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Montoya SM, Olaore P, Bastardo-Acosta J, Abdulla R, Schell MJ, Hidalgo A, Turner B, Rider M, Kishun-Jit N, Joshua A, Pollard J, Friedman M, Christy SM, Meade CD, Gwede CK. Protocol paper for an implementation science approach to promoting colorectal cancer screening in Federally Qualified Health Center clinics: A stepped-wedge, multilevel intervention trial. RESEARCH SQUARE 2024:rs.3.rs-4558718. [PMID: 39070625 PMCID: PMC11275978 DOI: 10.21203/rs.3.rs-4558718/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Background Colorectal cancer is the third leading cause of cancer-related deaths in the United States. Despite the Healthy People 2030 goal of 70.5%, colorectal cancer (CRC) screening rates in Federally Qualified Health Centers (FQHCs) are suboptimal at about 40%. The Colorectal Cancer Awareness, Research, Education and Screening-Rural Expansion, Access, and Capacity for Health (CARES-REACH) study seeks to address this disparity and accelerate the adoption and utilization of effective, evidence-based CRC screening practices. This paper describes the CARES-REACH study design and implementation methods. Methods Informed by a community-based participatory research (CBPR) framework and enriched by implementation science approaches, CARES-REACH features a stepped wedge design with extension for maintenance to support an implementation strategy focused on multiple levels: organizational, provider, and patient levels that entail processes to boost initial and repeat screening among average risk and age-eligible adults. This multilevel study entails the implementation of a core set of evidence-based interventions (EBIs) that include low literacy patient education (English, Spanish, and Haitian Creole language); provider education, system-wide electronic medical record (EMR) tools including provider prompts and patient reminders, FIT (fecal immunochemical test) kit distribution, plus an organization-wide cancer control champion who motivates providers, coaches and navigates patients, and monitors system-wide CRC screening activities. Trial registration NCT04464668.
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McKnight ER, Ebersole A, Gallup J, Haamid FW. Developing a Sustainable Quality Improvement Program in an Academic Center: The Experience of an Adolescent Unit. Pediatr Qual Saf 2024; 9:e742. [PMID: 38868760 PMCID: PMC11167228 DOI: 10.1097/pq9.0000000000000742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 05/17/2024] [Indexed: 06/14/2024] Open
Abstract
Introduction Successful quality improvement (QI) efforts use a comprehensive, institutional QI framework and professional development, but literature describing implementing QI frameworks in Adolescent Medicine practices is sparse. We aimed to implement and increase the number of formally structured QI projects (primary aim) and the number of projects achieving a centerline (CL) shift (secondary aim) in our hospital's Adolescent Medicine Clinic. Methods We used formal QI methodology to improve health outcomes by increasing the number of faculty with formalized QI education, creating interdisciplinary QI teams, and improving staff motivation. QI education was mandatory for Adolescent Medicine fellows and pediatric residents and encouraged for faculty and staff. The Divisional QI leadership team attended monthly meetings to review key driver diagrams, run and control charts, and receive intervention updates. All providers and staff received monthly updates, and the Hospital Quality and Safety Committee received biannual updates. We used run charts to share progress with primary and secondary aims. Results Since Q3 2014, the Adolescent Medicine team consistently achieved the primary aim of having 5 active projects in process, with 9 projects from Q1 2018-Q4 2020. For the secondary aim, a target of 50% of active QI projects attaining a sustained centerline shift was achieved in Q2 2018 and maintained in 16 of 20 quarters since. Conclusions Clinicians can use QI methodology to improve health outcomes while facilitating professional development. For this initiative to succeed, institutional leadership must provide an infrastructure prioritizing meaningful QI involvement.
