Understanding the complexity of redesigning care around the clinical microsystem

Strategies that facilitate the delivery of exceptionally good patient care in general practice: a qualitative study with patients and primary care professionals

BACKGROUND

In recent years, proactive strengths-based approaches to improving quality of care have been advocated. The positive deviance approach seeks to identify and learn from those who perform exceptionally well. Central to this approach is the identification of the specific strategies, behaviours, tools and contextual strategies used by those positive deviants to perform exceptionally well. This study aimed to: identify and collate the specific strategies, behaviours, processes and tools used to support the delivery of exceptionally good care in general practice; and to abstract the identified strategies into an existing framework pertaining to excellence in general practice; the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework.

METHODS

This study comprised a secondary analysis of data collected during semi-structured interviews with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers. Discussions explored the key factors and strategies that support the delivery of exceptional care across five levels of the primary care system; the patient, provider, team, practice, and external environment. For analysis, a summative content analysis approach was undertaken whereby data were inductively analysed and summated to identify the key strategies used to achieve the delivery of exceptionally good general practice care, which were subsequently abstracted as a new level of the IDEAL framework.

RESULTS

In total, 222 individual factors contributing to exceptional care delivery were collated and abstracted into the framework. These included specific behaviours (e.g., patients providing useful feedback and personal history to the provider), structures (e.g., using technology effectively to support care delivery (e.g., electronic referrals & prescriptions)), processes (e.g., being proactive in managing patient flow and investigating consistently delayed wait times), and contextual factors (e.g., valuing and respecting contributions of every team member).

CONCLUSION

The addition of concrete and contextual strategies to the IDEAL framework has enhanced its practicality and usefulness for supporting improvement in general practices. Now, a multi-level systems approach is needed to embed these strategies and create an environment where excellence is supported. The refined framework should be developed into a learning tool to support teams in general practice to measure, reflect and improve care within their practice.

More Process, Less Principles: The Ethics of Deploying AI and Robotics in Medicine

Current national and international guidelines for the ethical design and development of artificial intelligence (AI) and robotics emphasize ethical theory. Various governing and advisory bodies have generated sets of broad ethical principles, which institutional decisionmakers are encouraged to apply to particular practical decisions. Although much of this literature examines the ethics of designing and developing AI and robotics, medical institutions typically must make purchase and deployment decisions about technologies that have already been designed and developed. The primary problem facing medical institutions is not one of ethical design but of ethical deployment. The purpose of this paper is to develop a practical model by which medical institutions may make ethical deployment decisions about ready-made advanced technologies. Our slogan is "more process, less principles." Ethically sound decisionmaking requires that the process by which medical institutions make such decisions include participatory, deliberative, and conservative elements. We argue that our model preserves the strengths of existing frameworks, avoids their shortcomings, and delivers its own moral, practical, and epistemic advantages.

Feasibility and Safety of a "Shared Care" Model in Complex Hepatopancreatobiliary Surgery: A 5-year Observational Study of Outcomes in Pancreaticoduodenectomy

OBJECTIVE

To determine the safety of a fully functioning shared care model (SCM) in hepatopancreatobiliary surgery through evaluating outcomes in pancreaticoduodenectomy.

BACKGROUND

SCMs, where a team of surgeons share in care delivery and resource utilization, represent a surgeon-level opportunity to improve system efficiency and peer support, but concerns around clinical safety remain, especially in complex elective surgery.

METHODS

Patients who underwent pancreaticoduodenectomy between 2016 and 2020 were included. Adoption of shared care was demonstrated by analyzing shared care measures, including the number of surgeons encountered by patients during their care cycle, the proportion of patients with different consenting versus primary operating surgeon (POS), and the proportion of patients who met their POS on the day of surgery. Outcomes, including 30-day mortality, readmission, unplanned reoperation, sepsis, and length of stay, were collected from the institution's National Surgical Quality Improvement Program (NSQIP) database and compared with peer hospitals contributing to the pancreatectomy-specific NSQIP collaborative.

RESULTS

Of the 174 patients included, a median of 3 surgeons was involved throughout the patients' care cycle, 69.0% of patients had different consenting versus POS and 57.5% met their POS on the day of surgery. Major outcomes, including mortality (1.1%), sepsis (5.2%), and reoperation (7.5%), were comparable between the study group and NSQIP peer hospitals. Length of stay (10 day) was higher in place of lower readmission (13.2%) in the study group compared with peer hospitals.

CONCLUSIONS

SCMs are feasible in complex elective surgery without compromising patient outcomes, and wider adoption may be encouraged.

Sustainability of the Collaborative Chronic Care Model in Outpatient Mental Health Teams Three Years Post-Implementation: A Qualitative Analysis

Our goal was to investigate the sustainability of care practices that are consistent with the collaborative chronic care model (CCM) in nine outpatient mental health teams located within US Department of Veterans Affairs (VA) medical centers, three to four years after the completion of CCM implementation. We conducted qualitative interviews (N = 30) with outpatient mental health staff from each of the nine teams. We based our directed content analysis on the six elements of the CCM. We found variable sustainability of CCM-based care processes across sites. Some care processes, such as delivery of evidence-based psychotherapies (EBPs) and use of measurement-based care (MBC) to guide clinic decision-making, were robustly maintained or even expanded within participating teams. In contrast, other care processes-which had in some cases been developed with considerable effort-had not been sustained. For example, care manager roles were diminished in scope or eliminated completely in response to workload pressures, frontline care needs, or the COVID-19 pandemic. Similarly, processes for engaging Veterans more fully in decision-making had generally been scaled back. Leadership support in the form of adequate team staffing and time to conduct team meetings were seen as crucial for sustaining CCM-consistent care. Given the potential impact of leadership turnover on sustainability in mental health, future efforts to implement CCM-based mental health care should strive to involve multiple leaders in implementation and sustainment efforts, lest one key departure undo years of implementation work. Our results also suggest that implementing CCM processes may best be conceptualized as a partnership across multiple levels of medical center leadership.

