Dissemination of performance information and continuous improvement: A narrative systematic review

The relationship between conference presentations and in-hospital mortality in patients admitted with acute myocardial infarction: A retrospective analysis using a Japanese administrative database

BACKGROUND

Clinicians' research activities reportedly improve their healthcare performance. Presenting research at conferences may be related to improved patient care outcomes; however, few studies have investigated this relationship. Thus, we examined the association between presenting at conferences and the mortality of patients hospitalized for acute myocardial infarction.

METHODS

We analyzed an administrative database of acute care hospitals in Japan. The study compared patients admitted to hospitals in which physicians made at least one conference presentation during the patient's admission year (Presentation Group) with those admitted to hospitals with no conference presentations (Control group). We performed multivariable logistic regression analyses to estimate the risk of all-cause in-hospital mortality. Five models were fitted: a Crude model, unadjusted; Model 1, adjusted for personal factors, including sex, age, Killip classification, and so on; Model 2, adjusted for Model 1 plus hospital factors; Model 3 was a multilevel analysis clustered by hospital codes and adjusted for the same variables as Model 1; Model 4 was adjusted for Model 1 plus evidence-based practices through causal mediation analysis.

RESULTS

After excluding 3,544 patients with missing Killip classification or ambulance use, data for 56,923 patients in 384 acute care hospitals were analyzed. Drug prescription in accordance with the evidence was significantly greater in the Presentation group than in the Control group. Moreover, conference presentation was significantly associated with lower in-hospital mortality in all models (Odds ratios (OR) = 0.68, 95% Confidence intervals (CIs): 0.65 to 0.72 in the Crude model; OR = 0.73, 95% CIs: 0.68 to 0.79 in Model 1; OR = 0.76, 95% CIs: 0.70 to 0.82 in Model 2; OR = 0.84, 95% CIs: 0.76 to 0.92 in Model 3; OR = 1.00, 95% CIs: 0.92 to 1.09 in Model 4).

CONCLUSION

The promotion of scholarly activities such as conference presentations might improve patient outcomes through increased evidence-based practice.

Unlocking data: Decision-maker perspectives on cross-sectoral data sharing and linkage as part of a whole-systems approach to public health policy and practice

Background

Secondary data from different policy sectors can provide unique insights into the social, environmental, economic and political determinants of health. This is especially pertinent in the context of whole-systems approaches to healthy public policy, which typically combine cross-sectoral collaboration with the application of theoretical insights from systems science. However, the sharing and linkage of data between different sectors are still relatively rare. Previous research has documented the perspectives of researchers and members of the public on data sharing, especially healthcare data, but has not engaged with relevant policy and practice decision-makers.

Aim

We sought to work collaboratively with decision-makers relevant to healthy public policy and practice in Scotland to identify practical ways that cross-sectoral data sharing and linkage could be used to best effect to improve health and reduce health inequalities.

Methods

We facilitated three sequential stakeholder workshops with 20 participants from local and central government, public health teams, Health and Social Care Partnerships, the third sector, organisations which support data-intensive research and public representatives from across Scotland. Workshops were informed by two scoping reviews (carried out in June 2021) and three case studies of existing cross-sectoral linkage projects. Workshop activities included brainstorming of factors that would help participants make better decisions in their current role; reflective questions on lessons learnt from the case studies; and identifying and prioritising recommendations for change. Findings were synthesised using thematic analysis.

Setting and scope

Scotland; public and third sector data.

Results

Based on the workshops, and supported by the reviews and case studies, we created a visual representation of the use of evidence, and secondary data in particular, in decision-making for healthy public policy and practice. This covered three key overarching themes: differing understandings of evidence; diverse functions of evidence; and factors affecting use (such as technical, political and institutional, workforce and governance). Building on this, workshop participants identified six guiding principles for cross-sectoral data sharing and linkage: it should be pragmatic; participatory; ambitious; fair; iterative; with holistic and proportionate governance. Participants proposed 21 practical actions to this end, including: a strategic approach to identifying and sharing key data sets; streamlining governance processes (e.g. through standardised data sharing agreements; central data repositories; and a focus on reusable data resources) and building workforce capacity. To make these possible, participants identified a need for strong political and organisational leadership as well as a transparent and inclusive public conversation.

