multicomponent implementation strategy used to improve the capacity for practices to address care quality and implementation gaps. We sought to assess whether practice facilitators use of coaching strategies aimed at improving self-sufficiency were associated with improved implementation of quality improvement (QI) interventions in the Healthy Hearts in the Heartland Study. METHODS We mapped 27 practice facilitation activities to a framework that classifies practice facilitation strategies by the degree to which the practice develops its own process expertise (Doing Tasks, Project Management, Consulting, Teaching, and Coaching) and then used regression tree analysis to group practices by facilitation strategies experienced. Kruskal-Wallis tests were used to assess whether practice groups identified by regression tree analysis were associated with successful implementation of QI interventions and practice and study context variables. RESULTS There was no association between number of strategies performed by practice facilitators and number of QI interventions implemented. Regression tree analysis identified 4 distinct practice groups based on the number of Project Management and Coaching strategies performed. The median number of interventions increased across the groups. Practices receiving > 4 project management and > 6 coaching activities implemented a median of 17 of 35 interventions. Groups did not differ significantly by practice size, association with a healthcare network, or practice type. Statistically significant differences in practice location, number and duration of facilitator visits, and early study termination emerged among the groups, compared to the overall practice population. CONCLUSIONS Practices that engage in more coaching-based strategies with practice facilitators are more likely to implement more QI interventions, and practice receptivity to these strategies was not dependent on basic practice demographics.
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Affiliation(s)
- Theresa L Walunas
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N. Michigan, 15th Floor, Chicago, IL, 60611, USA.
| | - Jiancheng Ye
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N. Michigan, 15th Floor, Chicago, IL, 60611, USA
| | - Jennifer Bannon
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N. Michigan, 15th Floor, Chicago, IL, 60611, USA
| | - Ann Wang
- Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N. Michigan, 15th Floor, Chicago, IL, 60611, USA
| | - Abel N Kho
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Health Information Partnerships, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 625 N. Michigan, 15th Floor, Chicago, IL, 60611, USA.,Department of Preventive Medicine, Division of Healthcare and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Justin D Smith
- Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nicholas Soulakis
- Department of Preventive Medicine, Division of Healthcare and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Grady VM, Soylu TG, Goldberg DG, Kitsantas P, Grady JD. A Cross-Sectional Analysis of Primary Care Practice Characteristics and Healthcare Professionals' Behavioral Responses to Change. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:46958021996518. [PMID: 33645303 PMCID: PMC7923974 DOI: 10.1177/0046958021996518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The recent decade brought major changes to primary care practices. Previous research on change has focused on change processes, and change implementations rather than studying employee’s feelings, perceptions, and attitudes toward change. The objective of this cross-sectional study was to examine the relationship between healthcare professionals’ behavioral responses to change and practice characteristics. Our study, which builds upon Conner’s theory, addresses an extensive coverage of individual behaviors, feelings, and attitudes toward change. We analyzed survey responses of healthcare professionals (n = 1279) from 154 primary care practices in Virginia. Healthcare professionals included physicians, advanced practice clinicians, clinical support staff, and administrative staff. The Change Diagnostic Index© (CDI) was used to measure behavioral responses in 7 domains: anxiety, frustration, delayed development, rejection of environment, refusal to participate, withdrawal, and global reaction. We used descriptive statistics and multivariate regression analysis. Our findings indicate that professionals had a significantly lower aptitude for change if they work in larger practices (≥16 clinicians) compared to solo practices (P < .05) and at hospital-owned practices compared to independent practices (P < .05). Being part of an accountable care organization was associated with significantly lower anxiety (P < .05). Understanding healthcare professionals’ responses to change can help healthcare leaders design and implement successful change management strategies for future transformation.