How Can Personal Protective Equipment Be Best Used and Reused: A Closer Look at Donning and Doffing Procedures

OBJECTIVE

The aim of this study was to examine safety-related contamination threats and risks to health-care workers (HCWs) due to the reuse of personal protective equipment (PPE) among emergency department (ED) personnel.

METHODS

We used a Participatory Design (PD) approach to conduct task analysis (TA) of PPE use and reuse. TA identified the steps, risks, and protective behaviors involved in PPE reuse. We used the Centers for Disease Control and Prevention (CDC) guidance for PPE donning and doffing specifying the recommended task order. Then, we convened subject matter experts (SMEs) with relevant backgrounds in Patient Safety, Human Factors and Emergency Medicine to iteratively identify and map the tasks, risks, and protective behaviors involved in the PPE use and reuse.

RESULTS

Two emerging threats were associated with behaviors in donning, doffing, and re-using PPE: (i) direct exposure to contaminant, and (ii) transmission/spread of contaminant. Protective behaviors included: hand hygiene, not touching the patient-facing surface of PPE, and ensuring a proper fit and closure of all PPE ties and materials.

CONCLUSIONS

TA was helpful revealed that the procedure for donning and doffing of re-used PPE does not protect ED personnel from contaminant spread and risk of exposure, even with protective behaviors present (e.g., hand hygiene, respirator use, etc.). Future work should make more apparent the underlying risks associated with PPE use and reuse.

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study

OBJECTIVES

Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care.

SETTING

Primary care fall risk assessment clinics in the South of Ireland.

PARTICIPANTS

Focus groups using participatory mapping techniques with primary care staff (public health nurses (PHNs), physiotherapists (PT),and occupational therapists (OT)) were conducted to plot the processes and onward referral pathways at each clinic (n=5).

METHODS

Focus groups were analysed in NVivo V.12 using inductive thematic analysis. Routine administrative data from January to March 2018 included details of client referrals, assessments and demographics sourced from referral and assessment forms. Data were analysed in Stata V.12 to estimate the number, origin and focus of onward referrals and whether older adults received follow-up interventions. Quantitative and qualitative data were analysed separately and integrated to produce a map of the service.

RESULTS

Nine staff participated in three focus groups and one interview (PHN n=2; OT n=4; PT n=3). 85 assessments were completed at five clinics (female n=69, 81.2%, average age 77). The average number of risk factors was 5.4 out of a maximum of 10. Following assessment, clients received an average of three onward referrals. Only one-third of referrals (n=135/201, 33%) had data available on intervention receipt. Primary care staff identified variations in how formally onward referrals were managed and barriers, including a lack of client information, inappropriate referral and a lack of data management support.

CONCLUSION

Challenges to onward referral manifest early in an integrated care pathway, such as clients with multiple risk factors sent for initial assessment and the lack of an integrated IT system to share information across settings.

When uncertainty becomes the norm: The Chris Hani Baragwanath Academic Hospital’s Speech Therapy and Audiology Department’s response to the COVID-19 pandemic

Background

In March 2020 the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic. Management of this pandemic had significant implications for clinical departments across the world. Healthcare systems were urgently required to reorganise and redesign patient care as well as repurpose staff.

Objectives

We will share the lived experience of our response as speech therapy and audiology (STA) clinicians to the COVID-19 pandemic.

Method

This study adopted an autoethnographic approach within Bronfenbrenner’s bioecological model to describe STA clinicians’ response to the COVID-19 pandemic.

Results

Adaptations to practice were made to continue service provision whilst adhering to COVID-19 regulations. We assisted in other areas to meet the immediate needs of the hospital. Service delivery strategies consisted of a review of clinical and quality assurance protocols. We developed a telehealth service package which included a hybrid approach, within a context of digital poverty. We created resources to ensure continuity of care. Collaboration within our systems facilitated innovative solutions. Mental health and well-being of staff members were key to the response developed.

Conclusion

South African healthcare systems’ inequalities were highlighted by the pandemic. The response showed that the needs of vulnerable populations were not accounted for when developing this public health response. Lessons learnt included the importance of adaptability, becoming comfortable with uncertainty and maintaining open and transparent communication. Consultation and collaboration within various levels of our healthcare system were critical in responding to the needs of patients. Commitment to compassionate leadership and staff well-being were crucial.

A systematic review of the use of positive deviance approaches in primary care

BACKGROUND

The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care.

OBJECTIVE(S)

This review aimed to synthesize the extant research on applications of the PD approach in primary care.

METHODS

Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS).

RESULTS

In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels.

CONCLUSION

Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.

Real-life patient journey in neovascular age-related macular degeneration: a narrative medicine analysis in the Italian setting

OBJECTIVES

To investigate the real-life experience of patients affected by neovascular age-related macular degeneration (nAMD), in the healthcare pathway for the management of the disease, using a "patient journey" and narrative method approach.

METHODS

The patient journey of subjects affected by nAMD was designed using a process-mapping methodology involving a team from 11 Italian centres. Subsequently, narratives were collected from nAMD patients and family members. The interviews were analyzed using the narrative medicine methodology.

RESULTS

Eleven specialized retina centres across Italy were involved and 205 narratives collected. In 29% of cases, patients underestimated their symptoms or attributed them to non-pathological causes, thus delaying the specialist consultation. The delay in accessing to care was due to a lack of awareness of this disease (50% of the participants didn't know what nAMD is) and to critical issues faced at first visit (long waiting lists, failed diagnosis, underestimation of the problem). Despite anti-VEGF therapies were perceived as effective in improving or stabilizing vision in 91% of narratives collected, 77% of patients still reduced or ceased daily activities such as reading and driving. Within the pathway of care there was not a multidisciplinary approach, and the patients were treated just by the ophthalmologist.

