Measuring team factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

What and when to debrief: a scoping review examining interprofessional clinical debriefing

INTRODUCTION

Clinical debriefing (CD) improves teamwork and patient care. It is implemented across a range of clinical contexts, but delivery and structure are variable. Furthermore, terminology to describe CD is also inconsistent and often ambiguous. This variability and the lack of clear terminology obstructs understanding and normalisation in practice. This review seeks to examine the contextual factors relating to different CD approaches with the aim to differentiate them to align with the needs of different clinical contexts.

METHODS

Articles describing CD were extracted from Medline, CINAHL, ERIC, PubMed, PsychINFO and Academic Search Complete. Empirical studies describing CD that involved two or more professions were eligible for inclusion. Included papers were charted and analysed using the Who-What-When-Where-Why-How model to examine contextual factors which were then used to develop categories of CD. Factors relating to what prompted debriefing and when debriefing occurred were used to differentiate CD approaches.

RESULTS

Forty-six papers were identified. CD was identified as either prompted or routine, and within these overarching categories debriefing was further differentiated by the timing of the debrief. Prompted CD was either immediate or delayed and routine CD was postoperative or end of shift. Some contextual factors were unique to each category while others were relatively heterogeneous. These categories help clarify the alignment between the context and the intention of CD.

CONCLUSIONS

The proposed categories offer a practical way to examine and discuss CD which may inform decisions about implementation. By differentiating CD according to relevant contextual factors, these categories may reduce confusion which currently hinders discourse and implementation. The findings from this review promote context-specific language and a shift away from conceptions of CD that embody a one-size-fits-all approach.

Perceptions of interprofessional team collaboration among professionals working in the occupational health service in Sweden

OBJECTIVES

Interprofessional collaboration (IPC) among professionals in occupational health (OH) services is crucial when rendering a service to clients and customers. The aim of this study was to describe and compare perceptions relating to IPC among professionals working as OH providers in Sweden.

METHODS

This cross-sectional study with a descriptive and comparative design included 456 respondents representing different OH professions in Sweden. Data were collected using the Swedish short version of the Assessment of Interprofessional Team Collaboration Scale adapted for OH ([AITCS]-SII[OH]), with its 3 subscales Partnership, Cooperation, and Coordination, and were analyzed and presented descriptively. Items and sum scores were dichotomized into inadequate and adequate and compared between sexes, workplaces, types of employment, and professions.

RESULTS

According to the responses, items related to openness, honesty, and trust were perceived as adequate among the respondents. The findings show that perceptions about IPC differed among the professions. The perception of IPC also differed between different types of organizations.

CONCLUSIONS

The results show diverse perceptions between professionals and organizations. The perception of IPC may be influenced by the professional's education in occupational safety and health. Study findings may be used to support further development of IPC in the OH service for the benefit of the clients. To develop IPC in the best interests of both professionals and customers/clients, further studies need to be performed to gain a deeper understanding of IPC in the OH context.

Recommendations for creating a collaborative NICU environment to support teamwork and trainee education

In a 2022 survey, a majority of neonatology program directors reported regular conflict between neonatal-perinatal fellows and frontline providers (FLPs) (i.e., neonatal nurse practitioners (NNPs), neonatal physician assistants (PAs), and neonatal hospitalists). This paper reviews recommendations of a multidisciplinary workgroup for creating a more collaborative unit environment that supports teamwork and education. The self-study framework is a helpful tool to identify specific pressure points at individual institutions. Implementing clear guidelines for procedural distribution and role clarification are often critical interventions. FLPs and Pediatric Physician Trainees may benefit from conflict management coaching and communication training. At the same time, we recommend that respective leaders support a psychologically safe environment for team members to feel safe to solve problems on their own. Going forward, more work is important to optimize teamwork in the setting of anticipated staffing shortages, limitations to resident neonatology exposure, changes in training requirements, and ongoing development of the FLP role.

Talent management and job satisfaction of medical personnel in Polish healthcare entities

Background

There is a mass exodus of qualified medical personnel in countries such as Poland. As a result, it is becoming increasingly important to study the satisfaction of medical personnel employed in public healthcare entities and the factors influencing this satisfaction. One such factor is the quality of talent management.

Purpose

The study aimed to assess the quality of talent management in Polish healthcare entities and its impact on the job satisfaction of medical personnel. The study also considered the impact of other demographic, organizational and behavioral factors on medical personnel satisfaction, such as social competencies, job mobility, orientation toward the patient, gender and education stage.

Methods

A questionnaire for healthcare professionals was used to collect data. A total of 747 respondents (506 defined as medical talent) participated in the survey. A 5-point Likert scale was adopted to assess job satisfaction and talent management practices. Reliability analysis was conducted to investigate the properties of this scale and the items that comprise it. The data was analyzed using descriptive statistics and structural equation modeling.

Results

The survey showed that the quality of talent management in Polish healthcare institutions is not well assessed. Professional satisfaction of medical personnel working in Polish public healthcare entities depends mainly on talent management measured by talent motivation, talent development, employee appraisal and organizational culture. Among the factors that have a positive but smaller impact on job satisfaction are job mobility and the education stage. The impact of gender, patient orientation and social competence had the smallest but most significant impact on job satisfaction.

Conclusion

Healthcare organizations should improve their talent management strategy to meet healthcare professionals' current and future demands and improve their job satisfaction.