Limitations

Participation from some stakeholders was limited by workload pressures associated with the COVID-19 pandemic. No consensus was reached on the impact, effort, and/or timing of some recommendations. Findings were closely informed by the Scottish context but are nonetheless likely to be relevant to other jurisdictions.

Conclusions

There is broad consensus among key stakeholders that linked cross-sectoral data can be used far more extensively for public health decision-making than it is at present. No single change will lead to improved use of such data: a range of technical, organisational and political constraints must be addressed.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR133585.

Promoting mental wellbeing among youth Australian Rules footballers through a model of continuous improvement

The developmental period of adolescence is a known transitional life phase with unique risk and protective factors that can affect mental wellbeing outcomes. This, in combination with the pressures and demand of elite sport, make young elite athletes an important population in which positive mental wellbeing can be explored. This study aimed to examine the state of wellbeing, informed by positive psychology and the Positive emotions, Engagement, Relationships, Meaning, Accomplishment (PERMA) model of wellbeing, in a cohort of young athletes aged 16-19 years in the Australian setting as part of a model of continuous improvement. The objectives of these aims were to inform the development of a wellbeing curriculum for implementation in the Australian Rules Football talent pathway and to assess whether wellbeing presents differently in young athletes relative to the general school-attending population of that same age. Participants were 608 young Australian footballers participating in the developmental talent pathway during 2020 and 2021. There were 299 young male footballers, and 309 young women footballers who completed data collection. Wellbeing was assessed using the Engagement, Perseverance, Optimism, Connectedness, Happiness Measure of Adolescent Wellbeing (EPOCH) which corresponds to the PERMA model of wellbeing, and total mean scores were reported. Engagement and connectedness were similar for the young men and women athletes. Young men reported higher perseverance, optimism, happiness, and overall wellbeing relative to young women. Wellbeing among young athletes appears similar to the general population, however perseverance may be higher among young athletes. These findings form an important component of the continuous improvement model adopted in the football program in that the results informed the development of a tailored wellbeing curriculum program that is reflective of the wellbeing needs of the young athletes.

How insights from the field of information behavior can enrich understanding of knowledge mobilization

PURPOSE

The authors review the literature on information behavior, an autonomous body of work developed mainly in library studies and compare it with work on knowledge mobilization. The aim is to explore how information behavior can contribute to understanding knowledge mobilization in healthcare management.

DESIGN/METHODOLOGY/APPROACH

The authors conducted a narrative review using an exploratory, nonkeyword "double-sided systematic snowball" method. This is especially useful in the situation when the two traditions targeted are broad and relies on distinct vocabulary.

FINDINGS

The authors find that the two bodies of work have followed similar trajectories and arrived at similar conclusions, with a linear view supplemented first by a social approach and then by a sensitivity to practice. Lessons from the field of information behavior can be used to avoid duplication of effort, repeating the same errors and reinventing the wheel among knowledge translation scholars. This includes, for example, focusing on sources of information or ignoring the mundane activities in which managers and policymakers are involved.

ORIGINALITY/VALUE

The study is the first known attempt to build bridges between the field of information behavior and the study of knowledge mobilization. The study, moreover, foregrounds the need to address knowledge mobilization in context-sensitive and social rather than technical terms, focusing on the mundane work performed by a variety of human and nonhuman agents.

Public Reporting of Performance Indicators in Long-Term Care in Canada: Does it Make a Difference?