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Yu JA, McKernan G, Hagerman T, Schenker Y, Houtrow A. Most Children With Medical Complexity Do Not Receive Care in Well-Functioning Health Care Systems. Hosp Pediatr 2021; 11:183-191. [PMID: 33408158 PMCID: PMC7831373 DOI: 10.1542/hpeds.2020-0182] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe the access of children with medical complexity (CMC) to well-functioning health care systems. To examine the relationships between medical complexity status and this outcome and its component indicators. PATIENTS AND METHODS Secondary analysis of children in the National Survey of Children's Health combined 2016-2017 data set who received care in well-functioning health systems. Secondary outcomes included this measure's component indicators. The χ2 analyses were used to examine associations between child and family characteristics and the primary outcome. Adjusted multivariable logistic regression was used to examine relationships between medical complexity status and primary and secondary outcomes. Using these regression models, we examined the interaction between medical complexity status and household income. RESULTS CMC accounted for 1.6% of the weighted sample (n = 1.2 million children). Few CMC (7.6%) received care in a well-functioning health care system. CMC were significantly less likely than children with special health care needs (CSHCN) (odds ratio, 0.3) of meeting criteria for this primary outcome. Attainment rates for secondary outcomes (families feeling like partners in care; receives care within a medical home; received needed health care) were significantly lower among CMC than CSHCN. Family income was significantly associated with likelihood of meeting criteria for primary and secondary outcomes; however, the relationships between medical complexity status and our outcomes did not differ by income level. CONCLUSIONS CMC are less likely than other CSHCN to report receiving care in well-functioning health care systems at all income levels. Further efforts are necessary to better adapt current health care systems to meet the unique needs of CMC.
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Affiliation(s)
- Justin A Yu
- Divisions of Pediatric Hospital Medicine and Palliative and Supportive Care,
- Departments of Pediatrics and
| | - Gina McKernan
- Physical Medicine and Rehabilitation
- Department of Physical Medicine and Rehabilitation, Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Thomas Hagerman
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, and
| | - Amy Houtrow
- Division of Pediatric Rehabilitation Medicine, Department of Physical Medicine and Rehabilitation
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Harvey JB, Vanderbrink J, Mahmud Y, Kitt‐Lewis E, Wolf L, Shaw B, Ridgely MS, Damberg CL, Scanlon DP. Understanding how health systems facilitate primary care redesign. Health Serv Res 2020; 55 Suppl 3:1144-1154. [PMID: 33284524 PMCID: PMC7720713 DOI: 10.1111/1475-6773.13576] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work. STUDY SETTING A purposive sample of 24 health systems in 4 states. STUDY DESIGN Data were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR. DATA COLLECTION Semi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems. PRINCIPAL FINDINGS Leaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care. CONCLUSIONS Given their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts.
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Affiliation(s)
| | | | - Yasmin Mahmud
- The Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Erin Kitt‐Lewis
- The Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Laura Wolf
- The Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Bethany Shaw
- The Pennsylvania State UniversityUniversity ParkPennsylvaniaUSA
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Readiness and Implementation of Quality Improvement Strategies Among Small- and Medium-Sized Primary Care Practices: an Observational Study. J Gen Intern Med 2020; 35:2882-2888. [PMID: 32779136 PMCID: PMC7573036 DOI: 10.1007/s11606-020-05978-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 06/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Little is known about what determines strategy implementation around quality improvement (QI) in small- and medium-sized practices. Key questions are whether QI strategies are associated with practice readiness and practice characteristics. OBJECTIVE Grounded in organizational readiness theory, we examined how readiness and practice characteristics affect QI strategy implementation. The study was a component of a larger practice-level intervention, Heart of Virginia Healthcare, which sought to transform primary care while improving cardiovascular care. DESIGN This observational study analyzed practice correlates of QI strategy implementation in primary care at 3 and 12 months. Data were derived from surveys completed by clinicians and staff and from assessments by practice coaches. PARTICIPANTS A total of 175 small- and medium-sized primary care practices were included. MAIN MEASURES Outcome was QI strategy implementation in three domains: (1) aspirin, blood pressure, cholesterol, and smoking cessation (ABCS); (2) care coordination; and (3) organizational-level improvement. Coaches assessed implementation at 3 and 12 months. Readiness was measured by baseline member surveys, 1831 responses from 175 practices, a response rate of 73%. Practice survey assessed practice characteristics, a response rate of 93%. We used multivariate regression. KEY RESULTS QI strategy implementation increased from 3 to 12 months: the mean for ABCS from 1.20 to 1.59, care coordination from 2.15 to 2.75, organizational improvement from 1.37 to 1.78 (95% CI). There was no statistically significant association between readiness and QI strategy implementation across domains. Independent practice implementation was statistically significantly higher than hospital-owned practices at 3 months for ABCS (95% CI, P = 0.01) and care coordination (95% CI, P = 0.03), and at 12 months for care coordination (95% CI, P = 0.04). CONCLUSION QI strategy implementation varies by practice ownership. Independent practices focus on patient care-related activities. FQHCs may need additional time to adopt and implement QI activities. Practice readiness may require more structural and organizational changes before starting a QI effort.
