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Tran G, Kelly B, Hammersley M, Norman J, Okely A. The utility of website-based quality improvement tools for health professionals: a systematic review. Int J Qual Health Care 2024; 36:mzae068. [PMID: 38985665 PMCID: PMC11277856 DOI: 10.1093/intqhc/mzae068] [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: 03/15/2024] [Revised: 06/03/2024] [Accepted: 07/09/2024] [Indexed: 07/12/2024] Open
Abstract
As technology continues to advance, it is important to understand how website-based tools can support quality improvement. Website-based tools refer to resources such as toolkits that users can access and use autonomously through a dedicated website. This review examined how website-based tools can support healthcare professionals with quality improvement, including the optimal processes used to develop tools and the elements of an effective tool. A systematic search of seven databases was conducted to include articles published between January 2012 and January 2024. Articles were included if they were peer reviewed, written in English, based in health settings, and reported the development or evaluation of a quality improvement website-based tool for professionals. A narrative synthesis was conducted using NVivo. Risk of bias was assessed using the Mixed Methods Appraisal Tool. All papers were independently screened and coded by two authors using a six-phase conceptual framework by Braun and Clarke. Eighteen studies met the inclusion criteria. Themes identified were tool development processes, quality improvement mechanisms and barriers and facilitators to tool usage. Digitalizing existing quality improvement processes (n = 7), identifying gaps in practice (n = 6), and contributing to professional development (n = 3) were common quality improvement aims. Tools were associated with the reported enhancement of accuracy and efficiency in clinical tasks, improvement in adherence to guidelines, facilitation of reflective practice, and provision of tailored feedback for continuous quality improvement. Common features were educational resources (n = 7) and assisting the user to assess current practices against standards/recommendations (n = 6), which supported professionals in achieving better clinical outcomes, increased professional satisfaction and streamlined workflow in various settings. Studies reported facilitators to tool usage including relevance to practice, accessibility, and facilitating multidisciplinary action, making these tools practical and time-efficient for healthcare. However, barriers such as being time consuming, irrelevant to practice, difficult to use, and lack of organizational engagement were reported. Almost all tools were co-developed with stakeholders. The co-design approaches varied, reflecting different levels of stakeholder engagement and adoption of co-design methodologies. It is noted that the quality of included studies was low. These findings offer valuable insights for future development of quality improvement website-based tools in healthcare. Recommendations include ensuring tools are co-developed with healthcare professionals, focusing on practical usability and addressing common barriers to enhance engagement and effectiveness in improving healthcare quality. Randomized controlled trials are warranted to provide objective evidence of tool efficacy.
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Affiliation(s)
- Georgie Tran
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Bridget Kelly
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Megan Hammersley
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Jennifer Norman
- Health Promotion Service, Illawarra Shoalhaven Local Health District, Warrawong, NSW 2502, Australia
| | - Anthony Okely
- Early Start, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia
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Richburg CE, Pesavento CM, Vastardis A, Antunez AG, Gavrila V, Cuttitta A, Nathan H, Byrnes ME, Dossett LA. Targets for De-implementation of Unnecessary Testing Before Low-Risk Surgery: A Qualitative Study. J Surg Res 2024; 293:28-36. [PMID: 37703701 DOI: 10.1016/j.jss.2023.07.055] [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: 02/14/2023] [Revised: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Despite multispecialty recommendations to avoid routine preoperative testing before low-risk surgery, the practice remains common and de-implementation has proven difficult. The goal of this study as to elicit determinants of unnecessary testing before low-risk surgery to inform de-implementation efforts. METHODS We conducted focused ethnography at a large academic institution, including semi-structured interviews and direct observations at two preoperative evaluation clinics and one outpatient surgery center. Themes were identified through narrative thematic analysis and mapped to a comprehensive and integrated checklist of determinants of practice, the Tailored Implementation for Chronic Diseases framework (TICD). RESULTS Thirty individuals participated (surgeons, anesthesiologists, primary care physicians, physician assistants, nurses, and medical assistants). Three themes were identified: (1) Shared Values (TICD Social, Political, and Legal Factors), (2) Gaps in Knowledge (TICD Individual Health Professional Factors, Guideline Factors), and (3) Communication Breakdown (TICD Professional Interactions, Incentives and Resources, Capacity for Organizational Change). Shared Values describe core tenets expressed by all groups of clinicians, namely prioritizing patient safety and utilizing evidence-based medicine. Clinicians had Gaps in Knowledge related to existing data and preoperative testing recommendations. Communication Breakdowns within interdisciplinary teams resulted in unnecessary testing ordered to meet perceived expectations of other providers. CONCLUSIONS Clinicians have knowledge gaps related to preoperative testing recommendations and may be amenable to de-implementation efforts and educational interventions. Consensus guidelines may streamline interdisciplinary communication by clarifying interdisciplinary needs and reducing testing ordered to meet perceived expectations of other clinicians.