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Affiliation(s)
- Erin R. McKnight
- From the Division of Adolescent Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University Wexner College of Medicine, Columbus, Ohio
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
| | - Ashley Ebersole
- From the Division of Adolescent Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University Wexner College of Medicine, Columbus, Ohio
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
| | - James Gallup
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
- Quality Improvement Services, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
| | - Fareeda W. Haamid
- From the Division of Adolescent Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University Wexner College of Medicine, Columbus, Ohio
- Center for Clinical Excellence, Nationwide Children’s Hospital, Columbus, Ohio
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Poroes C, Seematter-Bagnoud L, Wyss K, Peytremann-Bridevaux I. Health System Performance and Resilience in Times of Crisis: An Adapted Conceptual Framework. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6666. [PMID: 37681806 PMCID: PMC10487449 DOI: 10.3390/ijerph20176666] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/15/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
With the COVID-19 pandemic, the notion of health system (HS) performance has been discussed, and the notion of resilience has become increasingly important. Lacking a recognised framework that measures the performance of HSs throughout a crisis, i.e., one that explicitly includes time as a key aspect, we examined the literature about conceptual frameworks for measuring the performance and the resilience of HSs. This review highlighted a significant diversity among 18 distinct HS performance frameworks and 13 distinct HS resilience frameworks. On this basis, we developed a model that integrates the WHO's widely recognised six building block framework in a novel approach derived from the European Observatory on HSs and Policies. The resulting framework adapts the building blocks to the different stages of a crisis, thereby allowing for a comprehensive assessment of an entire health system's performance throughout the crisis's duration, while also considering the key aspect of resilience. For a more pragmatic use of this framework in the future, indicators will be developed as a next step.
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Affiliation(s)
- Camille Poroes
- Centre for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, 1010 Lausanne, Switzerland
| | - Laurence Seematter-Bagnoud
- Centre for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, 1010 Lausanne, Switzerland
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland
- Faculty of Natural Science, University of Basel, 4001 Basel, Switzerland
| | - Isabelle Peytremann-Bridevaux
- Centre for Primary Care and Public Health (Unisanté), Department of Epidemiology and Health Systems, University of Lausanne, 1010 Lausanne, Switzerland
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Hamidi S, Auguste BL. Continuous quality improvement in peritoneal dialysis: Your questions answered. Perit Dial Int 2023:8968608231156924. [PMID: 36843355 DOI: 10.1177/08968608231156924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
Peritoneal dialysis (PD) uptake around the globe has steadily increased over the last several decades as a viable alternative to haemodialysis. Continued success of this technique for patients is contingent on the application of continuous quality improvement (CQI) principles in PD practice which can improve patient outcomes and in turn lead to more successful PD programmes worldwide. In this installation of 'Your Questions Answered', we will outline an approach to quality improvement initiatives and examine the importance of CQI principles in PD practice. We will also highlight common pitfalls and provide strategies to identify potential targets for improvement within your PD programme.
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Affiliation(s)
- Shabnam Hamidi
- Department of Medicine, University of Toronto, ON, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bourne L Auguste
- Department of Medicine, University of Toronto, ON, Canada.,Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Centre for Quality Improvement and Patient Safety, University of Toronto, ON, Canada
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Hespe CM, Brown E, Rychetnik L. Learning from the implementation of a quality improvement intervention in Australian general practice: a qualitative analysis of participants views of a CVD preventive care project. BMC PRIMARY CARE 2022; 23:79. [PMID: 35421935 PMCID: PMC9011978 DOI: 10.1186/s12875-022-01692-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/04/2022] [Indexed: 11/23/2022]
Abstract
Background Quality improvement collaborative projects aim to reduce gaps in clinical care provided in the healthcare system. This study evaluated the experience of key participants from a Quality Improvement Program (QPulse) that focussed on cardiovascular disease assessment and management. The study goal was to identify critical barriers and factors enabling the implementation of a quality improvement framework in Australian general practice. Methods This qualitative study examined in-depth semi-structured interviews with nineteen purposively-selected participants of the QPulse project. Interviewees were from General Practices and the local supporting organisation, a Primary Health Network. Interviews were analysed thematically using the Complex Systems Improvement framework, focusing on five domains: strategy, culture, structure, workforce and technology. Results Despite reported engagement with QPulse objectives to improve cardiovascular preventive care, implementation barriers associated with this program were considerable for all interviewees. Adoption of the quality improvement process was reliant on designated leadership, aligned practice culture, organised systems for clear communication, tailored education and utilisation of clinical audit and review processes. Rather than practice size and location, practice culture and governance alignment to quality improvement predicted successful implementation. Financial incentives for both general practice and the Primary Health Network were also identified as prerequisites for systematised quality improvement projects in the future, along with individualised support and education for each general practice. Technology was both an enabler and a barrier, and the Primary Health Network was seen as key to assisting the successful utilisation of the available tools. Conclusions Implementation of Quality Improvement programs remains a potential tool for achieving better health outcomes in General Practice. However, enablers such as financial incentives, individualised education and support provided via a supporting organisation, and IT tools and support are crucial if the full potential of Quality Improvement programs are to be realised in the Australian healthcare setting. Trial registration ACTRN12615000108516, UTN U1111-1163–7995. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01692-0.