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Egede LE, Walker RJ, Nagavally S, Thakkar M, O'Sullivan M, Stulac Motzel W. Redesigning primary care in an academic medical center: lessons, challenges, and opportunities. Postgrad Med 2020; 132:636-642. [PMID: 32441180 DOI: 10.1080/00325481.2020.1773685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate patient access, provider productivity, and patient satisfaction during a 24-month redesign process of an academic medical center, which requires balance between clinical and educational missions. METHODS A series of activities were conducted to optimize primary care across 17 attending physicians, 6 Advanced Practice Providers (APPs), and 39 residents. Patient access was defined as the next available appointment for either existing/established patients or new patients. Productivity was measured using panel sizes for each provider. Patient satisfaction was based on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS). RESULTS Despite decreasing clinical effort to allow faculty and APPs to participate in education and research, there was an overall increase in access for both new and established patients, and an increase the percent of each providers' panel that was full from 78.89% in 2017 to 115.29% in 2019. When comparing panel sizes for the 11 faculty present before and after strategic changes, we found significant increase in both overall panel size, and actual to expected ratios between 2017 and 2019. In addition, throughout the time period, patient satisfaction remained high with no significant changes. CONCLUSIONS While this project was limited to one site, the inclusion of a set of well-planned metrics, and tracking of processes over time can provide insight for ongoing primary care redesign efforts at similar sites seeking to balance the academic mission with clinical productivity and high patient satisfaction.
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Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin , Milwaukee, WI, USA.,Center for Advancing Population Science, Medical College of Wisconsin , Milwaukee, WI, USA
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin , Milwaukee, WI, USA.,Center for Advancing Population Science, Medical College of Wisconsin , Milwaukee, WI, USA
| | - Sneha Nagavally
- Center for Advancing Population Science, Medical College of Wisconsin , Milwaukee, WI, USA
| | - Madhuli Thakkar
- Center for Advancing Population Science, Medical College of Wisconsin , Milwaukee, WI, USA
| | - Monica O'Sullivan
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin , Milwaukee, WI, USA
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Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
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Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
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Noël PH, Barnard JM, Barry FM, Simon A, Lee ML, Olmos-Ochoa TT, Chawla N, Rose DE, Stockdale SE, Finley EP, Penney LS, Ganz DA. Patient experience of health care system hassles: Dual-system vs single-system users. Health Serv Res 2020; 55:548-555. [PMID: 32380578 DOI: 10.1111/1475-6773.13291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To compare health care system problems or "hassles" experienced by Veterans receiving VA health care only versus those receiving dual care from both VA and non-VA community providers. DATA SOURCES We collected survey data in 2017-2018 from 2444 randomly selected Veterans with four or more primary care visits in the prior year at one of 12 VA primary care clinics located in four geographically diverse regions of the United States. STUDY DESIGN We used baseline surveys from the Coordination Toolkit and Coaching quality improvement project to explore Veterans' experience of hassles (dependent variable), source of health care, self-rated physical and mental health, and sociodemographics. DATA COLLECTION Participants responded to mailed surveys by mail, telephone, or online. PRINCIPAL FINDINGS The number of reported hassles ranged from 0 to 16; 79 percent of Veterans reported experiencing one or more hassles. Controlling for sociodemographic characteristics and self-rated physical and mental health, zero-inflated negative binominal regression indicated that dual care users experienced more hassles than VA-only users (adjusted predicted average 5.5 [CI: 5.2, 5.8] vs 4.3 [CI: 4.1, 4.6] hassles [P < .0001]). CONCLUSIONS Anticipated increases in Veterans accessing community-based care may require new strategies to help VA primary care teams optimize care coordination for dual care users.
