A qualitative study of contextual factors' impact on measures to reduce surgery cancellations

Applying mixed methods to pilot feasibility studies to inform intervention trials

BACKGROUND

Pilot feasibility studies serve a uniquely important role in preparing for larger scale intervention trials by examining the feasibility and acceptability of interventions and the methods used to test them. Mixed methods (collecting, analyzing, and integrating quantitative and qualitative data and results) can optimize what can be learned from pilot feasibility studies to prepare rigorous intervention trials. Despite increasing use of mixed method designs in intervention trials, there is limited guidance on how to apply these approaches to address pilot feasibility study goals. The purpose of this article is to offer methodological guidance for how investigators can plan to integrate quantitative and qualitative methods within pilot feasibility studies to comprehensively address key research questions.

METHODS

We used an informal consensus-based process informed by key methodological resources and our team's complementary expertise as intervention researchers and mixed methodologists to develop guidance for applying mixed methods to optimize what can be learned from pilot feasibility studies. We developed this methodological guidance as faculty in the Mixed Methods Research Training Program (MMRTP) for the Health Sciences (R25MH104660) funded by the National Institutes of Health through the Office of Behavioral and Social Science Research.

RESULTS

We provide the following guidance for applying mixed methods to optimize pilot feasibility studies: (1) identify feasibility domain(s) that will be examined using mixed methods, (2) align quantitative and qualitative data sources for the domain(s) selected for mixing methods, (3) determine the timing of the quantitative and qualitative data collection within the flow of the pilot study, (4) plan integrative analyses using joint displays to understand feasibility, and (5) prepare to draw meta-inferences about feasibility and implications for the future trial from the integrated data.

CONCLUSIONS

By effectively integrating quantitative and qualitative data within pilot feasibility studies, investigators can harness the potential of mixed methods for developing comprehensive and nuanced understandings about feasibility. Our guidance can help researchers to consider the range of key decisions needed during intervention pilot feasibility testing to achieve a rigorous mixed methods approach generating enhanced insights to inform future intervention trials.

Protocol for an integrated evaluation framework to study training, curricular and contextual factors impacting the success of a measurement for improvement training programme for healthcare staff in Ireland

INTRODUCTION

Measurement for improvement is the process of collecting, analysing and presenting data to demonstrate whether a change has resulted in an improvement. It is also important in demonstrating sustainability of improvements through continuous measurement. This makes measurement for improvement a core element in quality improvement (QI) efforts. However, there is little to no research investigating factors that influence measurement for improvement skills in healthcare staff. This protocol paper presents an integrated evaluation framework to understand the training, curricular and contextual factors that influence the success of measurement for improvement training by using the experiences of trainees, trainers, programme and site coordinators.

METHODS AND ANALYSIS

This research will adopt a qualitative retrospective case study design based on constructivist-pragmatic philosophy. The Pressure Ulcers to Zero collaborative and the Clinical Microsystems collaborative from the Irish health system which included a measurement for improvement component have been selected for this study. This paper presents an integrated approach proposing a novel application of two pre-existing frameworks: the Model for Understanding Success in Quality framework and the Kirkpatrick Evaluation Model to evaluate an unexplored QI context and programme. A thematic analysis of the qualitative interview data and the documents collected will be conducted. The thematic analysis is based on a four-step coding framework adapted for this research study. The coding process will be conducted using NVivo V.12 software and Microsoft Excel. A cross-case comparison between the two cases will be performed.

ETHICS AND DISSEMINATION

The study has received an exemption from full ethical review from the Human Research Ethics Committee of University College Dublin, Ireland (LS-E-19-108). Informed consent will be obtained from all participants and the data will be anonymised and stored securely. The results of the study will be disseminated in peer-reviewed journals.

Contextual Factors Affecting Implementation of In-hospital Pediatric CPR Quality Improvement Interventions in a Resuscitation Collaborative

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Introduction:

Pediatric quality improvement (QI) collaboratives are multisite clinical networks that support cooperative learning. Our goal is to identify the contextual facilitators and barriers to implementing QI resuscitation interventions within a multicenter resuscitation collaborative.