CONCLUSIONS

nAMD may significantly affect the quality of life of affected patients, both from a functional and psychological point of view. The narrative medicine approach highlights some critical points in the healthcare journey of nAMD patients and represents a useful background in implementing patient management algorithms and pathways of care.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Development of an intervention to increase adherence to nebuliser treatment in adults with cystic fibrosis: CFHealthHub

BACKGROUND

Cystic fibrosis (CF) is a life-limiting genetic condition in which daily therapies to maintain lung health are critical, yet treatment adherence is low. Previous interventions to increase adherence have been largely unsuccessful and this is likely due to a lack of focus on behavioural evidence and theory alongside input from people with CF. This intervention is based on a digital platform that collects and displays objective nebuliser adherence data. The purpose of this paper is to identify the specific components of an intervention to increase and maintain adherence to nebuliser treatments in adults with CF with a focus on reducing effort and treatment burden.

METHODS

Intervention development was informed by the Behaviour Change Wheel (BCW) and person-based approach (PBA). A multidisciplinary team conducted qualitative research to inform a needs analysis, selected, and refined intervention components and methods of delivery, mapped adherence-related barriers and facilitators, associated intervention functions and behaviour change techniques, and utilised iterative feedback to develop and refine content and processes.

RESULTS

Results indicated that people with CF need to understand their treatment, be able to monitor adherence, have treatment goals and feedback and confidence in their ability to adhere, have a treatment plan to develop habits for treatment, and be able to solve problems around treatment adherence. Behaviour change techniques were selected to address each of these needs and were incorporated into the digital intervention developed iteratively, alongside a manual and training for health professionals. Feedback from people with CF and clinicians helped to refine the intervention which could be tailored to individual patient needs.

CONCLUSIONS

The intervention development process is underpinned by a strong theoretical framework and evidence base and was developed by a multidisciplinary team with a range of skills and expertise integrated with substantial input from patients and clinicians. This multifaceted development strategy has ensured that the intervention is usable and acceptable to people with CF and clinicians, providing the best chance of success in supporting people with CF with different needs to increase and maintain their adherence. The intervention is being tested in a randomised controlled trial across 19 UK sites.

The Differences in Antibiotic Decision-making Between Acute Surgical and Acute Medical Teams: An Ethnographic Study of Culture and Team Dynamics

BACKGROUND

Cultural and social determinants influence antibiotic decision-making in hospitals. We investigated and compared cultural determinants of antibiotic decision-making in acute medical and surgical specialties.

METHODS

An ethnographic observational study of antibiotic decision-making in acute medical and surgical teams at a London teaching hospital was conducted (August 2015-May 2017). Data collection included 500 hours of direct observations, and face-to-face interviews with 23 key informants. A grounded theory approach, aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of analysis ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of the findings.

RESULTS

In medicine, accepted norms of the decision-making process are characterized as collectivist (input from pharmacists, infectious disease, and medical microbiology teams), rationalized, and policy-informed, with emphasis on de-escalation of therapy. The gaps in antibiotic decision-making in acute medicine occur chiefly in the transition between the emergency department and inpatient teams, where ownership of the antibiotic prescription is lost. In surgery, team priorities are split between 3 settings: operating room, outpatient clinic, and ward. Senior surgeons are often absent from the ward, leaving junior staff to make complex medical decisions. This results in defensive antibiotic decision-making, leading to prolonged and inappropriate antibiotic use.

CONCLUSIONS

In medicine, the legacy of infection diagnosis made in the emergency department determines antibiotic decision-making. In surgery, antibiotic decision-making is perceived as a nonsurgical intervention that can be delegated to junior staff or other specialties. Different, bespoke approaches to optimize antibiotic prescribing are therefore needed to address these specific challenges.

The clinical microsystems approach: Does it really work? A systematic review of organizational theories of health care practices

OBJECTIVES

Faced with increased expectations regarding the quality and safety of health care delivery systems, a number of stakeholders are increasingly looking for more efficient ways to deliver care. This study was conducted to provide a critical appraisal and synthesize the best available evidence on the impact of implementing clinical microsystems (CMS) on the quality of care and safety of the health care delivery.

DATA SOURCES

A comprehensive and systematic search of 6 electronic databases, from 1998 to 2018, was conducted to identify empirical literature published in both English and French, evaluating the impact of implementing CMS in health care settings.

STUDY SELECTION

We included all study designs that evaluate the impact of implementing CMS in health care settings.

DATA EXTRACTION

Independent reviewers screened abstracts, read full texts, extracted data from the included studies, and appraised the methodological quality.

RESULTS

Of the 1907 records retrieved, 35 studies met the inclusion criteria. The settings included general practice clinics (n = 18), specialized care units (n = 14), and emergency and ambulatory units (n = 3). The implementation of CMS helped to develop the patient-centered approach, promote interdisciplinarity and quality improvement skills, increase the fluidity of the clinical acts performed, and increase patient safety. It contributed to increasing patients' and clinicians' satisfaction, as well as reducing hospital length of stay and reducing hospital-acquired infections. The implementation of CMS also contributed to the development and refinement of diagnostic tools and measurement instruments.

CONCLUSION

The CMS approach is unique because of the primacy given to the quality of care offered and the safety of patients over any other consideration, and its ability to redesign health care delivery systems. Efforts still need to be made to legitimize the approach in various health care settings worldwide.

Designing easy access to care for first-episode psychosis in complex organizations

AIMS

Developing early intervention services (EIS) in healthcare organizations (HCOs) is difficult because it is necessary to integrate service approaches across units. To accommodate the needs of patients and relatives, Oslo University Hospital (OUH) chose to use service design (SD) to redesign their first-episode services with an emphasis on easy access to care. This paper discusses the results and how SD can help to overcome known barriers to change in complex organizations.

METHOD

SD is a method that relies on principles of participation, innovation and visualization to develop coherent services. The method emphasizes the exploration of a problem area from the perspective of multiple stakeholders to create a shared understanding of the complexity. Idea generation, visualization and early modelling of possible solutions are employed to test alternatives involving stakeholders.

RESULTS

A low threshold EIS was developed. A helpline with a specialist managing the phone was established. High-quality assessment regarding possible psychosis development was thus made available to patients, relatives and professionals, eliminating the need for paper referral. This approach was supported by a communication strategy that includes web-based information. A dedicated cross-specialist team was established to increase collaboration in complex cases. Finally, outreach services were improved.