Evidence of the impact of public reporting of health care performance on quality improvement is not yet sufficient for definitive conclusions to be drawn, despite the important policy implications. This study explored the association of public reporting of performance indicators of long-term care facilities in Canada with performance trends. We considered 16 performance indicators in long-term care in Canada, 8 of which are publicly reported at a facility level, whereas the other 8 are not publicly reported, between the fiscal years 2011-2012 and 2018-2019. Data from 1,087 long-term care facilities were included. Improving trends were observed among publicly reported indicators more often than among indicators that were not publicly reported. Our analysis also suggests that the association between publication of data and improvement is stronger among indicators for which there was no improvement prior to publication and among the worst performing facilities.

Disparate Impacts of Two Public Reporting Initiatives on Clinical and Perceived Quality in Healthcare

Purpose

Transparency is increasingly viewed as a prerequisite for value-based health care that invites quality in the assessment of achieved value. However, nowadays the ability of transparency initiatives to enhance quality of care remains obscure, if not rejected. Thus, this study aims to investigate how transparency initiatives influence two types of quality of care: clinical and perceived quality.

Methods

First, factor analyses were conducted to construct three dependent variables: healthcare-associated infections (HAIs), 30-day readmission rates, and patient satisfaction. Then, the three quality models were compared by running ordinary least squares multiple regressions using STATA 14.1. The existence of heteroskedasticity was remedied by using robust standard errors.

Results

Examining general acute care hospitals in the US, the present study noted that the ability of public reporting to improve quality of care remains inconclusive and that the pursuit of transparency may lead to inadvertent results. The disclosure of all-payer claims data (APCD) was found to have the power to differentiate hospitals’ clinical and perceived quality, but it failed to reach the desired outcomes without market pressure. The impact of transparency on quality of care diverges depending on the unique characteristics of each transparency policy, even though they pursue the same ends through information dissemination. Furthermore, the same public policy showed starkly disparate impacts on clinical quality (eg, healthcare-associated infections (HAIs) and 30-day readmission rates) and perceived quality (eg, patient satisfaction).

Conclusion

Despite the theoretically acknowledged merits of transparency, the present study noted that its ability to enhance quality of care remains inconclusive, and the pursuit of transparency may even inadvertently harm quality of care. While hospitals may need to finetune their strategies for each quality measurement in order to cope with the new environmental pressure, it is health policymakers’ role to coordinate those quality metrics and improve the validity of patient experience measures and surveys.

Implementation of a national policy for improving health and social care: a comparative case study using the Consolidated Framework for Implementation Research

Background

Comprehensive policies are becoming common for addressing wicked problems in health and social care. Success of these policies often varies between target organizations. This variation can often be attributed to contextual factors. However, there is a lack of knowledge about the conditions for successful policy implementation and how context influences this process. The aim of this study was to investigate county-level actors’ perspectives on the implementation of a comprehensive national policy in three Swedish counties. The policy focused on developing quality of care for elderly based on the use of national quality registries (NQRs) and to improve coordination of care.

Methods

A comparative case study approach was used. Data was collected longitudinally through documents and interviews. The Consolidated Framework for Implementation Research (CFIR) guided the analysis.

Results

All three counties shared the view that the policy addressed important issues. Still, there was variation regarding how it was perceived and managed. Adaptable features—i.e., NQRs and improvement coaches—were perceived as relevant and useful. However, the counties differed in their perceptions of another policy component—i.e., senior management program—as an opportunity or a disturbance. This program, while tackling complex issues of collaboration, fell short in recognizing the counties’ pre-existing conditions and needs and also offered few opportunities for adaptations. Performance bonuses and peer pressure were strong incentives for all counties to implement the policy, despite the poor fit of policy content and local context.

Conclusions

Comprehensive health policies aiming to address wicked problems have better chances of succeeding if the implementation includes assessments of the target organizations’ implementation capacity as well as the implicit quid pro quos involved in policy development. Special attention is warranted regarding the use of financial incentives when dealing with wicked problems since the complexity makes it difficult to align incentives with the goals and to assess potential consequences. Other important aspects in the implementation of such policies are the use of collaborative approaches to engage stakeholders with differing perspectives, and the tailoring of policy communication to facilitate shared understanding and commitment.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

OBJECTIVES

Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

SETTING

Primary care.