COVID-19 and unintended steps towards further equity in global health research

There was, and possibly still is, potential for COVID-19 to disrupt power inequities and contribute to positive transformation in global health research that increases equity. While there is consensus about the need to decolonise by transforming global health, and a roadmap outlining how we could approach it, there are few examples of steps that could be taken to transform the mechanics of global health research. This paper contributes lessons learnt from experiences and reflections of our diverse multinational team of researchers involved in a multicountry research project. We demonstrate the positive impact on our research project of making further steps towards improving equity within our research practices. Some of the approaches adopted include redistributing power to researchers from the countries of interest at various stages in their career, by involving the whole team in decisions about the research; meaningfully involving the whole team in research data analysis; and providing opportunities for all researchers from the countries of interest to voice their perspectives as first authors in publications. Although this approach is consistent with how research guidance suggests research should be run, in reality it does not often happen in this way. The authors of this paper hope that by sharing our experience, we can contribute towards discussions about the processes required to continue developing a global health sector that is equitable and inclusive.

Impact of externally facilitated continuous quality improvement cohorts on Advanced Access to support primary healthcare teams: protocol for a quasi-randomized cluster trial

BACKGROUND

Improving access to primary health care is among top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results. The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes.

METHODS

Cluster-controlled trial allowing for a comprehensive and rigorous evaluation of the proposed intervention 48 multidisciplinary primary care clinics will be recruited to participate. 24 Clinics from the intervention regions will receive the CQI intervention for 18 months including three activities carried out iteratively until the clinic's improvement objectives are achieved: 1) reflective sessions and problem priorisation; 2) plan-do-study-act cycles; and 3) group mentoring. Clinics located in the control regions will receive an audit-feedback report on access. Complementary qualitative and quantitative data reflecting the quintuple aim will be collected over a period of 36 months.

RESULTS

This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients' experiences of care.

CONCLUSION

This mixed-method approach offers a unique opportunity to contribute to the scientific literature on large-scale CQI cohorts to improve AA in primary care teams and to better understand the processes of CQI.

TRIAL REGISTRATION

Clinical Trials: NCT05715151.

Development of a small and sick newborn clinical audit tool and its implementation guide using a human-centred design approach newborn clinical audit process and design

Clinical audits are an important intervention that enables health workers to reflect on their practice and identify and act on modifiable gaps in the care provided. To effectively audit the quality of care provided to the small and sick newborns, the clinical audit process must use a structured tool that comprehensively covers the continuum of newborn care from immediately after birth to the period of newborn unit care. The objective of the study was to co-design a newborn clinical audit tool that considered the key principles of a Human Centred Design approach. A three-step Human Centred Design approach was used that began by (1) understanding the context, the users and the available audit tools through literature, focus group discussions and a consensus meeting that was used to develop a prototype audit tool and its implementation guide, (2) the prototype audit tool was taken through several cycles of reviewing with users on real cases in a high volume newborn unit and refining it based on their feedback, and (3) the final prototype tool and the implementation guide were then tested in two high volume newborn units to determine their usability. Several cycles of evaluation and redesigning of the prototype audit tool revealed that the users preferred a comprehensive tool that catered to human factors such as reduced free text for ease of filling, length of the tool, and aesthetics. Identified facilitators and barriers influencing the newborn clinical audit in Kenyan public hospitals informed the design of an implementation guide that builds on the strengths and overcomes the barriers. We adopted a Human Centred Design approach to developing a newborn clinical audit tool and an implementation guide that we believe are comprehensive and consider the characteristics of the context of use and the user requirements.

Understanding how and why quality circles improve standards of practice, enhance professional development and increase psychological well-being of general practitioners: a realist synthesis

OBJECTIVES

To understand how and why participation in quality circles (QCs) improves general practitioners' (GPs) psychological well-being and the quality of their clinical practice. To provide evidence-informed and practical guidance to maintain QCs at local and policy levels.

DESIGN

A theory-driven mixed method.

SETTING

Primary healthcare.

METHOD

We collected data in four stages to develop and refine the programme theory of QCs: (1) coinquiry with Swiss and European expert stakeholders to develop a preliminary programme theory; (2) realist review with systematic searches in MEDLINE, Embase, PsycINFO and CINHAL (1980-2020) to inform the preliminary programme theory; (3) programme refinement through interviews with participants, facilitators, tutors and managers of QCs and (4) consolidation of theory through interviews with QC experts across Europe and examining existing theories.

SOURCES OF DATA

The coinquiry comprised 4 interviews and 3 focus groups with 50 European experts. From the literature search, we included 108 papers to develop the literature-based programme theory. In stage 3, we used data from 40 participants gathered in 6 interviews and 2 focus groups to refine the programme theory. In stage 4, five interviewees from different healthcare systems consolidated our programme theory.

RESULT

Requirements for successful QCs are governmental trust in GPs' abilities to deliver quality improvement, training, access to educational material and performance data, protected time and financial resources. Group dynamics strongly influence success; facilitators should ensure participants exchange knowledge and generate new concepts in a safe environment. Peer interaction promotes professional development and psychological well-being. With repetition, participants gain confidence to put their new concepts into practice.

CONCLUSION

With expert facilitation, clinical review and practice opportunities, QCs can improve the quality of standard practice, enhance professional development and increase psychological well-being in the context of adequate professional and administrative support.