CONCLUSION

SD is a suitable method to incorporate the views of different stakeholders (patients, relatives and professionals) to develop EIS services in complex organizations and can help overcome known barriers to change in HCOs.

Taxonomy of the form and function of primary care services in or alongside emergency departments: concepts paper

Primary care services in or alongside emergency departments look and function differently and are described using inconsistent terminology. Research to determine effectiveness of these models is hampered by outdated classification systems, limiting the opportunity for data synthesis to draw conclusions and inform decision-making and policy. We used findings from a literature review, a national survey of Type 1 emergency departments in England and Wales, staff interviews, other routine data sources and discussions from two stakeholder events to inform the taxonomy. We categorised the forms inside or outside the emergency department: inside primary care services may be integrated with emergency department patient flow or may run parallel to that activity; outside services may be offered on site or off site. We then describe a conceptual spectrum of integration: identifying constructs that influence how the services function-from being closer to an emergency medicine service or to usual primary care. This taxonomy provides a basis for future evaluation of service models that will comprise the evidence base to inform policy-making in this domain. Commissioners and service providers can consider these constructs in characterising and designing services depending on local circumstances and context.

Triaging Inpatient Admissions: an Opportunity for Resident Education

In the context of internal medicine, "triage" is a newly popularized term that refers to constellation of activities related to determining the most appropriate disposition plans for patients, including assessing patients for admissions into the inpatient medicine service. The physician or "triagist" plays a critical role in the transition of care from the outpatient to the inpatient settings, yet little literature exists addressing this particular transition. The importance of this set of responsibilities has evolved over time as health systems become increasingly complex to navigate for physicians and patients. With the emphasis on hospital efficiency metrics such as emergency department throughput and appropriateness of admissions, this type of systems-based thinking is a necessary skill for practicing contemporary inpatient medicine. We believe that triaging admissions is a critical transition in the care continuum and represents an entrustable professional activity that integrates skills across multiple Accreditation Council for Graduate Medical Education (ACGME) competencies that internal medicine residents must master. Specific curricular competencies that address the domains of provider, system, and patient will deliver a solid foundation to fill a gap in skills and knowledge for the triagist role in IM residency training.

The impact of general practitioners working in or alongside emergency departments: a rapid realist review

OBJECTIVES

Worldwide, emergency healthcare systems are under intense pressure from ever-increasing demand and evidence is urgently needed to understand how this can be safely managed. An estimated 10%-43% of emergency department patients could be treated by primary care services. In England, this has led to a policy proposal and £100 million of funding (US$130 million), for emergency departments to stream appropriate patients to a co-located primary care facility so they are 'free to care for the sickest patients'. However, the research evidence to support this initiative is weak.

DESIGN

Rapid realist literature review.

SETTING

Emergency departments.

INCLUSION CRITERIA

Articles describing general practitioners working in or alongside emergency departments.

AIM

To develop context-specific theories that explain how and why general practitioners working in or alongside emergency departments affect: patient flow; patient experience; patient safety and the wider healthcare system.

RESULTS

Ninety-six articles contributed data to theory development sourced from earlier systematic reviews, updated database searches (Medline, Embase, CINAHL, Cochrane DSR & CRCT, DARE, HTA Database, BSC, PsycINFO and SCOPUS) and citation tracking. We developed theories to explain: how staff interpret the streaming system; different roles general practitioners adopt in the emergency department setting (traditional, extended, gatekeeper or emergency clinician) and how these factors influence patient (experience and safety) and organisational (demand and cost-effectiveness) outcomes.

CONCLUSIONS

Multiple factors influence the effectiveness of emergency department streaming to general practitioners; caution is needed in embedding the policy until further research and evaluation are available. Service models that encourage the traditional general practitioner approach may have shorter process times for non-urgent patients; however, there is little evidence that this frees up emergency department staff to care for the sickest patients. Distinct primary care services offering increased patient choice may result in provider-induced demand. Economic evaluation and safety requires further research.

PROSPERO REGISTRATION NUMBER

CRD42017069741.

Supporting medication adherence for adults with cystic fibrosis: a randomised feasibility study

BACKGROUND

Preventative medication reduces hospitalisations in people with cystic fibrosis (PWCF) but adherence is poor. We assessed the feasibility of a randomised controlled trial of a complex intervention, which combines display of real time adherence data and behaviour change techniques.

METHODS

Design: Pilot, open-label, parallel-group RCT with concurrent semi-structured interviews.

PARTICIPANTS

PWCF at two Cystic Fibrosis (CF) units. Eligible: aged 16 or older; on the CF registry. Ineligible: post-lung transplant or on the active list; unable to consent; using dry powder inhalers.

INTERVENTIONS

Central randomisation on a 1:1 allocation to: (1) intervention, linking nebuliser use with data recording and transfer capability to a software platform, and behavioural strategies to support self-management delivered by trained interventionists (n = 32); or, (2) control, typically face-to-face meetings every 3 months with CF team (n = 32).

OUTCOMES

RCT feasibility defined as: recruitment of ≥ 48 participants (75% of target) in four months (pilot primary outcome); valid exacerbation data available for ≥ 85% of those randomised (future RCT primary outcome); change in % medication adherence; FEV1 percent predicted (key secondaries in future RCT); and perceptions of trial procedures, in semi-structured interviews with intervention (n = 14) and control (n = 5) participants, interventionists (n = 3) and CF team members (n = 5).

RESULTS

The pilot trial recruited to target, randomising 33 to intervention and 31 to control in the four-month period, June-September 2016. At study completion (30th April 2017), 60 (94%; Intervention = 32, Control =28) participants contributed good quality exacerbation data (intervention: 35 exacerbations; control: 25 exacerbation). The mean change in adherence and baseline-adjusted FEV1 percent predicted were higher in the intervention arm by 10% (95% CI: -5.2 to 25.2) and 5% (95% CI -2 to 12%) respectively. Five serious adverse events occurred, none related to the intervention. The mean change in adherence was 10% (95% CI: -5.2 to 25.2), greater in the intervention arm. Interventionists delivered insufficient numbers of review sessions due to concentration on participant recruitment. This left interventionists insufficient time for key intervention procedures. A total of 10 key changes that were made to RCT procedures are summarised.