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Rooke F, Burford J, Doorly A, Gush C, Brennan ML. Developing consensus for definitions of key veterinary-specific quality improvement (QI) terms using an eDelphi-study method. Vet Rec 2021; 191:e1174. [PMID: 34888878 DOI: 10.1002/vetr.1174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/18/2021] [Accepted: 10/28/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Quality improvement (QI) methods are a continuous process of iterative tests to improve the quality of a service or product. Using common language has been linked to the successful implementation of QI in human healthcare. This study aimed to assimilate and achieve consensus on veterinary-specific definitions for terms associated with quality care and QI methods in UK veterinary practice. METHODS A four-round modified eDelphi process with a panel of 50 UK veterinary practice stakeholders was used to generate consensus. The panel selected or suggested the definition they best felt 'fitted' each term. Consensus was reached if there was >70% agreement, and terms were eliminated if there was <15% selection. RESULTS Thirty-one panellists completed all three rounds of eDelphi; eight participants completed an optional feedback round. From 14 terms, 10 reached consensus, leaving four unresolved definitions. CONCLUSIONS A majority of terms reached consensus; 90% were new or amended definitions proposed by panel members. Utilising plain English refined by stakeholders will allow successful implementation of QI in veterinary healthcare. Not all terms achieved consensus, highlighting a need for further research to enable successful integration of QI principles as seen in human healthcare.
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Affiliation(s)
- Freya Rooke
- School of Veterinary Medicine and Science, University of Nottingham, Loughborough, UK.,Centre for Evidence-Based Veterinary Medicine, School of Veterinary Medicine and Science, University of Nottingham, Loughborough, UK
| | - John Burford
- School of Veterinary Medicine and Science, University of Nottingham, Loughborough, UK
| | | | | | - Marnie L Brennan
- School of Veterinary Medicine and Science, University of Nottingham, Loughborough, UK.,Centre for Evidence-Based Veterinary Medicine, School of Veterinary Medicine and Science, University of Nottingham, Loughborough, UK
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Hamilton S, Jennings A, Forster AJ. Development and evaluation of a quality improvement framework for healthcare. Int J Qual Health Care 2020; 32:456-463. [PMID: 32696048 PMCID: PMC7654383 DOI: 10.1093/intqhc/mzaa075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/30/2020] [Accepted: 07/07/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Develop and evaluate a framework for quality improvement which will provide a common approach, terminology and greater likelihood of success in achieving demonstrable and sustained improvement. DESIGN Descriptive with mixed methods evaluation. SETTING Tertiary care academic hospital in Ottawa, Canada. PARTICIPANTS Students enrolled in the Quality and Patient Safety Leadership Executive Program at the local university. METHODS The quality improvement (QI) framework was developed though comparison and coding of key strengths across four commonly applied quality improvement frameworks. Effectiveness of the framework was evaluated through a satisfaction survey of students who were taught the framework, and independent assessment of student improvement initiatives that followed the QI Framework versus initiatives from a prior year who did not. MAIN OUTCOME MEASURES Acceptability and effectiveness of the QI Framework. RESULTS All participants found the QI Framework to be useful and easy to follow. Independent evaluation of improvement initiatives following the QI Framework, as compared to those that did not, scored higher (95% CI: 3.0 ± 0.49) than the projects completed without the QI Framework (95% CI: 2.2 ± 0.30), P value < 0.01. Scores were higher for cohort 2017/18 in all criteria except scaling and spreading, in which there was no change (2015/16 95% CI: 1.2 ± 0.24, 2017/18 95% CI: 1.2 ± 0.38). CONCLUSIONS The method we have developed is acceptable and helpful to users, and overall application resulted in higher quality initiatives. We believe this method, which we have branded as The Ottawa Hospital Innovation Framework, can be beneficial in healthcare settings for a variety of change initiatives.