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Affiliation(s)
- Caroline E Richburg
- University of Michigan Medical School, Ann Arbor, Michigan; National Institute of Health Short-Term Biomedical Research Training Program, Bethesda, Maryland
| | - Cecilia M Pesavento
- University of Michigan Medical School, Ann Arbor, Michigan; National Institute of Health Short-Term Biomedical Research Training Program, Bethesda, Maryland
| | - Andrew Vastardis
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Alexis G Antunez
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Valerie Gavrila
- University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Anthony Cuttitta
- University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Mary E Byrnes
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan
| | - Lesly A Dossett
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; University of Michigan Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan.
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Admass BA, Ego BY, Tawye HY, Ahmed SA. Preoperative investigations for elective surgical patients in a resource limited setting: Systematic review. Ann Med Surg (Lond) 2022; 82:104777. [PMID: 36268455 PMCID: PMC9577970 DOI: 10.1016/j.amsu.2022.104777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 09/19/2022] [Accepted: 09/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Preoperative investigation for surgical patients is important to check for conditions that may affect surgical outcome. It helps the anesthetist and surgeon to plan perioperative anesthesia and surgical management appropriately. However, 60-70% of laboratory tests before surgery are not really required. This review was conducted to develop evidence-based recommendations on preoperative investigations for patients waiting for surgery in a resource limited setting. Methods After formulating the key questions, scope, and eligibility criteria for the articles to be included, advanced search strategy of electronic sources from data bases and websites was conducted. Duplication of literatures was avoided by endnote. Screening of literatures was conducted with proper appraisal. This review was reported in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) 2020 statement. Results A total of 553 articles were identified from data bases and websites using an electronic search. 75 articles were removed for duplication and 223 studies were excluded after reviewing titles and abstracts. At the screening stage, 82 articles were retrieved and evaluated for eligibility. Finally, 46 studies met the eligibility criteria and were included in this systematic review. Conclusion and recommendation: Selective laboratory ordering reduces the number and cost of investigations. Preoperative tests should be guided by the patient's clinical history, co-morbidities, and physical examination. Patients with signs or symptoms of certain types of disease should be evaluated with appropriate testing. Therefore, adherence to recommendations of guidelines on preoperative investigation is important for good surgical outcome and patient satisfaction.
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Affiliation(s)
- Biruk Adie Admass
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, P.O.Box: 196, Ethiopia
| | - Birhanu Yilma Ego
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, P.O.Box: 196, Ethiopia
| | - Hailu Yimer Tawye
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, P.O.Box: 196, Ethiopia
| | - Seid Adem Ahmed
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, P.O.Box: 196, Ethiopia
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Englert A, Bendz P. [Artificial intelligence-augmented perioperative clinical decision support, KIPeriOP]. Anaesthesist 2021; 70:962-963. [PMID: 34731276 DOI: 10.1007/s00101-021-00948-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Anne Englert
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - Pamela Bendz
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
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Anesthesia preoperative clinics: redefining the value proposition. Int Anesthesiol Clin 2021; 59:59-72. [PMID: 34433183 DOI: 10.1097/aia.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kjelle E, Andersen ER, Soril LJJ, van Bodegom-Vos L, Hofmann BM. Interventions to reduce low-value imaging - a systematic review of interventions and outcomes. BMC Health Serv Res 2021; 21:983. [PMID: 34537051 PMCID: PMC8449221 DOI: 10.1186/s12913-021-07004-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/02/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND It is estimated that 20-50% of all radiological examinations are of low value. Many attempts have been made to reduce the use of low-value imaging. However, the comparative effectiveness of interventions to reduce low-value imaging is unclear. Thus, the objective of this systematic review was to provide an overview and evaluate the outcomes of interventions aimed at reducing low-value imaging. METHODS An electronic database search was completed in Medline - Ovid, Embase-Ovid, Scopus, and Cochrane Library for citations between 2010 and 2020. The search was built from medical subject headings for Diagnostic imaging/Radiology, Health service misuse or medical overuse, and Health planning. Keywords were used for the concept of reduction and avoidance. Reference lists of included articles were also hand-searched for relevant citations. Only articles written in English, German, Danish, Norwegian, Dutch, and Swedish were included. The Mixed Methods Appraisal Tool was used to appraise the quality of the included articles. A narrative synthesis of the final included articles was completed. RESULTS The search identified 15,659 records. After abstract and full-text screening, 95 studies of varying quality were included in the final analysis, containing 45 