PROSPERO REGISTRATION NUMBER

CRD42013004826.

Facilitators and barriers for the implementation of exercise are medicine in routine clinical care in Dutch university medical centres: a mixed methodology study on clinicians' perceptions

OBJECTIVES

Despite the many proven advantages of a physically active lifestyle in patient populations, prescription of exercise is currently not widely implemented in routine clinical practice. The aims of this study were twofold: (1) to assess perceptions of clinicians on the current practice of exercise is medicine (E=M) prescription in two Dutch university medical centres and (2) to determine their perceived barriers and facilitators for the implementation of E=M in routine clinical care in Dutch university medical centres.

DESIGN

A mixed methodologies study, using both online questionnaires and semi-structured interviews.

SETTING

Dutch university medical centres.

PARTICIPANTS

Clinicians working within the departments of medical oncology, orthopaedics and rehabilitation medicine of two university medical centres.

RESULTS

Forty-five clinicians (response rate of 51%) completed the questionnaire, and 19 clinicians were interviewed. The results showed that even though clinicians had a positive attitude towards prescribing E=M, only a few reported to regularly prescribe E=M to their patients. The 52 identified facilitators and barriers for implementation of E=M were categorised into four main themes: (1) beliefs toward the implementation of E=M (eg, clinicians knowledge and skills, and social support), (2) factors related to the patient perspective (eg, patient priorities or motivation), (3) factors related to the referral options (eg, knowledge of and trust in local referral options) and (4) practical considerations when implementing E=M (eg, time constraints).

CONCLUSIONS

Our study showed that even though many clinicians have a positive attitude toward an active lifestyle, many are not prescribing E=M on a regular basis. In order for clinicians to effectively implement E=M, strategies should focus on increasing clinicians E=M referral skills, improving clinicians knowledge of E=M referral options and develop a support system to ensure that E=M is high on the priority list of clinicians.

Investigation of the critical factors required to improve the disclosure and discussion of harm with affected women and families: a study protocol for a qualitative, realist study in NHS maternity services (the DISCERN study)

Patients and families are entitled to an open disclosure and discussion of healthcare incidents affecting them. This reduces distress and contributes to learning for safety improvement. Complex barriers prevent effective disclosure and continue in the English NHS, despite a legal duty of candour. NHS maternity services are the focus of significant efforts to improve this. There is limited understanding of how, and to what effect, they are achieving this. METHODS AND ANALYSIS: A 27-month, three-phased realist evaluation identifying the critical factors contributing to improvements in the disclosure and discussion of incidents with affected families. The evaluation asks 'what works, for whom, in what circumstances, in why respects and why?'.Phase 1: establish working hypotheses of key factors and outcomes of interventions improving disclosure and discussion, by realist literature review and in-depth realist interviews with key stakeholders (n=approximately 20]Phase 2: refine or overturn hypotheses, by ethnographic case-study analysis using triangulated qualitative methods (non-participant observation, interviews (n=12) and documentary analysis) in up to 4 purposively sampled NHS trusts.Phase 3: consider hypotheses and design outputs during seven interpretive forums. ETHICS AND DISSEMINATION: Phase 1 study approval by King's College London's Ethics Panel (BDMRESC 22033) and National Research Ethical Approval for Phases 2-3 (IRASID:262197) (CAG:20/CAG/0121) (REC:20/LO/1152). Study sponsorship by King's College London (HS&DR 17/99/85).Findings to be disseminated through tailored management briefings; clinician and family guidance (written and video); lay summaries, academic papers, and report with outputs tailored to maximise academic and societal impact. Views of women/family groups are represented throughout.

State of science: models and methods for understanding and enhancing teams and teamwork in complex sociotechnical systems

This state of the science review brings together the disparate literature of effective strategies for enhancing and accelerating team performance. The review evaluates and synthesises models and proposes recommended avenues for future research. The two major models of the Input-Mediator-Output-Input (IMOI) framework and the Big Five dimensions of teamwork were reviewed and both will need significant development for application to future teams comprising non-human agents. Research suggests that a multi-method approach is appropriate for team measurements, such as the integration of methods from self-report, observer ratings, event-based measurement and automated recordings. Simulations are recommended as the most effective team-based training interventions. The impact of new technology and autonomous agents is discussed with respect to the changing nature of teamwork. In particular, whether existing teamwork models and measures are suitable to support the design, operation and evaluation of human-nonhuman teams of the future. Practitioner summary: This review recommends a multi-method approach to the measurement and evaluation of teamwork. Team models will need to be adapted to describe interaction with non-human agents, which is what the future is most likely to hold. The most effective team training interventions use simulation-based approaches.

Adaptation and psychometric evaluation of the Swedish version of the Assessment of Inter professional Team Collaboration Scale (AITCS-S) for use in occupational health services

Interprofessional team collaboration (ITC) in the Swedish Occupational Health Service is an important part of the service given to the customer. The Occupational Health Service (OHS) could be more competitive if they were able to show how successful is their ITC. The Assessment of Interprofessional Team Collaboration Scale (AITCS) is an instrument that measures ITC in teams working with the client as part of the team. The aim of this study was to adapt the Swedish version of the instrument for use in OHS and to evaluate the psychometric properties of the adapted version and the adapted short version. The study included 472 participants from different OHSs, all members of the trade association of occupational health care in Sweden. Face and content validity of the instrument were assessed, and floor and ceiling effects were measured. Internal consistency was measured with Cronbach's alpha and an exploratory factor analysis was conducted on the 42-item adapted instrument and the short, 24-item version. The exploratory factor analysis gave a three-factor solution with an eigenvalue >1 and explaining a total variance of 57.1% and 62.3% for the short version. The study concludes that AITCS-S-(OHS) as well as the short version, is a reliable and valid questionnaire. Further development of the AITCS-S-(OHS) needs to be undertaken and assessed by confirmatory factor analysis.