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Affiliation(s)
- Samantha Hamilton
- Innovation & Quality, The Ottawa Hospital, Civic Campus, 1053 Carling Ave Ottawa, ON, K1Y 4E9
| | - Alison Jennings
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave., Ottawa, ON, K1Y 4E9
| | - Alan J Forster
- Innovation & Quality, The Ottawa Hospital, Civic Campus, 1053 Carling Ave Ottawa, ON, K1Y 4E9
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Ave., Ottawa, ON, K1Y 4E9
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Low LL, Ab Rahim FI, Johari MZ, Abdullah Z, Abdul Aziz SH, Suhaimi NA, Jaafar N, Mohd Hanafiah AN, Kong YL, Mahmud SH, Zulkepli MZ, Perialathan K, Muharam N, Zainudin NH, Mohd Zin Z, Mohd Roslan N, Aris T, Murad S. Assessing receptiveness to change among primary healthcare providers by adopting the consolidated framework for implementation research (CFIR). BMC Health Serv Res 2019; 19:497. [PMID: 31311538 PMCID: PMC6636000 DOI: 10.1186/s12913-019-4312-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 07/01/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Amid the current burden of non-communicable (NCD) diseases in Malaysia, there is a growing demand for more efficient service delivery of primary healthcare. A complex intervention is proposed to improve NCD management in Malaysia. This exploratory study aimed to assess primary healthcare providers' receptiveness towards change prior to implementation of the proposed complex intervention. METHOD This study was conducted using an exploratory qualitative approach on purposely selected healthcare providers at primary healthcare clinics. Twenty focus group discussions and three in-depth interviews were conducted using a semi-structured interview guide. Consent was obtained prior to interviews and for audio-recordings. Interviews were transcribed verbatim and thematically analysed, guided by the Consolidated Framework for Implementation Research (CFIR), a framework comprised of five major domains promoting implementation theory development and verification across multiple contexts. RESULTS The study revealed via CFIR that most primary healthcare providers were receptive towards any proposed changes or intervention for the betterment of NCD care management. However, many challenges were outlined across four CFIR domains-intervention characteristics, outer setting, inner setting, and individual characteristics-that included perceived barriers to implementation. Perception of issues that triggered proposed changes reflected the current situation, including existing facilitating aspects that can support the implementation of any future intervention. The importance of strengthening the primary healthcare delivery system was also expressed. CONCLUSION Understanding existing situations faced at the primary healthcare setting is imperative prior to implementation of any intervention. Healthcare providers' receptiveness to change was explored, and using CFIR framework, challenges or perceived barriers among healthcare providers were identified. CFIR was able to outline the clinics' setting, individual behaviour and external agency factors that have direct impact to the organisation. These are important indicators in ensuring feasibility, effectiveness and sustainability of any intervention, as well as future scalability considerations.
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Affiliation(s)
- Lee Lan Low
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Fathullah Iqbal Ab Rahim
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Mohammad Zabri Johari
- Institute for Behavioural Research, National Institute of Health, Ministry of Health Malaysia, Block B3, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Zalilah Abdullah
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Siti Hajar Abdul Aziz
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Nur Ajeerah Suhaimi
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Norrafizah Jaafar
- Institute for Behavioural Research, National Institute of Health, Ministry of Health Malaysia, Block B3, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Ainul Nadziha Mohd Hanafiah
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Yuke Lin Kong
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Siti Haniza Mahmud
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Mohamad Zaidan Zulkepli
- Institute for Behavioural Research, National Institute of Health, Ministry of Health Malaysia, Block B3, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Komathi Perialathan
- Institute for Behavioural Research, National Institute of Health, Ministry of Health Malaysia, Block B3, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Norazlin Muharam
- Department of Statistics, Block C6, Complex C, Federal Government Administrative CentrE, 62514 Putrajaya, Malaysia
| | - Nur Hani Zainudin
- Institute for Health Systems Research, National Institute of Health, Ministry of Health Malaysia, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Zaikiah Mohd Zin
- Institute for Behavioural Research, National Institute of Health, Ministry of Health Malaysia, Block B3, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Norazilah Mohd Roslan
- Family Health Development Division, Putrajaya, Ministry of Health Malaysia, Block E1, E3, E7 & E10, Complex E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia
| | - Tahir Aris
- Institute for Public Health, National Institute of Health, Ministry of Health Malaysia, Block B5, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Shahnaz Murad
- Office of Deputy Director General of Health (Research and Technical Support), Ministry of Health Malaysia, Block E1, E3, E7 & E10, Complex E, Federal Government Administrative Centre, 62590 Putrajaya, Malaysia
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Kreindler SA. The stipulation-stimulation spiral: A model of system change. Int J Health Plann Manage 2019; 34:e1464-e1477. [PMID: 31120177 DOI: 10.1002/hpm.2811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/10/2022] Open
Abstract
This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.