CONCLUSIONS

With improved research processes and lower monthly participant recruitment targets, a full-scale trial is feasible.

TRIAL REGISTRATION

ISRCTN13076797 . Prospectively registered on 07/06/2016.

A transformative translational change programme to introduce genomics into healthcare: a complexity and implementation science study protocol

INTRODUCTION

Translating scientific advances in genomic medicine into evidence-based clinical practice is challenging. Studying the natural translation of genomics into 'early-adopting' health system sectors is essential. We will (a) examine 29 health systems (Australian and Melbourne Genomics Health Alliance flagships) integrating genomics into practice and (b) combine this learning to co-design and test an evidence-based generalisable toolkit for translating genomics into healthcare.

METHODS AND ANALYSIS

Twenty-nine flagships integrating genomics into clinical settings are studied as complex adaptive systems to understand emergent and self-organising behaviours among inter-related actors and processes. The Effectiveness-Implementation Hybrid approach is applied to gather information on the delivery and potential for real-world implementation. Stages '1' and '2a' (representing hybrid model 1) are the focus of this protocol. The Translation Science to Population Impact (TSci Impact) framework is used to study policy decisions and service provision, and the Theoretical Domains Framework (TDF) is used to understand individual level behavioural change; both frameworks are applied across stages 1 and 2a. Stage 1 synthesises interview data from 32 participants involved in developing the genomics clinical practice systems and approaches across five 'demonstration-phase' (early adopter) flagships. In stage 2a, stakeholders are providing quantitative and qualitative data on process mapping, clinical audits, uptake and sustainability (TSci Impact), and psychosocial and environmental determinants of change (TDF). Findings will be synthesised before codesigning an intervention toolkit to facilitate implementation of genomic testing. Study methods to simultaneously test the comparative effectiveness of genomic testing and the implementation toolkit (stage 2b), and the refined implementation toolkit while simply observing the genomics intervention (stage 3) are summarised.

ETHICS AND DISSEMINATION

Ethical approval has been granted. The results will be disseminated in academic forums and used to refine interventions to translate genomics evidence into healthcare. Non-traditional academic dissemination methods (eg, change in guidelines or government policy) will also be employed.

Drivers of intentions to use healthcare information systems among health and care professionals

Although investment in healthcare technology is rapidly increasing, the readiness to use emerging technologies among healthcare professionals is still low. The present study relies on an integrated model derived from the unified theory of acceptance and use of technology and the diffusion of innovation model to assess the factors that predicted healthcare professionals’ intentions to use healthcare information systems. Using a cross-sectional correlational design, 105 healthcare professionals (M age = 41.06, standard deviation = 9.18; 49% consultants and General Practitioners (GPs); 56.2% females) from hospitals in England completed online structured questionnaires. One-way analysis of variance showed that there were no differences in healthcare information systems usage intentions, unified theory of acceptance and use of technology and diffusion of innovation variables between consultants/GPs and non-medical staff (i.e. nurses and administration staff). Linear regression analysis demonstrated that the integrative model predicted 78.1 per cent (adjusted R2) in intentions to use healthcare information systems, and variables from both unified theory of acceptance and use of technology and the diffusion of innovation had significant effects. Moderated regression analysis further revealed that the interaction between voluntariness and effort expectancy, and voluntariness and social influence significantly predicted usage intentions on top of the main effects of the individual predictors. This poses direct implications for both practice and theory in this field. Future research should consider the predictive validity of integrative theoretical models of technology acceptance and utilization in healthcare settings.

Narrative medicine in metastatic prostate cancer reveals ways to improve patient awareness & quality of care

AIM

To describe the journey of patients with metastatic castration-resistant prostate cancer (mCRPC) in treatment with radium-223.

METHODS

A multiperspective analysis was performed using narrative medicine in four Italian centers.

RESULTS

The substantial impact of mCRPC on quality of life through all phases of the disease was described. After an initial lack of awareness of the disease or denial of its effects, symptoms of pain, fatigue and side effects often led to sadness, fear and loneliness. The majority underwent radium-223 therapy positively, restoring their quality of life and routine activities.

CONCLUSION

Using narrative medicine, the importance of a patient-centered approach in the pathway of care for patients with mCRPC through all the stages of the disease was highlighted.

Optimizing Endoscope Reprocessing Resources Via Process Flow Queuing Analysis

The Massachusetts General Hospital (MGH) is merging its older endoscope processing facilities into a single new facility that will enable high-level disinfection of endoscopes for both the ORs and Endoscopy Suite, leveraging economies of scale for improved patient care and optimal use of resources. Finalized resource planning was necessary for the merging of facilities to optimize staffing and make final equipment selections to support the nearly 33,000 annual endoscopy cases. To accomplish this, we employed operations management methodologies, analyzing the physical process flow of scopes throughout the existing Endoscopy Suite and ORs and mapping the future state capacity of the new reprocessing facility. Further, our analysis required the incorporation of historical case and reprocessing volumes in a multi-server queuing model to identify any potential wait times as a result of the new reprocessing cycle. We also performed sensitivity analysis to understand the impact of future case volume growth. We found that our future-state reprocessing facility, given planned capital expenditures for automated endoscope reprocessors (AERs) and pre-processing sinks, could easily accommodate current scope volume well within the necessary pre-cleaning-to-sink reprocessing time limit recommended by manufacturers. Further, in its current planned state, our model suggested that the future endoscope reprocessing suite at MGH could support an increase in volume of at least 90% over the next several years. Our work suggests that with simple mathematical analysis of historic case data, significant changes to a complex perioperative environment can be made with ease while keeping patient safety as the top priority.