Organizational contextual factors that predict success of a quality improvement collaborative approach to enhance integrated HIV-tuberculosis services: a sub-study of the Scaling up TB/HIV Integration trial

Background

A quality improvement (QI) collaborative approach to enhancing integrated HIV-Tuberculosis (TB) services may be effective in scaling up and improving the quality of service delivery. Little is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives. This study aims to determine which OCFs were associated with improvement in a QI collaborative intervention to enhance integrated HIV-TB services delivery.

Methods

This is a nested sub-study embedded in a cluster-randomized controlled trial. Sixteen nurse supervisors (clusters) overseeing 40 clinics were randomized (1:1) to receive QI training and mentorship, or standard of care support (SOC). In the QI arm, eight nurse supervisors and 20 clinics formed a “collaborative” which aimed to improve HIV-TB process indicators, namely HIV testing, TB screening, isoniazid preventive therapy (IPT) initiations, viral load testing, and antiretroviral therapy for TB patients. OCFs measured at baseline were physical infrastructure, key staff, flexibility of clinic hours, monitoring data for improvement (MDI), and leadership support. Surveys were administered to clinic staff at baseline and month 12 to assess perceptions of supportiveness of contexts for change, and clinic organization for delivering integrated HIV-TB services. Linear mixed modelling was used to test for associations between OCFs and HIV-TB process indicators.

Results

A total of 209 clinic staff participated in the study; 97 (46.4%) and 112 (53.6%) from QI and SOC arms, respectively. There were no differences between the QI and SOC arms scores achieved for physical infrastructure (78.9% vs 64.7%; p = 0.058), key staff (95.8 vs 92; p = 0.270), clinic hours (66.9 vs 65.5; p = 0.900), MDI (63.3 vs 65; p = 0.875, leadership support (46.0 vs 57.4; p = 0.265), and perceptions of supportiveness of contexts for change (76.2 vs 79.7; p = 0.128 and clinic organization for delivering integrated HIV-TB services (74.1 vs 80.1; p = 0.916). IPT initiation was the only indicator that was significantly improved in the parent study. MDI was a significantly associated with increasing IPT initiation rates [beta coefficient (β) = 0.004; p = 0.004].

Discussion

MDI is a practice that should be fostered in public health facilities to increase the likelihood of success of future QI collaboratives to improve HIV-TB service delivery.

Trial registration

Clinicaltrials.gov, NCT02654613. Registered 01 June 2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01155-7.

Communication in interprofessional rehabilitation teams: a scoping review

PURPOSE

Effective communication in interprofessional rehabilitation teams is essential for optimal patient care. Despite the established importance, it remains unclear how interprofessional communication (IPC) within teams contributes to rehabilitation service delivery. The aim of this scoping review was to investigate how IPC has been described in rehabilitation literature.

METHODS

Databases (Medline, CINAHL, ERIC, Embase, PsychInfo, and Academic Search Complete) were searched for studies including rehabilitation interprofessional communication. Inclusion and exclusion criteria were identified and applied, data were charted, and thematic analysis conducted.

RESULTS

Twenty-nine papers were identified, and analysis revealed interrelated themes: communication processes, and inputs and effects. Formal communication processes were most prevalent, portraying variability in professional participation and a lack of patient involvement in dialogue and decision making. Inputs and effects were described at an organisational, team and individual level, highlighting the importance of communication throughout the healthcare hierarchy.

CONCLUSIONS

IPC in rehabilitation is central to effective team function and patient care. To further our understanding, empirical studies examining everyday informal IPC, as well as formal ritualised encounters are needed. Additionally, conceptualisations of IPC would benefit from including the patients' perspective and by using theoretical framing to attend to places, spaces, and artefacts identified in this review.

Perspectives and experiences of Chinese nurses on quality improvement initiatives: A mixed-methods study

AIM

To investigate Chinese nurses' views and experiences in relation to quality improvement implementation, as well as to determine the impact of contextual factors on nursing quality improvement initiatives.

BACKGROUND

Nurses play a major role in carrying out quality improvement initiatives. Contextual factors influence the implementation and success of quality improvement initiatives. Studies that investigated the impact of contextual factors on Chinese nurses' practice in quality improvement remain limited.

METHODS

A sequential explanatory mixed-methods design was used for this study. A quantitative cross-sectional survey was used to assess the context of quality improvement initiatives. Simple random sampling was used to recruit quality improvement teams. The sample included 356 nurses from tertiary teaching hospitals; 291 (81.7%) of them completed questionnaires. Nursing managers and nurses (n = 18) were purposively selected to participate in semi-structured interviews; their experiences and perceptions regarding the contextual factors of quality improvement initiatives were obtained.

RESULTS

In the quantitative phase, the "microsystem" (mean=5.24) and "QI team" (mean = 4.97) contexts were reported as supportive contexts. The organizational context was weak, with a mean score of 3.92. In the qualitative phase, three themes related to the contextual challenges emerged: (1) nurses' attitudes and satisfaction, (2) team efficacy, and (3) organizational infrastructure and culture.