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Affiliation(s)
- Sara A Kreindler
- Department of Community Health Sciences and George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
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Adamu AA, Uthman OA, Wambiya EO, Gadanya MA, Wiysonge CS. Application of quality improvement approaches in health-care settings to reduce missed opportunities for childhood vaccination: a scoping review. Hum Vaccin Immunother 2019; 15:2650-2659. [PMID: 30945976 DOI: 10.1080/21645515.2019.1600988] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Missed opportunities for vaccination (MOV) is a poor reflection of the quality of care for children attending health facilities. It also contributes to a reduction in overall immunization coverage. Although there is a growing interest in the use of quality improvement (QI) in complex health systems to improve health outcomes, the degree to which this approach has been used to address MOV is poorly understood. We conducted a scoping review using Arksey and O'Malley's framework to investigate the extent to which QI has been used in health facilities to reduce MOV. The review followed five stages as follows: (1) identifying the research question; (2) identifying the relevant studies; (3) selecting the studies; (4) charting data; and (5) collating, summarizing, and reporting results. The search strategy included electronic databases and gray literature. A total of 12 literatures on QI projects focused on addressing MOV were identified. Eleven were published manuscripts, and one was a conference presentation. All the QI projects published were conducted in the United States and majority were between 2014 and 2018. In these projects, 45 change ideas targeting providers, clients, and health system were used. This study generated important evidence on the use of QI in health facilities to reduce MOV. In addition, the result suggests that there is a growing interest in the use of this approach to address MOV in recent years. However, no literature was found in low- and middle-income countries especially sub-Saharan Africa.
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Affiliation(s)
- Abdu A Adamu
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa.,Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Olalekan A Uthman
- Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, University of Warwick Medical School, Coventry, UK
| | - Elvis O Wambiya
- Education and Youth Empowerment Unit, African Population and Health Research Centre, Nairobi, Kenya
| | - Muktar A Gadanya
- Department of Community Medicine, Bayero University/Aminu Kano Teaching Hospital, Kano, Kano State, Nigeria
| | - Charles S Wiysonge
- Cochrane South Africa, South African Medical Research Council, Tygerberg, South Africa.,Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Pandhi N, Kraft S, Berkson S, Davis S, Kamnetz S, Koslov S, Trowbridge E, Caplan W. Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons learned from implementing a microsystems approach. BMC Health Serv Res 2018; 18:847. [PMID: 30413205 PMCID: PMC6230270 DOI: 10.1186/s12913-018-3650-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 10/24/2018] [Indexed: 11/29/2022] Open
Abstract
Background Health systems in the United States are increasingly required to become leaders in quality to compete successfully in a value-conscious purchasing market. Doing so involves developing effective clinical teams using approaches like the clinical microsystems framework. However, there has been limited assessment of this approach within United States primary care settings. Methods This paper describes the implementation, mixed-methods evaluation results, and lessons learned from instituting a Microsystems approach across 6 years with 58 primary care teams at a large Midwestern academic health care system. The evaluation consisted of a longitudinal survey augmented by interviews and focus groups. Structured facilitated longitudinal discussions with leadership captured ongoing lessons learned. Quantitative analysis employed ordinal logistic regression and compared aggregate responses at 6-months and 12-months to those at the baseline period. Qualitative analysis used an immersion/crystallization approach. Results Survey results (N = 204) indicated improved perceptions of: organizational support, team effectiveness and cohesion, meeting and quality improvement skills, and team communication. Thematic challenges from the qualitative data included: lack of time and coverage for participation, need for technical/technology support, perceived devaluation of improvement work, difficulty aggregating or spreading learnings, tensions between team and clinic level change, a part-time workforce, team instability and difficulties incorporating a data driven improvement approach. Conclusions These findings suggest that a microsystems approach is valuable for building team relationships and quality improvement skills but is challenged in a large, diverse academic primary care context. They additionally suggest that primary care transformation will require purposeful changes implemented across the micro to macro-level including but not only focused on quality improvement training for microsystem teams.