The use of process mapping in healthcare quality improvement projects

Introduction Process mapping provides insight into systems and processes in which improvement interventions are introduced and is seen as useful in healthcare quality improvement projects. There is little empirical evidence on the use of process mapping in healthcare practice. This study advances understanding of the benefits and success factors of process mapping within quality improvement projects. Methods Eight quality improvement projects were purposively selected from different healthcare settings within the UK's National Health Service. Data were gathered from multiple data-sources, including interviews exploring participants' experience of using process mapping in their projects and perceptions of benefits and challenges related to its use. These were analysed using inductive analysis. Results Eight key benefits related to process mapping use were reported by participants (gathering a shared understanding of the reality; identifying improvement opportunities; engaging stakeholders in the project; defining project's objectives; monitoring project progress; learning; increased empathy; simplicity of the method) and five factors related to successful process mapping exercises (simple and appropriate visual representation, information gathered from multiple stakeholders, facilitator's experience and soft skills, basic training, iterative use of process mapping throughout the project). Conclusions Findings highlight benefits and versatility of process mapping and provide practical suggestions to improve its use in practice.

Introduction of microsystems in a level 3 neonatal intensive care unit-an interprofessional approach

Background

Growth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care.

Methods/Design

The clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model.

Discussion

In depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns.

Trial registration

ClinicalTrial.gov, NCT02912780. Retrospectively registered on 22 September 2016.

Circle of care modelling: an approach to assist in reasoning about healthcare change using a patient-centric system

Background

Many health system and health Information and Communication Technology (ICT) projects do not achieve their expected benefits. This paper presents an approach to exploring changes in the healthcare system to better understand the expected improvements and other changes by using a patient-centric modelling approach. Circle of care modeling (CCM) was designed to assist stakeholders in considering healthcare system changes using a patient centric approach.

Methods

The CCM approach is described. It includes four steps, based on soft systems methodology: finding out, conceptual modelling, structured discussion, and describing potential improvements. There are four visualizations that are used though this process: patient-persona based rich pictures of care flows (as part of finding out), and three models: provider view, communication view, and information repository view (as part of conceptual modelling).

Results

Three case studies are presented where CCM was applied to different real-world healthcare problems: 1. Seeking improvements in continuity of care for end of life patients. 2. Exploring current practices for medication communication for ambulatory patients prior to an update of a jurisdictional drug information system. 3. Deciding how to improve attachment of patients to primary care. The cases illustrate how CCM helped stakeholders reason from a patient centered approach about gaps and improvements in care such as: data fragmentation (in 1), coordination efforts of medication management (in 2), and deciding to support a community health centre for unattached patients (in 3).

Discussion

The circle of care modelling approach has proved to be a useful tool in assisting stakeholders explore health system change in a patient centric approach. It is one way to instantiate the important principle of being patient centered into practice when considering health system changes.

[Innovation in healthcare processes and patient safety using clinical simulation]

OBJECTIVE

Many excellent ideas are never implemented or generalised by healthcare organisations. There are two related paradigms: thinking that individuals primarily change through accumulating knowledge, and believing that the dissemination of that knowledge within the organisation is the key element to facilitate change. As an alternative, a description and evaluation of a simulation-based inter-professional team training program conducted in a Regional Health Service to promote and facilitate change is presented.

MATERIAL AND METHODS

The Department of Continuing Education completed the needs assessment using the proposals presented by clinical units and management. Skills and behaviors that could be learned using simulation were selected, and all personnel from the units participating were included. Experiential learning principles based on clinical simulation and debriefing, were used for the instructional design. The Kirkpatrick model was used to evaluate the program.

RESULTS

Objectives included: a) decision-making and teamwork skills training in high prevalence diseases with a high rate of preventable complications; b) care processes reorganisation to improve efficiency, while maintaining patient safety; and, c) implementation of new complex techniques with a long learning curve, and high preventable complications rate. Thirty clinical units organised 39 training programs in the 3 public hospitals, and primary care of the Regional Health Service during 2013-2014. Over 1,559 healthcare professionals participated, including nursing assistants, nurses and physicians.

CONCLUSION

Simulation in healthcare to train inter-professional teams can promote and facilitate change in patient care, and organisational re-engineering.

Challenges, solutions and future directions in the evaluation of service innovations in health care and public health

Evaluating service innovations in health care and public health requires flexibility, collaboration and pragmatism; this collection identifies robust, innovative and mixed methods to inform such evaluations.

Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries

Background

Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness.

Objective

To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems.

Design

Multicenter, multilevel cross-sectional study.

Setting and Participants

Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries.

Intervention

None.

Measures

Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding.

Results and Limitations

Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities.

Conclusions

There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems.

A quality improvement project to decrease emergency department and medical intensive care unit transfer times

OBJECTIVE

To reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU).

DESIGN

A prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center.

INTERVENTIONS

A team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes. Measurements and Main Results The team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P<.001). Hospital length of stay decreased from 9.9±9 to 8.3±7 days (P<.03).

CONCLUSION

A team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care.

The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda

Background

Although global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet—Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.

Methods

The ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011–February 2012) and five follow-up months.

Results

Workshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader—community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.

Conclusions

The Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO’s Reaching Every District (RED) immunization strategy.

Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals

BACKGROUND

Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these.

METHODS

We used a mixed methods, controlled before and after design. At baseline, wards were audited on medication safety indicators; during the 'feedback' phase scorecard results were presented to intervention wards on a weekly basis over 7 weeks. We interviewed 49 staff, including clinicians and managers, about scorecard implementation.

RESULTS

At baseline, 18.7% of patients (total n=630) had incomplete allergy documentation; 53.4% of patients (n=574) experienced a drug omission in the preceding 24 h; 22.5% of omitted doses were classified as 'critical'; 22.1% of patients (n=482) either had ID wristbands not reflecting their allergy status or no ID wristband; and 45.3% of patients (n=237) had drugs that were either unlabelled or labelled for another patient in their drug lockers. The quantitative analysis found no significant improvement in intervention wards following scorecard feedback. Interviews suggested staff were interested in scorecard feedback and described process and culture changes. Factors influencing scorecard implementation included 'normalisation' of errors, study duration, ward leadership, capacity to engage and learning preferences.