studies found through hand-searching techniques. Both controlled and uncontrolled before-and-after studies, time series, chart reviews, and cohort studies were included. Most interventions were aimed at referring physicians. Clinical practice guidelines (n = 28) and education (n = 28) were most commonly evaluated interventions, either alone or in combination with other components. Multi-component interventions were often more effective than single-component interventions showing a reduction in the use of low-value imaging in 94 and 74% of the studies, respectively. The most addressed types of imaging were musculoskeletal (n = 26), neurological (n = 23) and vascular (n = 16) imaging. Seventy-seven studies reported reduced low-value imaging, while 3 studies reported an increase. CONCLUSIONS Multi-component interventions that include education were often more effective than single-component interventions. The contextual and cultural factors in the health care systems seem to be vital for successful reduction of low-value imaging. Further research should focus on assessing the impact of the context in interventions reducing low-value imaging and how interventions can be adapted to different contexts.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, Alberta T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, the Netherlands
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, University of Oslo, Postbox 1130, Blindern, 0318 Oslo, Norway
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Hynes JP, Hunter K, Rochford M. Utilization and appropriateness in cervical spine trauma imaging: implementation of clinical decision support criteria. Ir J Med Sci 2020; 189:333-336. [DOI: 10.1007/s11845-019-02059-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 07/02/2019] [Indexed: 11/30/2022]
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Rispoli M, Perrotta F, Buono S, Corcione A. Role of a digital tool in preoperative lung resection surgery assessment. Digit Health 2019; 5:2055207619885783. [PMID: 31723435 PMCID: PMC6836304 DOI: 10.1177/2055207619885783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/07/2019] [Indexed: 12/25/2022] Open
Abstract
The assessment of patients likely to undergo lung resection surgery is a multidisciplinary approach involving pulmonologists, surgeons and anaesthesiologists. In thoracic surgery, medical operability is also a calculation of postoperative lung function. A mobile application – PreParAPP MSD – to calculate postoperative lung function has been developed with the endorsement of the Italian Society of Anaesthesia, Analgesia and Intensive Care and with the unconditional support of MSD Italia. Thanks to a simple graphic interface, the calculation becomes fast and intuitive, while the possibility of storing and sharing data in an analytical and computerised way with other clinicians might help with the full assessment of patients without forcing them to undergo several medical examinations. These simple calculated parameters are performed by a minority of clinicians, generally anaesthesiologists. In our facility, there is a team involved in the perioperative evaluation of lung resection surgery (13 pulmonologists, 9 surgeons and 5 anaesthesiologists). In order to evaluate the possible Awareness towards postoperative lung function calculation better, we organised an internal survey with 27 clinicians who are members of such a team before and after the introduction of the PreParAPP MSD. It was found that after the introduction of PreParAPP MSD, the percentage of clinicians involved in postoperative lung function calculation rose from 18% to 70%. The implementation of a digital tool may help to improve guideline adherence, in accordance with other experiences in which such tools represented the start for various quality improvement purposes throughout the medical field.
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Affiliation(s)
- Marco Rispoli
- Anaesthesia and Intensive Care Unit, Vincenzo Monaldi Hospital, Italy
| | - Fabio Perrotta
- Department of Medicine and Health Sciences 'V. Tiberio', University of Molise, Italy
| | - Salvatore Buono
- Anaesthesia and Intensive Care Unit, Vincenzo Monaldi Hospital, Italy
| | - Antonio Corcione
- Anaesthesia and Intensive Care Unit, Vincenzo Monaldi Hospital, Italy
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The impact of reduction of testing at a Preoperative Evaluation Clinic for elective cases: Value added without adverse outcomes. J Clin Anesth 2019; 55:92-99. [DOI: 10.1016/j.jclinane.2018.12.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/16/2018] [Accepted: 12/18/2018] [Indexed: 11/20/2022]
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Sim EY, Tan DJA, Abdullah HR. The use of computerized physician order entry with clinical decision support reduces practice variance in ordering preoperative investigations: A retrospective cohort study. Int J Med Inform 2017; 108:29-35. [DOI: 10.1016/j.ijmedinf.2017.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/12/2017] [Accepted: 09/26/2017] [Indexed: 12/19/2022]
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Abstract
Preoperative evaluation clinics have been shown to enhance operating room efficiency, decrease day-of-surgery cancellations, reduce hospital costs, and improve the quality of patient care. Although programs differ in staffing, structure, financial support, and daily operations, they share the common goal of preoperative risk reduction in order for patients to proceed safely through the perioperative period. Effective preoperative evaluation occurs if processes are standardized to ensure clinical, regulatory, and accreditation guidelines are met while keeping medical optimization and patient satisfaction at the forefront. Although no universally accepted standard model exists, there are key components to a successful preoperative process.