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Affiliation(s)
- Polly H Noël
- Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, Texas.,Department of Family and Community Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Jenny M Barnard
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Frances M Barry
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Alissa Simon
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Martin L Lee
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California.,Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California
| | - Tanya T Olmos-Ochoa
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Neetu Chawla
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California.,Fielding School of Public Health, University of California at Los Angeles, Los Angeles, California
| | - Danielle E Rose
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California
| | - Susan E Stockdale
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California.,Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, California
| | - Erin P Finley
- Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, Texas.,Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Lauren S Penney
- Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, Texas.,Department of Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - David A Ganz
- HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Sepulveda, California.,David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
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Margolis KL, Crain AL, Bergdall AR, Beran M, Anderson JP, Solberg LI, O'Connor PJ, Sperl-Hillen JM, Pawloski PA, Ziegenfuss JY, Rehrauer D, Norton C, Haugen P, Green BB, McKinney Z, Kodet A, Appana D, Sharma R, Trower NK, Williams R, Crabtree BF. Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure. Contemp Clin Trials 2020; 92:105939. [PMID: 31981712 DOI: 10.1016/j.cct.2020.105939] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Uncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. POPULATION Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care. AIMS/OBJECTIVES To compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research. METHODS The design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18-85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects. CONCLUSION This pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - MarySue Beran
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Dan Rehrauer
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Christine Norton
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA 98101, United States of America
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Amy Kodet
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Deepika Appana
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - RaeAnn Williams
- HealthPartners, Mailstop 31100A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ 08901, United States of America
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Crabtree BF, Miller WL, Howard J, Rubinstein EB, Tsui J, Hudson SV, O'Malley D, Ferrante JM, Stange KC. Cancer Survivorship Care Roles for Primary Care Physicians. Ann Fam Med 2020; 18:202-209. [PMID: 32393555 PMCID: PMC7213992 DOI: 10.1370/afm.2498] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/27/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.
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Affiliation(s)
- Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey .,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Jenna Howard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Denalee O'Malley
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Jeanne M Ferrante
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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Metusela C, Usherwood T, Lawson K, Angus L, Kmet W, Ferdousi S, Reath J. Patient Centred Medical Home (PCMH) transitions in western Sydney, Australia: a qualitative study. BMC Health Serv Res 2020; 20:285. [PMID: 32252751 PMCID: PMC7137239 DOI: 10.1186/s12913-020-05123-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 03/18/2020] [Indexed: 12/05/2022] Open
Abstract
Background Patient Centred Medical Homes (PCMHs), increasingly evidenced to provide high quality primary care, are new to Australia. To learn how this promising new healthcare model works in an Australian setting we explored experiences of healthcare providers in outer urban Sydney, where a number of practices are transitioning from traditional Australian general practice models to incorporate elements of PCMH approaches. Methods We collected qualitative data from semi-structured interviews with healthcare providers working in a range of transitioning practices and thematically analysed the data. We interviewed 35 participants including general practitioners, practice managers and practice nurses from 25 purposively sampled general practices in western Sydney, Australia, seeking maximal variation in practice size, patient demographics and type of engagement in practice transformation. Results Interviewees described PCMH transformation highlighting the importance of whole of practice engagement with a shared vision; key strategies for transformation to PCMH models of care including leadership, training and supportive information technology; structures and processes required to provide team-based, data-driven care; and constraints such as lack of space and the current Australian fee-for-service general practice funding model. They also reported their perceptions of early outcomes of the PCMH model of care, describing enhanced patient and staff satisfaction and also noting fewer hospital admissions, as likely to reduce costs of care. Conclusions Our study exploring the experience of early adopters of PCMH models of care in Australia, informs the international movement towards PCMH models of care. Our findings provide guidance for practices considering similar transitions and describe the challenges of such transitions within a fee-for-service payment system.