Methods:

A mixed-methods evaluation of the contextual facilitators and barriers to implementation of a resuscitation QI bundle. We administered a quantitative questionnaire, the Model for Understanding Success in Quality (MUSIQ), to the Pediatric Resuscitation Quality (pediRES-Q) Collaborative. Its primary goal is to optimize the care of children who experience in-hospital cardiac arrest through a resuscitation QI bundle. We also conducted semistructured phone interviews with site primary investigators adapted from the Consolidated Framework for Implementation Research qualitative interview guide.

Results:

All 13 actively participating US sites completed the MUSIQ questionnaire. Total MUSIQ scores ranged from 86.0 to 140.5 (median of 118.7, interquartile range 103.6–124.5). Evaluation of the QI team subsection noted a mean score of 5.5 for low implementers and 6.1 for high implementers (P = 0.02). We conducted 8 interviews with the local QI team leadership. Contextual facilitators included a unified institutional approach to QI, a fail forward climate, leadership support, strong microculture, knowledge of other organizations, and prioritization of goals. Contextual barriers included low team tenure, no specific allocation of resources, lack of formalized QI training, and lack of support and buy-in by leaders and staff.

Conclusions:

Using mixed methods, we identified an association between the local QI team’s strength and the successful implementation of the QI interventions.

Quality improvement in the surgery-related processes: Managerial challenges and solutions from hospitals of Iran

BACKGROUND

There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The first step in any QI initiative is identifying the challenges and barriers to achieve such goals and then to define appropriate actions. This study aims to provide an overview of the QI challenges in Iranian hospitals' surgery-related processes and suggest applied solutions accordingly.

METHODS

This is a sequential (qual-quant) mixed-method study from November 2019 to January 2020, involving 21 face-to-face interviews with hospital managers, quality officers, and surgery-related clinicians and staff, followed by a Delphi consensus-seeking stage to finalize solutions. MAXQDA software was applied for organizing the concepts, and thematic content analysis was used for analyzing the data as an inductive approach to extract the emerging themes and sub-themes.

RESULTS

The managerial problems were classified into four groups of (I) defects and delays in completing patient medical records, (II) irregularity and the lack of transparency in the direction of processes in the hospital, (III) inappropriate and unrealistic operating scheduling, and (IV) poor safety considerations. The proposed solutions included imposing stricter regulations for competing for medical records, such as reduction of payments, development of guiding brochures or protocols for patients on their arrival, assigning a certain number of experienced nurses and surgeons for schedule management, rewarding the report of medical and surgical error cases, and developing a regular monitoring program for the proper implementation of surgical safety guidelines.

CONCLUSION

There are various managerial barriers that hamper QI in hospitals' surgery-related processes. Implementing simple but agreed solutions can lead to saving patients' lives, reduction of the unnecessary use of resources, and enhance of patient and staff satisfaction.

The influence of contextual factors on healthcare quality improvement initiatives: a realist review

BACKGROUND

Recognising the influence of context and the context-sensitive nature of quality improvement (QI) interventions is crucial to implementing effective improvements and successfully replicating them in new settings, yet context is still poorly understood. To address this challenge, it is necessary to capture generalisable knowledge, first to understand which aspects of context are most important to QI and why, and secondly, to explore how these factors can be managed to support healthcare improvement, in terms of implementing successful improvement initiatives, achieving sustainability and scaling interventions. The research question was how and why does context influence quality improvement initiatives in healthcare?

METHODS

A realist review explored the contextual conditions that influence healthcare improvement. Realist methodology integrates theoretical understanding and stakeholder input with empirical research findings. The review aimed to identify and understand the role of context during the improvement cycle, i.e. planning, implementation, sustainability and transferability; and distil new knowledge to inform the design and development of context-sensitive QI initiatives. We developed a preliminary theory of the influence of context to arrive at a conceptual and theoretical framework.