DISCUSSION

Presenting evidence-based performance indicators may potentially influence staff behaviour. Several practical and cultural factors may limit feedback effectiveness and should be considered when developing improvement interventions. Quality scorecards should be designed with care, attending to evidence of indicators' effectiveness and how indicators and overall scorecard composition fit the intended audience.

Articulating current service development practices: a qualitative analysis of eleven mental health projects

BACKGROUND

The utilisation of good design practices in the development of complex health services is essential to improving quality. Healthcare organisations, however, are often seriously out of step with modern design thinking and practice. As a starting point to encourage the uptake of good design practices, it is important to understand the context of their intended use. This study aims to do that by articulating current health service development practices.

METHODS

Eleven service development projects carried out in a large mental health service were investigated through in-depth interviews with six operation managers. The critical decision method in conjunction with diagrammatic elicitation was used to capture descriptions of these projects. Stage-gate design models were then formed to visually articulate, classify and characterise different service development practices.

RESULTS

Projects were grouped into three categories according to design process patterns: new service introduction and service integration; service improvement; service closure. Three common design stages: problem exploration, idea generation and solution evaluation - were then compared across the design process patterns. Consistent across projects were a top-down, policy-driven approach to exploration, underexploited idea generation and implementation-based evaluation.

CONCLUSIONS

This study provides insight into where and how good design practices can contribute to the improvement of current service development practices. Specifically, the following suggestions for future service development practices are made: genuine user needs analysis for exploration; divergent thinking and innovative culture for idea generation; and fail-safe evaluation prior to implementation. Better training for managers through partnership working with design experts and researchers could be beneficial.

From simplicity towards complexity: the Italian multidimensional approach to obesity

Obesity is the result of a complex interplay among several factors leading to medical, functional and psychosocial consequences that markedly reduce life expectancy and impair quality of life. Is obesity itself a disease? Is obesity a brain disease? Who should treat obesity? This paper is a narrative review aimed to describe and to argue the prevalent position of some major Italian scientific and academic institutions dealing with obesity. According to the recent statements and recommendations published by the Italian Society for Obesity (SIO) and the Italian Society for the Study of Eating Disorders (SISDCA), the management of obese patients should include five main levels of care: (1) primary care, (2) outpatient treatment, (3) intensive outpatient treatment, (4) residential rehabilitative treatment, and (5) hospitalization. Ideally, patients suffering from obesity need a multidimensional evaluation intended to design an individualized treatment plan applying different procedures and therapeutic strategies (diet, physical activity and functional rehabilitation, educational therapy, cognitive-behavior therapy, drug therapy, and bariatric surgery). This thorough approach should address not only weight loss but also quality of weight loss, medical and psychiatric comorbidity, psychosocial problems, and physical disability. Such management of obesity requires an effective multiprofessional team, while health services have to overcome a number of administrative and organizational barriers that do not account for diseases requiring resources and professionals from different areas of medicine. Integrating several competences in a team-based approach demands specific education, skills and expertise. As for other diseases, the principles of complexity theory may offer a model useful to implement both teamwork and care delivery for patients with obesity.

How does care coordination provided by registered nurses "fit" within the organisational processes and professional relationships in the general practice context?

AIM

The aim of this study was to develop understanding about how a registered nurse-provided care coordination model can "fit" within organisational processes and professional relationships in general practice.

BACKGROUND

In this project, registered nurses were involved in implementation of registered nurse-provided care coordination, which aimed to improve quality of care and support patients with chronic conditions to maintain their care and manage their lifestyle.

METHOD

Focus group interviews were conducted with nurses using a semi-structured interview protocol. Interpretive analysis of interview data was conducted using Normalization Process Theory to structure data analysis and interpretation.

RESULTS

Three core themes emerged: (1) pre-requisites for care coordination, (2) the intervention in context, and (3) achieving outcomes. Pre-requisites were adequate funding mechanisms, engaging organisational power-brokers, leadership roles, and utilising and valuing registered nurses' broad skill base. To ensure registered nurse-provided care coordination processes were sustainable and embedded, mentoring and support as well as allocated time were required. Finally, when registered nurse-provided care coordination was supported, positive client outcomes were achievable, and transformation of professional practice and development of advanced nursing roles was possible.

CONCLUSION

Registered nurse-provided care coordination could "fit" within the context of general practice if it was adequately resourced. However, the heterogeneity of general practice can create an impasse that could be addressed through close attention to shared and agreed understandings. Successful development and implementation of registered nurse roles in care coordination requires attention to educational preparation, support of the individual nurse, and attention to organisational structures, financial implications and team member relationships.

Applying Process Mapping and Analysis as a Quality Improvement Strategy to Increase the Adoption of Fruit, Vegetable, and Water Breaks in Australian Primary Schools

Over the past decade, public health policy in Australia has prioritized the prevention and control of obesity and invested in programs that promote healthy eating–related behaviors, which includes increasing fruit and vegetable consumption in children. This article reports on a study that used process mapping and analysis as a quality improvement strategy to improve the delivery of a nutrition primary prevention program delivered in primary schools in New South Wales, Australia. Crunch&Sip® has been delivered since 2008. To date, adoption is low with only 25% of schools implementing the program. We investigated the cause of low adoption and propose actions to increase school participation. We conducted semistructured interviews with key stakeholders and analyzed the process of delivering Crunch&Sip to schools. Interviews and process mapping and analysis identified a number of barriers to schools adopting the program. The analyses identified the need to simplify and streamline the process of delivering the program to schools and introduce monitoring and feedback loops to track ongoing participation. The combination of stakeholder interviews and process mapping and analysis provided important practical solutions to improving program delivery and also contributed to building an understanding of factors that help and hinder program adoption. The insight provided by this analysis helped identify usable routine measures of adoption, which were an improvement over those used in the existing program plan. This study contributed toward improving the quality and efficiency of delivering a health promoting program to work toward achieving healthy eating behaviors in children.