PARTICIPANTS

Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

INTERVENTIONS

We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

RESULTS

All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

CONCLUSIONS

A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

Use of comparative performance indicators in rehabilitation

BACKGROUND

The development of performance indicators that enable benchmarking between organizations is an important mechanism for accountability, organizational learning, and performance improvement. In the province of Quebec (Canada), 21 rehabilitation organizations developed a common set of performance indicators through interorganizational collaboration.

PURPOSE

The aims of this study were to describe the rehabilitation organizations' use of a common set of performance indicators and to identify the factors influencing such use.

APPROACH

A qualitative survey was performed. Individual semistructured interviews were conducted with executives (n = 18) working at 16 rehabilitation organizations using a common set of performance indicators. A thematic analysis of the factors of use was performed according to the Consolidated Framework for Implementation Research. The use of performance indicators was categorized as purposeful, political, or passive.

FINDINGS

Our results showed that all organizations used the common set of performance indicators. Four factors were identified as important to all the rehabilitation organizations to explain their interest in comparative performance indicators: the need to develop their own performance indicators, the compatibility of performance information with organizational needs, complexity/simplicity of performance information, and the support offered by their common association. Sixty-three percent of rehabilitation organizations made purposeful or political use of performance indicators. Three main factors contributed to typify those organizations from the others: the perceived quality of the performance indicators, the leadership of decision makers, and the resources available.

PRACTICE IMPLICATIONS

Our results showed that use of performance indicators can support the initiation of projects for improving the quality of care. Key recommendations are proposed to decision makers that may enhance performance indicators' use.

How do aggregated patient-reported outcome measures data stimulate health care improvement? A realist synthesis

Objectives Internationally, there has been considerable debate about the role of data in supporting quality improvement in health care. Our objective was to understand how, why and in what circumstances the feedback of aggregated patient-reported outcome measures data improved patient care. Methods We conducted a realist synthesis. We identified three main programme theories underlying the use of patient-reported outcome measures as a quality improvement strategy and expressed them as nine 'if then' propositions. We identified international evidence to test these propositions through searches of electronic databases and citation tracking, and supplemented our synthesis with evidence from similar forms of performance data. We synthesized this evidence through comparing the mechanisms and impact of patient-reported outcome measures and other performance data on quality improvement in different contexts. Results Three programme theories were identified: supporting patient choice, improving accountability and enabling providers to compare their performance with others. Relevant contextual factors were extent of public disclosure, use of financial incentives, perceived credibility of the data and the practicality of the results. Available evidence suggests that patients or their agents rarely use any published performance data when selecting a provider. The perceived motivation behind public reporting is an important determinant of how providers respond. When clinicians perceived that performance indicators were not credible but were incentivized to collect them, gaming or manipulation of data occurred. Outcome data do not provide information on the cause of poor care: providers needed to integrate and interpret patient-reported outcome measures and other outcome data in the context of other data. Lack of timeliness of performance data constrains their impact. Conclusions Although there is only limited research evidence to support some widely held theories of how aggregated patient-reported outcome measures data stimulate quality improvement, several lessons emerge from interventions sharing the same programme theories to help guide the increasing use of these measures.

Physician level reporting of surgical and pathology performance indicators: a regional study to assess feasibility and impact on quality

BACKGROUND

There is increased awareness that, to minimize variation in clinician practice and improve quality, performance reporting should be implemented at the provider level. This optimizes physician engagement and creates a sense of professional responsibility for quality and performance measurement at the individual and organizational levels.

METHODS

Individual provider level reporting was implemented within a provincial health region involving 56 clinicians (general surgeons, surgical oncologists, urologists and pathologists). The 2 surgical pathology indicators chosen were colorectal cancer (CRC) lymph node retrieval rate and pT2 prostate cancer margin positivity rate. Surgical resections for all prostate and colorectal cancer performed between Jan. 1, 2011, and Mar. 30, 2012, were included. We used a pre- and postsurvey design to obtain physician perceptions and focus groups with program leadership to determine organizational impact.