CONCLUSIONS

Efforts to elevate organizational culture and reward systems are needed in Chinese hospitals. Further education aimed at increasing skills and knowledge should be provided, to ensure effective quality improvement implementation.

IMPLICATIONS FOR NURSING MANAGEMENT

During quality improvement initiatives, management tasks should focus on increasing nurses' satisfaction, solving skill and knowledge deficits, and clarifying nurses' roles in relation to quality improvement.

Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care

BACKGROUND

The delivery of emergency, trauma, critical, and intensive care services requires coordination among all members of the care team. Perceived teamwork and role clarity may vary among physicians (MDs) and nurse practitioners (NPs).

PURPOSE

To examine differences in perceived roles and responsibilities of NPs and MDs practicing in emergency, trauma, critical, and intensive care.

METHODS

Secondary Analysis of the National Survey of Emergency, Intensive, and Critical Care Nurse Practitioners and Physicians, a cross-sectional national survey of clinicians. Mail survey of randomly selected stratified cross-sectional samples of MDs and NPs drawn from national lists of clinicians in eligible specialties working in emergency, trauma, intensive, and critical care units in the United States. 814 clinicians (351 NPs and 463 MDs) were recruited from national by postal mail survey. Our initial sample included n = 2,063 clinicians, n = 1,031 NPs and n = 1,032 MDs in eligible specialties. Of these, 63.5% of NPs and 70.1% of MDs completed and returned the survey excluding those who were ineligible due to lack of current practice in a relevant specialty.

FINDINGS

NPs in ICU/CCU are more likely to be female and report working fewer hours than do MDs and provide direct care to more patients. 55% of NPs and 82% of MDs agree that their individual role in their unit is clear (p < .001); 34% of MDs and 42% of NPs agree that their unit is an example of excellent team work among professionals (p = 0.021); 41% of MD and 37% of NP clinicians (p = 0.061) agree that their teams are "prepared to provide outstanding care in a crisis or disaster." Perceived role clarity was significantly associated with increased perceptions of excellent teamwork and disaster preparedness.

DISCUSSION

At the time of this survey, and majority of NPs and MDs working in emergency, critical and intensive care did not agree that their teams were prepared for a crisis or disaster. Leaders of health organizations should encourage teamwork and professional role clarity to assist units to perform effectively in emergency and disaster preparedness.

Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol

BACKGROUND

Chronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD) are common and burdensome diseases primarily managed in primary care. Yet, evidence points to suboptimal quality of care for these conditions in primary care settings. Quality improvement collaboratives (QICs) are organized, multifaceted interventions that can be effective in improving chronic disease care processes and outcomes. In Quebec, Canada, the Institut national d'excellence en santé et en services sociaux (INESSS) has developed a large-scale QIC province-wide program called COMPAS+ that aims to improve the prevention and management of chronic diseases in primary care. This paper describes the protocol for our study, which aims to evaluate implementation and impact of COMPAS+ QICs on the prevention and management of targeted chronic diseases like diabetes and COPD.

METHODS

This is a mixed-methods, integrated knowledge translation study. The quantitative component involves a controlled interrupted time series involving nine large integrated health centres in the province. Study sites will receive one of two interventions: the multifaceted COMPAS+ intervention (experimental condition) or a feedback only intervention (control condition). For the qualitative component, a multiple case study approach will be used to achieve an in-depth understanding of individual, team, organizational and contextual factors influencing implementation and effectiveness of the COMPAS+ QICs.

DISCUSSION

COMPAS+ is a QI program that is unique in Canada due to its integration within the governance of the Quebec healthcare system and its capacity to reach many primary care providers and people living with chronic diseases across the province. We anticipate that this study will address several important gaps in knowledge related to large-scale QIC projects and generate strong and useful evidence (e.g., on leadership, organizational capacity, patient involvement, and implementation) having the potential to influence the design and optimisation of future QICs in Canada and internationally.

Psychometrics properties of the Team Interaction Scale and influencing factors of team interaction of tertiary hospital physicians in China: a cross-sectional study

OBJECTIVES

To administer a cross-cultural adaptation of the Team Interaction Scale (TIS), test its psychometric properties and investigate influencing factors of team interactions in a physician population in Chinese tertiary hospitals.

DESIGN

Cross-sectional survey.

SETTINGS

Two rounds of surveys, a pilot and a large sampling survey, were conducted in two and nine tertiary hospitals, respectively, in Liaoning Province, China.

PARTICIPANTS

In the pilot survey, 363 of 390 physicians sampled were included in the analysis, resulting in an effective response rate of 93.08%. In the large sampling survey, the effective response rate was 89.10% (3653 of 4100 physicians).

OUTCOME MEASURES

The TIS and a short version of a burn-out scale were administrated to assess the physician's team interaction and burn-out. Psychometric properties of TIS were tested by confirmatory factor analysis (CFA), exploratory factor analysis (EFA) and internal consistency analysis. Gender, age, discipline, education level, professional title, hospital scale and burn-out were explored as influencing factors with independent sample t-tests, one-way analyses of variance and a correlation analysis.