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Affiliation(s)
- Christine Metusela
- Department of General Practice, School of Medicine, Western Sydney University, Building 30.3.24 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia
| | - Tim Usherwood
- General Practice, School of Medicine, University of Sydney, Sydney, Australia
| | - Kenny Lawson
- Translational Health Research Institute, Western Sydney University, Sydney, Australia
| | - Lisa Angus
- Providence Center for Outcomes Research & Education, Portland, OR, USA
| | - Walter Kmet
- Macquarie University Hospital and Clinical Services, Sydney, Australia
| | - Shahana Ferdousi
- WentWest Ltd, Western Sydney Primary Health Network, Blacktown, Australia
| | - Jennifer Reath
- Department of General Practice, School of Medicine, Western Sydney University, Building 30.3.24 Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
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Stockdale SE, Hamilton AB, Bergman AA, Rose DE, Giannitrapani KF, Dresselhaus TR, Yano EM, Rubenstein LV. Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration. Implement Sci 2020; 15:18. [PMID: 32183873 PMCID: PMC7079486 DOI: 10.1186/s13012-020-0979-y] [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: 07/22/2019] [Accepted: 03/04/2020] [Indexed: 12/25/2022] Open
Abstract
Background Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants’ fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity. Methods Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010–2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis. Results Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity. Conclusions This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.
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Affiliation(s)
- Susan E Stockdale
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA. .,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA.
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Alicia A Bergman
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA
| | - Danielle E Rose
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA
| | - Karleen F Giannitrapani
- HSR&D Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | | | - Elizabeth M Yano
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.,Department of Health Policy & Management Fielding School of Public Health, University of California, Los Angeles, USA
| | - Lisa V Rubenstein
- Department of Health Policy & Management Fielding School of Public Health, University of California, Los Angeles, USA.,Department of Medicine David Geffen School of Medicine, University of California, Los Angeles, USA.,RAND Corporation, Santa Monica, CA, USA
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Sinnott C, Georgiadis A, Park J, Dixon-Woods M. Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature. Ann Fam Med 2020; 18:159-168. [PMID: 32152021 PMCID: PMC7062478 DOI: 10.1370/afm.2485] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 07/11/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians. METHODS We conducted a critical interpretive synthesis. We searched 7 databases for papers published in English from database inception until October 2017 for primary research of any design that addressed problems interfering with primary care physicians' work. All potentially eligible titles/abstracts were screened by 1 reviewer; 30% were subject to second screening. We conducted an iterative critique, analysis, and synthesis of included studies. RESULTS Our search retrieved 8,544 unique citations. Though no paper explicitly referred to "operational failures," we identified 95 papers that conformed to our general definition. The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures-including those relating to technology, information, and coordination-over which physicians often had limited control. Operational failures actively configured physicians' work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience. CONCLUSIONS Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.
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Affiliation(s)
- Carol Sinnott
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom
| | - Alexandros Georgiadis
- THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, Cambridge, United Kingdom
- ICON Plc, The Translation & Innovation Hub Building, Imperial College London, LondonUnited Kingdom
| | - John Park
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Abstract
Introduction Organisational culture is believed to be an important facilitator for better integrated care, yet how organisational culture impacts integrated care remains underspecified. In an exploratory study, we assessed the relationship between organisational culture in primary care centres as perceived by primary care teams and patient-perceived levels of integrated care. Theory and methods We analysed a sample of 2,911 patient responses and 17 healthcare teams in four primary care centres. We used three-level ordered logistic regression models to account for the nesting of patients within health care teams within primary care centres. Results Our results suggest a non-linear relationship between organisational culture at the team level and integrated care. A combination of different culture types-including moderate levels of production-oriented, hierarchical and team-oriented cultures and low or high levels of adhocracy cultures-related to higher patient-perceived levels of integrated care. Conclusions and discussion Organisational culture at the level of healthcare teams has significant associations with patient-perceived integrated care. Our results may be valuable for primary care organisations in their efforts to compose healthcare teams that are predisposed to providing better integrated care.
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Abstract
BACKGROUND Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns. METHODS We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes. RESULTS Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support. CONCLUSIONS Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.