Evaluation of or staffing and postoperative patient outcomes

The purpose of this cross-sectional cohort study was to evaluate the relationship between the number of OR personnel involved in a surgery and subsequent postoperative outcomes. We collected data from a sample of general surgery patients (N = 911) by using the American College of Surgeons National Surgical Quality Improvement Project processes. Data obtained from electronic medical records about the number of different personnel involved in the surgeries were used to create total OR staffing and nurse staffing variables for each surgery. Two associations approached statistical significance after we controlled for significant risk factors, including OR duration. A higher number of total nursing personnel involved in a surgical procedure was associated with any postoperative complication at the P = .095 level. A higher number of total OR personnel was associated with surgical site infections at the P = .057 level. We recommend further evaluation of these measures in multiple hospital settings.

Interprofessional practice in primary care: development of a tailored process model

Purpose

This study investigated the improvement of interprofessional practice in primary care by performing the first three steps of the implementation model described by Grol et al. This article describes the targets for improvement in a setting for children with complex care needs (step 1), the identification of barriers and facilitators influencing interprofessional practice (step 2), and the development of a tailored interprofessional process model (step 3).

Methods

In step 2, thirteen qualitative semistructured interviews were held with several stakeholders, including parents of children, an occupational therapist, a speech and language therapist, a physical therapist, the manager of the team, two general practitioners, a psychologist, and a primary school teacher. The data were analyzed using directed content analysis and using the domains of the Chronic Care Model as a framework. In step 3, a project group was formed to develop helpful strategies, including the development of an interprofessional process through process mapping.

Results

In step 2, it was found that the most important barriers to implementing interprofessional practice related to the lack of structure in the care process. A process model for interprofessional primary care was developed for the target group.

Conclusion

The lack of a shared view of what is involved in the process of interprofessional practice was the most important barrier to its successful implementation. It is suggested that the tailored process developed, supported with the appropriate tools, may provide both professional staff and their clients, in this setting but also in other areas of primary care, with insight to the care process and a clear representation of “who should do what, when, and how.”

Beliefs and experiences can influence patient participation in handover between primary and secondary care--a qualitative study of patient perspectives

Background

Communication between healthcare settings at patient transfers between primary and secondary care, ‘handover’, is a critical and risky process for patients. Patients’ views on their roles in these processes are often lacking despite the knowledge that patient participation contributes to enhanced safety and wellbeing.

Objective

This study aims to improve the knowledge and understanding of patients’ perspectives about their participation in handover.

Methods

Twenty-three Swedish patients with chronic diseases were individually interviewed about their experiences with handovers between three clinical microsystems: emergency room, emergency ward and primary healthcare centres. Data were analysed using inductive qualitative content analysis.

Results

Patients participated within the microsystems by exchanging information, and between microsystems by making contact with and conveying information to their next healthcare provider. Enablers for participation included positive encounters with providers, patient empowerment and beliefs about organisational factors. Patients’ trust in their providers, and providers’ attitudes were important factors in patients’ willingness to communicate. Patients who thought medical records access was shared across microsystems volunteered less information to their providers. Patients with experiences of non-effective handovers took more responsibility in the handover to ensure continuity of care.

Conclusions

Patients participate actively in handovers when they feel a need for involvement to ensure continuity of care, and are less active when they perceive that their contribution is unnecessary or not valued. In acute care settings with short hospital stays and less time to establish a trusting relationship between patients and their providers, discharge encounters may be important enablers for patient engagement in handovers. The advantages of a redundant handover process need to be considered.

Explaining the effects of a multifaceted intervention to improve inpatient care in rural Kenyan hospitals--interpretation based on retrospective examination of data from participant observation, quantitative and qualitative studies

Background

We have reported the results of a cluster randomized trial of rural Kenyan hospitals evaluating the effects of an intervention to introduce care based on best-practice guidelines. In parallel work we described the context of the study, explored the process and perceptions of the intervention, and undertook a discrete study on health worker motivation because this was felt likely to be an important contributor to poor performance in Kenyan public sector hospitals. Here, we use data from these multiple studies and insights gained from being participants in and observers of the intervention process to provide our explanation of how intervention effects were achieved as part of an effort to better understand implementation in low-income hospital settings.

Methods

Initial hypotheses were generated to explain the variation in intervention effects across place, time, and effect measure (indicator) based on our understanding of theory and informed by our implementation experience and participant observations. All data sources available for hospitals considered as cases for study were then examined to determine if hypotheses were supported, rejected, or required modification. Data included transcriptions of interviews and group discussions, field notes and that from the detailed longitudinal quantitative investigation. Potentially useful explanatory themes were identified, discussed by the implementing and research team, revised, and merged as part of an iterative process aimed at building more generic explanatory theory. At the end of this process, findings were mapped against a recently reported comprehensive framework for implementation research.

Results

A normative re-educative intervention approach evolved that sought to reset norms and values concerning good practice and promote 'grass-roots' participation to improve delivery of correct care. Maximal effects were achieved when this strategy and external support supervision helped create a soft-contract with senior managers clarifying roles and expectations around desired performance. This, combined with the support of facilitators acting as an expert resource and 'shop-floor' change agent, led to improvements in leadership, accountability, and resource allocation that enhanced workers' commitment and capacity and improved clinical microsystems. Provision of correct care was then particularly likely if tasks were simple and a good fit to existing professional routines. Our findings were in broad agreement with those defined as part of recent work articulating a comprehensive framework for implementation research.

Conclusions

Using data from multiple studies can provide valuable insight into how an intervention is working and what factors may explain variability in effects. Findings clearly suggest that major intervention strategies aimed at improving child and newborn survival in low-income settings should go well beyond the fixed inputs (training, guidelines, and job aides) that are typical of many major programmes. Strategies required to deliver good care in low-income settings should recognize that this will need to be co-produced through engagement often over prolonged periods and as part of a directive but adaptive, participatory, information-rich, and reflective process.