RESULTS

Based on CFA, a 17-item modified scale was developed following the pilot survey. In the large sampling survey, EFA was conducted with half of the samples, producing six dimensions: 'Communication', 'Coordination', 'Mutual help', 'Team goals', 'Work norms' and 'Cohesion and conflict resolution'. Fit of the modified model was confirmed by CFA with the other half of the samples (root mean square error of approximation=0.067, Comparative Fit Index=0.98, Normed Fit Index=0.97, Goodness of Fit Index=0.94, Adjusted Goodness of Fit Index=0.92). A high Cronbach's α coefficient of 0.98 demonstrated reliability of the modified scale. The Team Interaction Score was significantly lower in younger physicians, in men, in paediatricians and in physicians from larger-scale tertiary hospitals. Team Interaction Scores were negatively associated with burn-out.

CONCLUSIONS

The adapted TIS, containing 17 items and six dimensions, was reliable and valid for Chinese tertiary hospital physicians. To address physician burn-out, team interaction should be highlighted.

Evaluation of the elements of interprofessional education for end-of-life care among homecare nurses, care managers, and head care workers: A cluster-randomized controlled trial

Our group developed an interprofessional education (IPE) program for home-based end-of-life (EOL) care among health and welfare professionals, with the purpose of understanding professional roles in EOL care and promoting mutual respect among team members. This study aimed to verify the understanding and awareness of the elements of IPE. Seven districts in a city in Japan were cluster-randomized into an education group or a control group. A questionnaire survey using original items to evaluate two purposes of the IPE program was conducted before the IPE workshop and seven months later. In total, 291 professionals participated in the study: 64 homecare nurses, 129 care managers, and 98 head care workers. Care managers and care workers in the education group significantly understood their own and other professional roles in EOL care (p= .01, p < .0001, respectively) and gained confidence in collaboration among health and welfare professionals (p = .02, p < .0001, respectively). Care workers in the education group felt respect for team members (p = .02). For homecare nurses, no significant effects were observed. The IPE was more effective for welfare professionals who had difficulty cooperating in end-of-life care.

The role of psychological safety and learning behavior in the development of effective quality improvement teams in Ghana: an observational study

BACKGROUND

As lower-income countries look to develop a mature healthcare workforce and to improve quality and reduce costs, they are increasingly turning to quality improvement (QI), a widely-used strategy in higher-income countries. Although QI is an effective strategy for promoting evidence-based practices, QI interventions often fail to deliver desired results. This failure may reflect a problem with implementation. As the key implementing unit of QI, teams are critical for the success or failure of QI efforts. Thus, we used the model of work-team learning to identify factors related to the effectiveness of newly-formed hospital-based QI teams in Ghana.

METHODS

This was a cross-sectional, observational study. We used structural equation modeling to estimate relationships between coaching-oriented team leadership, perceived support for teamwork, team psychological safety, team learning behavior, and QI implementation. We used an observer-rated measure of QI implementation, our outcome of interest. Team-level factors were measured using aggregated survey data from 490 QI team members, resulting in a sample size of 122 teams. We assessed model fit and tested significance of standardized parameters, including direct and indirect effects.

RESULTS

Learning behavior mediated a positive relationship between psychological safety and QI implementation (β = 0.171, p = 0.001). Psychological safety mediated a positive relationship between team leadership and learning behavior (β = 0.384, p = 0.068). Perceived support for teamwork did not have a significant effect on psychological safety or learning behavior.

CONCLUSIONS

Psychological safety and learning behavior are key for the success of newly formed QI teams working in lower-income countries. Organizational leaders and implementation facilitators should consider these leverage points as they work to establish an environment where QI and other team-based activities are supported and encouraged.

Multidisciplinary work promotes preventive medicine and health education in primary care: a cross-sectional survey

Background

Preventive medicine and health education are among the strategies used in coping with chronic diseases. However, it is yet to be determined what effect do personal and organizational aspects have on its’ implementation in primary care.

Methods

A cross-sectional survey was conducted in order to assess and compare preventive medicine and health education activities in three types of primary care models: solo working independent physicians, nurse-physician collaborations and teamwork (nurses, dietitians and social workers working alongside a physician). Questionnaires were emailed to 1203 health professionals between September and November 2015, working at Maccabi Healthcare Services, the second largest Israeli healthcare organization.

Self-reported rates of health education groups conducted, proactive appointments scheduling and self-empowerment techniques use during routine appointments, were compared among the three models. Independent variables included clinic size as well as health professionals’ occupation, health behaviors and training.

A series of multivariate linear regressions were performed in order to identify predictors of preventive medicine and health education implementation.

Computerized health records (CHR) validated our self-report data through data regarding patients’ health behaviours and outcomes, including health education group registration, adherence to occult blood tests and influenza vaccinations as well as blood lipid levels.

Results

Responders included physicians, nurses, dietitians and social workers working at 921 clinics (n = 516, response rate = 31%).

Higher rates of proactive appointments scheduling and health education groups were found in the Teamwork and Collaboration models, compared to the Independent Physician Model. Occupation (nurses and dietitians), group facilitation training and personal screening adherence were identified as preventive medicine and health education implementation predictors.

Group registration, occult blood tests, healthy population’s well-controlled blood lipids as well as influenza vaccinations among chronically ill patients were all significantly higher in the Teamwork and Collaboration models, compared to the Independent Physician Model.

Conclusions

The Teamwork and Collaboration models presented higher rates of preventive medicine and health education implementation as well as higher rates of patients’ positive health behaviours documented in these models.