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Frey R, Balmer D, Boyd M, Robinson J, Gott M. Palliative care nurse specialists' reflections on a palliative care educational intervention in long-term care: an inductive content analysis. BMC Palliat Care 2019; 18:103. [PMID: 31744507 PMCID: PMC6864945 DOI: 10.1186/s12904-019-0488-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/12/2019] [Indexed: 12/02/2022] Open
Abstract
Background Older people in long-term care facilities are at a greater risk of receiving care at the end of life that does not adequately meet their needs, yet staff in long-term care are often unprepared to provide palliative care. The objective of the study was to explore palliative care nurse specialists’ experiences regarding the benefits of and barriers to the implementation of a palliative care educational intervention, Supportive Hospice Aged Residential Exchange (SHARE) in 20 long-term care facilities. Methods Reflective logs (465), recorded over the course of the yearlong SHARE intervention by the three palliative care nurse specialists from two local hospices, who were the on-site mentors, were qualitatively analyzed by two researchers utilizing inductive content analysis. Results Categories emerging from the logs include the importance of relationships, knowledge exchange, communication, and the challenges of providing palliative care in a long-term care setting. Conclusion Evidence from the logs indicated that sustained relationships between the palliative care nurse specialists and staff (registered nurses, healthcare assistants) as well as reciprocal learning were key factors supporting the implementation of this palliative care educational intervention. Challenges remain however in relation to staffing levels, which further emphasizes the importance of palliative care nurse specialist presence as a point of stability.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Jackie Robinson
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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Fetters MD, Rubinstein EB. The 3 Cs of Content, Context, and Concepts: A Practical Approach to Recording Unstructured Field Observations. Ann Fam Med 2019; 17:554-560. [PMID: 31712294 PMCID: PMC6846267 DOI: 10.1370/afm.2453] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 04/12/2019] [Accepted: 05/07/2019] [Indexed: 12/17/2022] Open
Abstract
Most primary care researchers lack a practical approach for including field observations in their studies, even though observations can offer important qualitative insights and provide a mechanism for documenting behaviors, events, and unexpected occurrences. We present an overview of unstructured field observations as a qualitative research method for analyzing material surroundings and social interactions. We then detail a practical approach to collecting and recording observational data through a "3 Cs" template of content, context, and concepts. To demonstrate how this method works in practice, we provide an example of a completed template and discuss the analytical approach used during a study on informed consent for research participation in the primary care setting of Qatar.
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Affiliation(s)
- Michael D Fetters
- Mixed Methods Program, Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, North Dakota
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Callahan CM, Bateman DR, Wang S, Boustani MA. State of Science: Bridging the Science-Practice Gap in Aging, Dementia and Mental Health. J Am Geriatr Soc 2019; 66 Suppl 1:S28-S35. [PMID: 29659003 DOI: 10.1111/jgs.15320] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/26/2018] [Accepted: 01/29/2018] [Indexed: 12/21/2022]
Abstract
The workforce available to care for older adults has not kept pace with the need. In response to workforce limitations and the growing complexity of healthcare, scientists have tested new models of care that redesign clinical practice. This article describes why new models of care in aging, dementia, and mental health diffuse inadequately into the healthcare systems and communities where they might benefit older adults. We review a general framework for the diffusion of innovations and highlight the importance of other features of innovations that deter or facilitate diffusion. Although scientists often focus on generating evidence-based innovations, end-users apply their own criteria to determine an innovation's value. In 1962, Rogers suggested six features of an innovation that facilitate or deter diffusion suggested: relative advantage, compatibility with the existing environment, ease or difficulty of implementation, trial-ability or ability to "test drive", adaptability, and observed effectiveness. We describe examples of models of care in aging, dementia and mental health that enjoy a modicum of diffusion into practice and place the features of these models in the context of deterrents and facilitators for diffusion. Developers of models of care in aging, dementia, and mental health typically fail to incorporate the complexities of health systems, the barriers to diffusion, and the role of emotion into design considerations of new models. We describe agile implementation as a strategy to facilitate the speed and scale of diffusion in the setting of complex adaptive systems, social networks, and dynamic macroenvironments.
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Affiliation(s)
- Christopher M Callahan
- Center for Aging Research, Indiana University, Indianapolis, Indiana.,Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana
| | - Daniel R Bateman
- Center for Aging Research, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana.,Department of Psychiatry, School of Medicine, Indiana University, Indianapolis, Indiana.,Center for Health Innovation and Implementation Science, Indiana University, Indianapolis, Indiana
| | - Sophia Wang
- Department of Psychiatry, School of Medicine, Indiana University, Indianapolis, Indiana.,Center for Health Innovation and Implementation Science, Indiana University, Indianapolis, Indiana.,Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Malaz A Boustani
- Center for Aging Research, Indiana University, Indianapolis, Indiana.,Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Inc., Indianapolis, Indiana.,Center for Health Innovation and Implementation Science, Indiana University, Indianapolis, Indiana
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