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Affiliation(s)
- Nancy Pandhi
- Department of Family and Community Medicine, University of New Mexico School of Medicine, MSC 09 5040, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
| | - Sally Kraft
- Population Health at Geisel School of Medicine at Dartmouth College, 1 Rope Ferry Rd, Hanover, NH, 03755, USA.,Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA
| | - Stephanie Berkson
- Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA.,Planning and Business Development, UW Health, Madison, WI, USA
| | - Sarah Davis
- Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA.,University of Wisconsin Law School, Madison, WI, USA.,Center for Patient Partnerships, Madison, WI, USA
| | - Sandra Kamnetz
- Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA.,Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Steven Koslov
- Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA.,Department of Pediatric and Adolescent Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Elizabeth Trowbridge
- Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA.,General Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - William Caplan
- Primary Care Academics Transforming Healthcare Collaborative, Madison, WI, USA.,General Internal Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Hill JN, Locatelli SM, Bokhour BG, Fix GM, Solomon J, Mueller N, LaVela SL. Evaluating broad-scale system change using the Consolidated Framework for Implementation Research: challenges and strategies to overcome them. BMC Res Notes 2018; 11:560. [PMID: 30075807 PMCID: PMC6076417 DOI: 10.1186/s13104-018-3650-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 07/25/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE The objective of this paper is to demonstrate the utility of the CFIR framework for evaluating broad-scale change by discussing the challenges to be addressed when planning the assessment of broad-scale change and the solutions developed by the evaluation team to address those challenges. The evaluation of implementation of Patient-centered Care and Cultural Transformation (PCC&CT) within the Department of Veterans Affairs (VA) will be used as a demonstrative example. Patient-Centered Care (PCC) is personalized health care that considers a patient's circumstances and goals. The Department of Veterans Affairs (VA) is working towards implementing PCC throughout its healthcare system, comprised of multiple interventions with a singular long-term goal of cultural transformation, however little is known about the factors influencing its implementation. This paper discusses the issues that arose using CFIR to qualitatively assess the factors influencing implementation of cultural transformation. RESULTS Application of CFIR to this broad-scale evaluation revealed three strategies recommended for use in evaluating implementation of broad-scale change: (1) the need for adapted definitions for CFIR constructs (especially due to new application to broad-scale change), (2) the use of a mixed deductive-inductive approach with thematic coding to capture emergent themes not encompassed by CFIR, and (3) its use for expedited analysis and synthesis for rapid delivery of findings to operational partners. This paper is among the first to describe use of CFIR to guide the evaluation of a broad-scale transformation, as opposed to discrete interventions. The processes and strategies described in this paper provide a detailed example and structured approach that can be utilized and expanded upon by others evaluating implementation of broad-scale evaluations. Although CFIR was the framework selected for this evaluation, the strategies described in this paper including: use of adapted definitions, use of mixed deductive-inductive approach, and the approach for expedited analysis and synthesis can be transferred and tested with other frameworks.
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Affiliation(s)
- Jennifer N Hill
- Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Center of Innovation for, Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, 5000 S. 5th Ave (151H), Hines, IL, 60141, USA.
| | - Sara M Locatelli
- Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Center of Innovation for, Complex Chronic Health Care (CINCCH), Edward Hines Jr. VA Hospital, 5000 S. 5th Ave (151H), Hines, IL, 60141, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center, Center for Evaluating Patient-Centered Care (EPCC), Boston University School of Public Health, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Gemmae M Fix
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Health Services Research and Development Service, Evaluating Patient-Centered Care (EPCC), Boston University School of Public Health, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Jeffrey Solomon
- Evaluating Patient-Centered Care (EPCC), Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Nora Mueller
- Center for Healthcare Organization and Implementation Research (CHOIR), ENRM Veterans Affairs Medical Center, Center for Evaluating Patient-Centered Care (EPCC), Boston University School of Public Health, Edith Nourse Rogers Memorial VA Hospital, 200 Springs Rd, Bedford, MA, 01730, USA
| | - Sherri L LaVela
- Center for Evaluation of Practices and Experiences of Patient-Centered Care (CEPEP), Center of Innovation for Complex Chronic Health Care (CINCCH), Center for Healthcare Studies, Institute for Public Health and Medicine General Internal Medicine and Geriatrics, Edward Hines Jr. VA Hospital, Northwestern University, Feinberg School of Medicine, 5000 S. 5th Ave (151H), Hines, IL, 60141, USA
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13
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Champion C, Alvarez GG, Affleck E, Kuziemsky C. A systems perspective on rural and remote colorectal cancer screening access. J Cancer Policy 2017. [DOI: 10.1016/j.jcpo.2017.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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14
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Kraft S, Caplan W, Trowbridge E, Davis S, Berkson S, Kamnetz S, Pandhi N. Building the learning health system: Describing an organizational infrastructure to support continuous learning. Learn Health Syst 2017; 1:e10034. [PMID: 31245569 PMCID: PMC6508554 DOI: 10.1002/lrh2.10034] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/13/2017] [Accepted: 05/24/2017] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Academic health centers are reorganizing in response to dramatic changes in the health-care environment. To improve value, they and other health systems must become a learning health system, specifically one that has the capacity to understand performance across the continuum of care and use that information to achieve continuous improvements in efficiency and effectiveness. While learning health system concepts have been well described, the practical steps to create such a system are not well defined. Establishing the necessary infrastructure is particularly challenging at academic health centers due to their tripartite missions and complex organizational structures. METHODS Using an evidence-based framework, this article describes a series of organizational-level interventions implemented at an academic health center to create the structures and processes to support the functions of a learning health system. RESULTS Following implementation of changes from 2008 to 2013, system-level performance improved in multiple domains: patient satisfaction, population health screenings, improvement education, and patient engagement. CONCLUSIONS This experience can be applied to health systems that wrestle with making system-level change when existing cultures, structures, and processes vary. Using an evidence -based framework is useful when developing the structures and processes that support the functions of a learning health system.