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Affiliation(s)
- Angela F Edwards
- Department of Anesthesiology, Wake Forest Baptist Health, Wake Forest University School of Medicine, Medical Center Boulevard, 9 CSB, Winston Salem, NC 27157, USA.
| | - Barbara Slawski
- Section of Perioperative and Consultative Medicine, Department of Medicine, Froedtert Hospital Clinical Cancer Center, Froedtert and Medical College of Wisconsin, Suite 5400, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
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Goldzweig CL, Orshansky G, Paige NM, Miake-Lye IM, Beroes JM, Ewing BA, Shekelle PG. Electronic health record-based interventions for improving appropriate diagnostic imaging: a systematic review and meta-analysis. Ann Intern Med 2015; 162:557-65. [PMID: 25894025 DOI: 10.7326/m14-2600] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND One driver of increasing health care costs is the use of radiologic imaging procedures. More appropriate use could improve quality and reduce costs. PURPOSE To review interventions that use the computerized clinical decision-support (CCDS) capabilities of electronic health records to improve appropriate use of diagnostic radiologic test ordering. DATA SOURCES English-language articles in PubMed from 1995 to September 2014 and searches in Web of Science and PubMed of citations related to key articles. STUDY SELECTION 23 studies, including 3 randomized trials, 7 time-series studies, and 13 pre-post studies that assessed the effect of CCDS on diagnostic radiologic test ordering in adults. DATA EXTRACTION 2 independent reviewers extracted data on functionality, study outcomes, and context and assessed the quality of included studies. DATA SYNTHESIS Thirteen studies provided moderate-level evidence that CCDS improves appropriateness (effect size, -0.49 [95% CI, -0.71 to -0.26]) and reduces use (effect size, -0.13 [CI, -0.23 to -0.04]). Interventions with a "hard stop" that prevents a clinician from overriding the CCDS without outside consultation, as well as interventions in integrated care delivery systems, may be more effective. Harms have rarely been assessed but include decreased ordering of appropriate tests and physician dissatisfaction. LIMITATION Potential for publication bias, insufficient reporting of harms, and poor description of context and implementation. CONCLUSION Computerized clinical decision support integrated with the electronic health record can improve appropriate use of diagnostic radiology by a moderate amount and decrease use by a small amount. Before widespread adoption can be recommended, more data are needed on potential harms. PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs. (PROSPERO registration number: CRD42014007469).
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Affiliation(s)
- Caroline Lubick Goldzweig
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Greg Orshansky
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Neil M. Paige
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Isomi M. Miake-Lye
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Jessica M. Beroes
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Brett A. Ewing
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
| | - Paul G. Shekelle
- From West Los Angeles Veterans Affairs Medical Center and University of California, Los Angeles, Fielding School of Public Health, Los Angeles, and RAND Corporation, Southern California Evidence-based Practice Center, Santa Monica, California
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Stark C, Gent A, Kirkland L. Improving patient flow in pre-operative assessment. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:u201341.w1226. [PMID: 26734351 PMCID: PMC4645878 DOI: 10.1136/bmjquality.u201341.w1226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/10/2014] [Indexed: 11/03/2022]
Abstract
Annual patient attendances at a pre-operative assessment department increased by 24.8% from 5659 in 2009, to 7062 in 2012. The unit was staffed by administrative staff, nurses, and health care assistants (HCA). Medical review was accessed via on call medical staff, or notes were sent to anaesthetists for further review. With rising demand, patient waits increased. The average lead time for a patient (time from entering the department to leaving) was 79 minutes. 9.3% of patients attended within two weeks of their scheduled surgery date. 10% of patients were asked to return on a later day, as there was not sufficient capacity to undertake their assessment. There were nine routes of referral in to the department. Patients moved between different clinic rooms and the waiting area several times. Work patterns were uneven, as many attendances were from out-patient clinics which meant peak attendance times were linked to clinic times. There were substantial differences in the approaches of different nurses, making the HCA role difficult. Patients reported dissatisfaction with waits. Using a Lean quality improvement process with rapid PDSA cycles, the service changed to one in which patients were placed in a room, and remained there for the duration of their assessment. Standard work was developed for HCWs and nurses. Rooms were standardised using 5S processes, and set up improved to reduce time spent looking for supplies. A co-ordinator role was introduced using existing staff to monitor flow and to organise the required medical assessments and ECGs. Timing of booked appointments were altered to take account of clinic times. Routes in to the department were reduced from nine to one. Ten months after the work began, the average lead time had reduced to 59 minutes. The proportion of people attending within two weeks of their surgery decreased from 9.3% to 5.3%. Referrals for an anaesthetic opinion decreased from 30% to 20%, and in the month reviewed no one had to return to be seen as a result of limited capacity.
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The electronic health record as a healthcare management strategy and implications for obstetrics and gynecologic practice. Curr Opin Obstet Gynecol 2013; 25:476-81. [DOI: 10.1097/gco.0000000000000029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009; 2009:CD001096. [PMID: 19588323 PMCID: PMC4171964 DOI: 10.1002/14651858.cd001096.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.
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Affiliation(s)
- Kaveh G Shojania
- Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5
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