This suggests multidisciplinary primary care models may contribute to population’s health by enhancing preventive medicine and health education implementation alongside health professionals’ characteristics.

What Influences Sustainment and Nonsustainment of Facilitation Activities in Implementation? Analysis of Organizational Factors in Hospitals Implementing TeamSTEPPS

Implementation processes are often long and complex, requiring sustained facilitation efforts. Drawing on organizational and implementation literature, we examined the influence of senior management support (SMS), middle management support (MMS), facilitator team time availability (TIME) and team continuity (CONTINUITY) on sustainment of internal facilitation activities. For 2 years, we followed 10 small rural hospitals implementing TeamSTEPPS, a patient safety program, and conducted quarterly interviews with key informants. We coded, calibrated, and analyzed the data using the fuzzy-set qualitative comparative analysis. We found that five hospitals sustained facilitation activities and the combination of SMS, MMS, and CONTINUITY (i.e., presence of all three factors) was a sufficient condition for sustainment. Five other hospitals did not sustain facilitation activities and they either lacked MMS or lacked both TIME and CONTINUITY. In follow-up analyses, we found that team leadership continuity also influenced sustainment patterns. We discussed the implications for research and practice.

Contextual factors that influence quality improvement implementation in primary care: The role of organizations, teams, and individuals

BACKGROUND

Recent emphasis on value-based health care has highlighted the importance of quality improvement (QI) in primary care settings. QI efforts, which require providers and staff to work in cross-functional teams, may be implemented with varying levels of success, with implementation being affected by factors at the organizational, teamwork, and individual levels.

PURPOSE

The purpose of our study was to (a) identify contextual factors (organizational, teamwork, and individual) that affect implementation effectiveness of QI interventions in primary care settings and (b) compare perspectives about these factors across roles (health care administrators, physician and nonphysician clinicians, and administrative staff).

METHODS/APPROACH

We conducted semistructured interviews with 24 health care administrators, physician and nonphysician primary care providers, and administrative staff representing 10 primary care practices affiliated with one integrated delivery system.

RESULTS

Participants across all roles identified similar organizational- and team-level factors that influence QI implementation including organizational capacity to take on new initiatives (e.g., time availability of physicians), technical capability for QI (e.g., data analysis skills), and team climate (e.g., how well staff work together). There was greater variation in terms of individual-level factors, particularly perceived meaning and purpose of QI. Perceptions about value of QI ranged from positive impacts on patient care and practice competitiveness to decreased efficiency and distractions from patient care, but differences did not appear attributable to role.

CONCLUSIONS

Successful QI implementation requires effective collaboration within cross-functional teams. Additional research is needed to assess how best to employ implementation strategies that promote cross-understanding of QI among team members and, ultimately, effective implementation of QI programs.

PRACTICE IMPLICATIONS

Health care managers in primary care settings should strive to create a strong teamwork climate, reinforced by opportunities for staff in various roles to discuss QI as a collective.

Healthcare Providers' Perceptions of Single-Room Versus Traditional Maternity Models: A Concurrent Mixed-Methods Study

While many hospitals have transitioned from traditional maternity care to a single-room maternity model, little is known about how healthcare providers' practice differs between the models. This mixed-methods study compared healthcare providers' job satisfaction and team collaboration between traditional and single-room maternity care and explored how each model shaped providers' practice. Data were collected via questionnaires and interviews with healthcare providers from 2 hospitals. Independent t tests, Mann-Whitney U tests, and thematic analysis were used in analysis; findings were then triangulated. No difference was found in team collaboration and job satisfaction scores between single-room (n = 84) and traditional (n = 42) maternity care; however, providers described different means toward satisfaction and collaboration in the interviews (n = 18). Single-room maternity care providers valued interprofessional teamwork, patient/family involvement, and continuity of care. Traditional maternity care providers enjoyed specialization but described teamwork as uniprofessional and disconnected across professions; transfers between units weakened communication and fragmented care. While single-room maternity care providers described less tension and a more holistic patient-family journey, further research must be undertaken to examine whether and how interprofessional collaboration and communication impact patient and health system outcomes.

Importance of Team Functioning as a Target of Quality Improvement Initiatives in Nursing Homes: A Qualitative Process Evaluation

INTRODUCTION

Quality improvement interventions demonstrate variable degrees of effectiveness. The aim of this work was to (1) qualitatively explore whether, how, and why an academic detailing intervention could improve evidence uptake and (2) identify perceived changes that occurred to inform outcomes appropriate for quantitative evaluation.

METHODS

A qualitative process evaluation was conducted involving semistructured interviews with nursing home staff. Interviews were analyzed inductively using the framework method.

RESULTS

A total of 29 interviews were conducted across 13 nursing homes. Standard processes to reduce falls are well-known but not fully implemented due to a range of mostly postintentional factors that influence staff behavior. Conflicting expectations around professional roles impeded evidence uptake; physicians report a disconnection between the information they would like to receive and the information communicated; and a high proportion of casual and part-time staff creates challenges for those looking to effect change. These factors are amenable to change in the context of an active, tailored intervention such as academic detailing. This seems especially true when the entire care team is actively engaged and when the intervention can be tailored to the varied determinants of behaviors across different team members.