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Affiliation(s)
- Sally Kraft
- Dartmouth‐Hitchcock Medical CenterLebanonNew Hampshire
- Geisel School of MedicineDartmouth CollegeHanoverNew Hampshire
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
| | - William Caplan
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
- Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
| | - Elizabeth Trowbridge
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
- Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
| | - Sarah Davis
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
- University of Wisconsin Law SchoolMadisonWisconsin
- Center for Patient PartnershipsMadisonWisconsin
| | - Stephanie Berkson
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
- UW HealthMadisonWisconsin
| | - Sandra Kamnetz
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
- Department of Family Medicine and Community HealthUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
| | - Nancy Pandhi
- Primary Care Academics Transforming Healthcare CollaborativeUW HealthMadisonWisconsin
- Department of Family Medicine and Community HealthUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsin
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15
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Kraft S, Caplan W, Trowbridge E, Davis S, Berkson S, Kamnetz S, Pandhi N. Building the learning health system: Describing an organizational infrastructure to support continuous learning. Learn Health Syst 2017. [PMID: 31245569 DOI: 10.1002/lrh2.10034team] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Academic health centers are reorganizing in response to dramatic changes in the health-care environment. To improve value, they and other health systems must become a learning health system, specifically one that has the capacity to understand performance across the continuum of care and use that information to achieve continuous improvements in efficiency and effectiveness. While learning health system concepts have been well described, the practical steps to create such a system are not well defined. Establishing the necessary infrastructure is particularly challenging at academic health centers due to their tripartite missions and complex organizational structures. METHODS Using an evidence-based framework, this article describes a series of organizational-level interventions implemented at an academic health center to create the structures and processes to support the functions of a learning health system. RESULTS Following implementation of changes from 2008 to 2013, system-level performance improved in multiple domains: patient satisfaction, population health screenings, improvement education, and patient engagement. CONCLUSIONS This experience can be applied to health systems that wrestle with making system-level change when existing cultures, structures, and processes vary. Using an evidence -based framework is useful when developing the structures and processes that support the functions of a learning health system.
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Affiliation(s)
- Sally Kraft
- Dartmouth-Hitchcock Medical Center Lebanon New Hampshire.,Geisel School of Medicine Dartmouth College Hanover New Hampshire.,Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin
| | - William Caplan
- Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin.,Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Elizabeth Trowbridge
- Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin.,Department of Medicine University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Sarah Davis
- Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin.,University of Wisconsin Law School Madison Wisconsin.,Center for Patient Partnerships Madison Wisconsin
| | - Stephanie Berkson
- Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin.,UW Health Madison Wisconsin
| | - Sandra Kamnetz
- Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin.,Department of Family Medicine and Community Health University of Wisconsin School of Medicine and Public Health Madison Wisconsin
| | - Nancy Pandhi
- Primary Care Academics Transforming Healthcare Collaborative UW Health Madison Wisconsin.,Department of Family Medicine and Community Health University of Wisconsin School of Medicine and Public Health Madison Wisconsin
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Barnard JA, Davis JT. Quality Improvement Leadership in Academic Children's Hospitals. Pediatr Qual Saf 2017; 2:e034. [PMID: 30229170 PMCID: PMC6132479 DOI: 10.1097/pq9.0000000000000034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/19/2017] [Indexed: 11/25/2022] Open
Affiliation(s)
- John A. Barnard
- From the Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio; Hospital Administration, Nationwide Children’s Hospital, Columbus, Ohio; Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio; and Nationwide Children’s Hospital, Columbus, Ohio
| | - J. Terrance Davis
- From the Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio; Hospital Administration, Nationwide Children’s Hospital, Columbus, Ohio; Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio; and Nationwide Children’s Hospital, Columbus, Ohio
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17
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Rao SK, Carballo V, Cummings BM, Millham F, Jacobson JO. Developing an Interdisciplinary, Team-Based Quality Improvement Leadership Training Program for Clinicians: The Partners Clinical Process Improvement Leadership Program. Am J Med Qual 2016; 32:271-277. [PMID: 27259877 DOI: 10.1177/1062860616648773] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although there has been tremendous progress in quality improvement (QI) education for students and trainees in recent years, much less has been published regarding the training of active clinicians in QI. The Partners Clinical Process Improvement Leadership Program (CPIP) is a 6-day experiential program. Interdisciplinary teams complete a QI project framed by didactic sessions, interactive exercises, case-based problem sessions, and a final presentation. A total of 239 teams composed of 516 individuals have graduated CPIP. On completion, participant satisfaction scores average 4.52 (scale 1-5) and self-reported understanding of QI concepts improved. At 6 months after graduation, 66% of survey respondents reported sustained QI activity. Three opportunities to improve the program have been identified: (1) increasing faculty participation through online and tiered course offerings, (2) integrating the faculty-focused program with the trainee curriculum, and (3) developing a postgraduate curriculum to address the challenges of sustained improvement.