RESULTS

Survey results showed that respondents felt the data provided in the reports were valid (67%), consistent with expectations (70%), maintained confidentiality (80%) and were not used in a punitive manner (77%). During the study period the pT2 prostate margin positivity rate decreased from 57.1% to 27.5%. For the CRC lymph node retrieval rate indicator, high baseline performance was maintained.

CONCLUSION

We developed a robust process for providing physicians with confidential, individualized surgical and pathology quality indicator reports. Our results reinforce the importance of individual physician feedback as a strategy for improving and sustaining quality in surgical and diagnostic oncology.

Improving hospital care: are learning organizations the answer?

PURPOSE

Hospital leaders are being challenged to become more consumer-oriented, more interprofessional in their approach to care and more focused on outcome measures and continuous quality improvement. The concept of the learning organization could provide the conceptual framework necessary for understanding and addressing these various challenges in a systematic way. The paper aims to discuss these issues.

DESIGN/METHODOLOGY/APPROACH

A scan of the literature reveals that this concept has been applied to hospitals and other health care institutions, but it is not known to what extent this concept has been linked to hospitals and with what outcomes. To bridge this gap, the question of whether learning organizations are the answer to improving hospital care needs to be considered. Hospitals are knowledge-intensive organizations in that there is a need for constant updating of the best available evidence and the latest medical techniques. It is widely acknowledged that learning may become the only sustainable competitive advantage for organizations, including hospitals.

FINDINGS

With the increased demand for accountability for quality care, fiscal responsibility and positive patient outcomes, exploring hospitals as learning organizations is timely and highly relevant to senior hospital administrators responsible for integrating best practices, interprofessional care and quality improvement as a primary means of achieving these outcomes.

ORIGINALITY/VALUE

To date, there is a dearth of research on hospitals as learning organizations as it relates to improving hospital care.

Narrative reviews

Although qualitative researches (QR) are invaluable in understanding complex healthcare situations, the quantitative systematic reviews could not treat them. To improve quality of healthcare services, results of QR should be considered in healthcare decision-making processes. Several methods and theories for synthesizing evidences of QR have been developed. In order to activate the narrative reviews and mixed methods reviews in Korean healthcare academies, I arranged the related nomenclatures and suggested some issues to conduct them.

Promoting state health department evidence-based cancer and chronic disease prevention: a multi-phase dissemination study with a cluster randomized trial component

Background

Cancer and other chronic diseases reduce quality and length of life and productivity, and represent a significant financial burden to society. Evidence-based public health approaches to prevent cancer and other chronic diseases have been identified in recent decades and have the potential for high impact. Yet, barriers to implement prevention approaches persist as a result of multiple factors including lack of organizational support, limited resources, competing emerging priorities and crises, and limited skill among the public health workforce. The purpose of this study is to learn how best to promote the adoption of evidence based public health practice related to chronic disease prevention.

Methods/design

This paper describes the methods for a multi-phase dissemination study with a cluster randomized trial component that will evaluate the dissemination of public health knowledge about evidence-based prevention of cancer and other chronic diseases. Phase one involves development of measures of practitioner views on and organizational supports for evidence-based public health and data collection using a national online survey involving state health department chronic disease practitioners. In phase two, a cluster randomized trial design will be conducted to test receptivity and usefulness of dissemination strategies directed toward state health department chronic disease practitioners to enhance capacity and organizational support for evidence-based chronic disease prevention. Twelve state health department chronic disease units will be randomly selected and assigned to intervention or control. State health department staff and the university-based study team will jointly identify, refine, and select dissemination strategies within intervention units. Intervention (dissemination) strategies may include multi-day in-person training workshops, electronic information exchange modalities, and remote technical assistance. Evaluation methods include pre-post surveys, structured qualitative phone interviews, and abstraction of state-level chronic disease prevention program plans and progress reports.

Trial registration

clinicaltrials.gov: NCT01978054.