RESULTS

Thirty-five studies were included in the review, demonstrating the interaction of key contextual factors across healthcare system levels during the improvement cycle. An evidence-based explanatory theoretical model is proposed to illustrate the interaction between contextual factors, system levels (macro, meso, micro) and the stages of the improvement journey. Findings indicate that the consideration of these contextual factors would enhance the design and delivery of improvement initiatives, across a range of improvement settings.

CONCLUSIONS

This is the first realist review of context in QI and contributes to a deeper understanding of how context influences quality improvement initiatives. The distillation of key contextual factors offers the potential to inform the design and development of context-sensitive interventions to enhance improvement initiatives and address the challenge of spread and sustainability. Future research should explore the application of our conceptual model to enhance improvement-planning processes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017062135.

Contextual Factors Associated With Quality Improvement Success in a Multisite Ambulatory Setting

The Model for Understanding Success in Quality (MUSIQ) is a framework of contextual factors for quality improvement (QI) projects. We sought to determine which MUSIQ contextual factors were associated with successful QI initiatives. In a cross-sectional survey study, at a 21-site, ambulatory, urban primary care network, a modified MUSIQ survey tool questionnaire was administered to QI team members. The primary analysis associated objective measures of QI success with MUSIQ contextual factors. Objective QI success was defined as reaching goal percentages of adult patients with diabetes achieving glycated hemoglobin less than 8% and/or pediatric patients who had received combination toddler vaccines. Objective outcomes were compared with a subjective, self-reported outcome measure of QI success because previous literature found subjective outcomes were associated with specific MUSIQ factors. In the 143 survey responses collected, across 21 sites, no contextual factors from the MUSIQ survey were associated with either the adult or pediatric objective measure of QI project success. In a post hoc analysis, objective and subjective measures of success were often not associated and/or negatively correlated. In conclusion, contextual factors were not associated with objective measures of QI outcomes, in contrast to previous studies finding associations with subjective QI outcome measures.

Machine learning for identification of surgeries with high risks of cancellation

Surgery cancellations waste scarce operative resources and hinder patients' access to operative services. In this study, the Wilcoxon and chi-square tests were used for predictor selection, and three machine learning models - random forest, support vector machine, and XGBoost - were used for the identification of surgeries with high risks of cancellation. The optimal performances of the identification models were as follows: sensitivity - 0.615; specificity - 0.957; positive predictive value - 0.454; negative predictive value - 0.904; accuracy - 0.647; and area under the receiver operating characteristic curve - 0.682. Of the three models, the random forest model achieved the best performance. Thus, the effective identification of surgeries with high risks of cancellation is feasible with stable performance. Models and sampling methods significantly affect the performance of identification. This study is a new application of machine learning for the identification of surgeries with high risks of cancellation and facilitation of surgery resource management.

Incidence and root causes of delays in emergency orthopaedic procedures: a single-centre experience of 36,017 consecutive cases over seven years

Background

Emergency surgery is unplanned by definition and patients are scheduled for surgery with minimal preparation. Some patients who have sustained emergency orthopaedic trauma or other conditions must be operated on immediately or within a few hours, while others can wait until the hospital’s resources permit and/or the patients’ health status has been optimised as needed. This may affect the prioritisation procedures for both emergency and elective surgery and might result in waiting lists, not only for planned procedures but also for emergencies.

Method

The main purpose of this retrospective, observational, single-centre study was to evaluate and describe for the number and reasons of delays, as well as waiting times in emergency orthopaedic surgery using data derived from the hospital’s records and registers. All the emergency patients scheduled for emergency surgery whose procedures were rescheduled and delayed between 1 January 2007 and 31 December 2013 were studied.

Result

We found that 24% (8474) of the 36,017 patients scheduled for emergency surgeries were delayed and rescheduled at least once, some several times. Eighty per cent of these delays were due to organisational causes. Twenty-one per cent of all the delayed patients had surgery within 24 h, whilst 41% waited for more than 24 h, up to 3 days.