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Affiliation(s)
- Sandhya K Rao
- 1 Massachusetts General Hospital, Boston, MA.,2 Harvard Medical School, Boston, MA.,3 Partners HealthCare, Boston, MA
| | | | - Brian M Cummings
- 1 Massachusetts General Hospital, Boston, MA.,2 Harvard Medical School, Boston, MA.,3 Partners HealthCare, Boston, MA
| | - Frederick Millham
- 2 Harvard Medical School, Boston, MA.,4 South Shore Hospital, Quincy, MA
| | - Joseph O Jacobson
- 2 Harvard Medical School, Boston, MA.,5 Dana Farber Cancer Center, Boston, MA
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18
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Koslov S, Trowbridge E, Kamnetz S, Kraft S, Grossman J, Pandhi N. Across the divide: "Primary care departments working together to redesign care to achieve the Triple Aim". HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 4:200-6. [PMID: 27637827 DOI: 10.1016/j.hjdsi.2015.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 11/10/2015] [Accepted: 12/08/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary care is considered the foundation of an effective health care system. However, primary care departments at academic health centers have numerous challenges to overcome when trying to achieve the Triple Aim. METHODS As part of an organizational initiative to redesign primary care at a large academic health center, departments of internal medicine, general pediatrics and adolescent medicine, and family medicine worked together to comprehensively redesign primary care. This article describes the process of aligning these three primary care departments: defining panel size, developing a common primary care job description, redesigning the primary care compensation plan, redesigning the care model, and developing standardized staffing. RESULTS Prior to the initiative, the rate of patient satisfaction was 85%, anticoagulation measurement 65%, pneumococcal vaccination 85%, breast cancer screening 79%, and colorectal cancer screening 69%. These rates all improved to 87%, 75%, 88%, 80%, and 80% respectively. Themes around key challenges to departmental integration are identified: (1) implementing effective communication strategies; (2) addressing specialty differences in primary care delivery; (3) working within resource limitations; and (4) developing long-term sustainability. CONCLUSIONS Primary care in this large academic health center was transformed through developing a united primary care leadership team that bridged individual departments to create and adopt a common vision and solutions to shared problems. Our collaboration has achieved improvements across patient satisfaction, clinical safety metrics, and publicly-reported preventive care outcomes. IMPLICATIONS The description of this experience may be useful for other academic health centers or other non-integrated delivery systems undertaking primary care practice transformation.
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Affiliation(s)
- Steven Koslov
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, United States; Primary Care Academics Transforming Healthcare Collaborative, UW Health, United States
| | - Elizabeth Trowbridge
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, United States; Primary Care Academics Transforming Healthcare Collaborative, UW Health, United States
| | - Sandra Kamnetz
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, United States; Primary Care Academics Transforming Healthcare Collaborative, UW Health, United States
| | - Sally Kraft
- Dartmouth Institute for Health Policy and Clinical Practice, United States; Primary Care Academics Transforming Healthcare Collaborative, UW Health, United States
| | - Jeffrey Grossman
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, United States; University of Wisconsin Medical Foundation, United States
| | - Nancy Pandhi
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, United States; Primary Care Academics Transforming Healthcare Collaborative, UW Health, United States.
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