Conclusion

A large number of the clinic’s emergency orthopaedic procedures were rescheduled and delayed and the majority of the delays were related to organisational reasons. The results can be interpreted in two ways; first, organisational reasons are avoidable and the potential for improvement is great and, secondly and most importantly, the delays might negatively affect patient outcomes.

What are the key contextual factors when preparing for successful implementation of assistive living technology in primary elderly care? A case study from Norway

OBJECTIVE

To identify contextual factors at different organisational levels to guide the implementation of an assistive living technology intervention in Norwegian primary home care.

DESIGN

A single embedded case study design was carried out in an urban municipality in Western Norway to get an overview of key contextual factors from the municipality's perspective.

DATA COLLECTION AND ANALYSIS

The data collection was based on a triangulation of methods involving document analysis, semi-structured individual interviews and focus group interviews to get a broad insight when preparing for an intervention. Data were collected on three levels of the healthcare system: (1) national policy documents and regulations (macro), (2) five individual interviews with senior managers and municipal strategy documents (meso) and (3) two focus group interviews with nurses and nurse managers in direct patient care (micro). The Model for Understanding Success in Quality framework was used as a guide in the data analysis.

RESULTS

The main contextual factors identified were external motivators and project sponsorship (macro level); leadership, workforce focus and maturity (meso level);and motivation to change and maturity (micro level). Strategies developed in policy documents affected upper management in the municipality, but healthcare personnel at the micro level were not so familiar with strategies and emphasis on assistive living technologies. Healthcare personnel in our study were motivated to use technological solutions, but lack of data infrastructure and resource availability hindered this.

CONCLUSIONS

Aligning interests across multiple stakeholders remain a challenge when planning for an assistive living technology intervention in primary care. In the studied municipality, integration of technological solutions into healthcare services was more a vision than a reality because of a low level of organisational readiness.

The interplay of contextual elements in implementation: an ethnographic case study

Background

Contextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative.

Methods

We completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis.

Results

Key contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak.

Conclusion

Interrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.

Organizational readiness for knowledge translation in chronic care: a Delphi study

Background

Health-care organizations need to be ready prior to implement evidence-based interventions. In this study, we sought to achieve consensus on a framework to assess the readiness of health-care organizations to implement evidence-based interventions in the context of chronic care.

Methods

We conducted a web-based modified Delphi study between March and May 2013. We contacted 76 potentially eligible international experts working in the fields of organizational readiness (OR), knowledge translation (KT), and chronic care to comment upon the 76 elements resulting from our proposed conceptual map. This conceptual map was based on a systematic review of the existing frameworks of Organizational Readiness for Change (ORC) in health-care. We developed a conceptual map that proposed a set of core concepts and their associated 17 dimensions and 59 sub-dimensions. Experts rated their agreement concerning the applicability and importance of ORC elements on a 5-point Likert scale, where 1 indicates total disagreement and 5 indicates total agreement. Two rounds were needed to get a consensus from the experts. Consensus was a priori defined as strong (≥75%) or moderate (60-74%). Simple descriptive statistics was used.

Results

In total, 14 participants completed the first round and 10 completed the two rounds. Panel members reached consensus on the applicability and importance of 6 out of 17 dimensions and 28 out of 59 sub-dimensions to assess OR for KT in the context of chronic care. A strong level of consensus (≥75%) was attained on the Organizational contextual factors, Leadership/participation, Organizational support, and Motivation dimensions. The Organizational climate for change and Change content dimensions reached a moderate consensus (60-74%). Experts also reached consensus on 28 out of 59 sub-dimensions to assess OR for KT. Twenty-one sub-dimensions reached a strong consensus (≥75%) and seven a moderate consensus (60-74%).

Conclusion

This study results provided the most important and applicable dimensions and sub-dimensions for assessing OR-KT in the context of chronic care. They can be used to guide the design of an assessment tool to improve knowledge translation in the field of chronic care.