DISCUSSION

Interventions aiming to increase evidence-based practice in the nursing home sector need to move beyond education to explicitly address team functioning and communication. Variability in team functioning requires a flexible intervention with the ability to tailor to individual- and home-level needs. Evaluations in this setting may benefit from measuring changes in team functioning as an early indicator of success.

Primary care networks and team effectiveness: the case of a large-scale quality improvement disparity reduction program

Documentation of primary care teams' involvement in disparity reduction efforts exists, yet little is known about how teams interact or perceive their effectiveness. We investigated how the social network and structural ties among primary-care-clinic team members relate to their perceived team effectiveness (TE), in a large-scale disparity reduction intervention in Israel's largest insurer and provider of services. A mixed-method design of Social Network Analysis and qualitative data collection was employed. 108 interviews with medical, nursing, and administrative teams of 26 clinics and their respective managerial units were performed and information on the organizational ties, analyzing density and centrality, collected. Pearson correlations examined association between network measures and perceived TE. Clinics with strong intra-clinic density and high clinic-subregional-management density were positively correlated with perceived TE. Clinic in-degree centrality was also positively associated with perceived TE. Qualitative analyses support these findings with teamwork emerging as a factor which can impede or facilitate teams' ability to design and implement disparity reduction interventions. The study demonstrates that in an organization-wide disparity reduction initiative, cohesive intra-network structure and close relations with mid-level management increase the likelihood that teams perceive themselves as possessing the skills and resources needed to lead and implement disparity reduction efforts. List of abbreviations Team Effectiveness (TE); Clalit Health Services (Clalit); Social Network Analysis (SNA); Quality Improvement (QI); National Health Care Collaborative (NHPC); Tampa Bay Community Cancer Network (TBCCN).

Leadership experiences and practices of South African health managers: what is the influence of gender? -a qualitative, exploratory study

BACKGROUND

The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women's full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being 'left behind' in terms of career development and progression into senior health leadership positions.

METHODS

Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments.

RESULTS

Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the 'first' to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture.

CONCLUSION

This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play.

Interprofessional collaboration and patient-reported outcomes in inpatient care: protocol for a systematic review

BACKGROUND

Interprofessional collaboration (IPC) is a core demand of policymakers, funding parties, and health care professionals in practice. Although the causal mechanism from increased IPC to improved patient outcomes seems to be intuitive, there is a lack of credible causal evidence concerning the effects not only on the objective but also on the subjective patient outcomes. The aim of the planned systematic review is to focus on the effect of IPC on patient-reported outcomes and experiences in inpatient care.

METHODS

A systematic literature review will be undertaken by searching the following electronic databases: PubMed, Web of Science/Social Science Citation Index, Cochrane Library (CENTRAL), Current Contents (LIVIVO), CINAHL, and EMBASE. Additional studies will be identified through forward and backward citation tracking, manually searching the Internet and Google Scholar, and consultation of experts. Data will be synthesized through narrative description, grouping, and thematic analysis of the extracted data. If heterogeneity for some studies and outcomes is sufficiently low, a quantitative meta-analysis of effect sizes and standard errors will be applied.

DISCUSSION

The systematic review will synthesize the evidence regarding the effectiveness of IPC and how it is perceived by patients in inpatient care. As the patients' perspective becomes increasingly relevant in the context of quality improvement, the results can help decision-makers in policy- and health care institutions to understand and develop strategies to ensure a high quality of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42017073900 ; date of registration in PROSPERO 07 August 2017.

Unpacking Partnership, Engagement, and Collaboration Research to Inform Implementation Strategies Development: Theoretical Frameworks and Emerging Methodologies

Background: Partnership, engagement, and collaboration (PEC) are critical factors in dissemination and implementation (D&I) research. Despite a growing recognition that incorporating PEC strategies in D&I research is likely to increase the relevance, feasibility, impacts, and of evidence-based interventions or practices (EBIs, EBPs), conceptual frameworks and methodologies to guide the development and testing of PEC strategies in D&I research are lacking. To address this methodological gap, a review was conducted to summarize what we know, what we think we know, and what we need to know about PEC to inform D&I research.

Methods: A cross-field scoping review, drawing upon a broad range of PEC related literature in health, was conducted. Publications reviewed focused on factors influencing PEC, and processes, mechanisms and strategies for promoting effective PEC. The review was conducted separately for three forms of partnerships that are commonly used in D&I research: (1) consumer-provider or patient-implementer partnership; (2) delivery system or implementation team partnership; and (3) sustainment/support or interagency/community partnership. A total of 39 studies, of which 21 were review articles, were selected for an in-depth review.

Results: Across three forms of partnerships, four domains (cognitive, interpersonal/affective, behavioral, and contextual domains) were consistently identified as factors and strategies for promoting PEC. Depending on the stage (preparation or execution) and purpose of the partnership (regulating performance or managing maintenance), certain PEC strategies are more or less relevant. Recent developments of PEC frameworks, such as Partnership Stage of Change and multiple dynamic processes, provide more comprehensive conceptual explanations for PEC mechanisms, which can better guide PEC strategies selection and integration in D&I research.

Conclusions: This review contributes to D&I knowledge by identifying critical domain factors, processes, or mechanisms, and key strategies for PEC, and offers a multi-level PEC framework for future research to build the evidence base. However, more research is needed to test PEC mechanisms.

Implementation of continuous quality improvement in Aboriginal and Torres Strait Islander primary health care in Australia: a scoping systematic review

BACKGROUND

Continuous Quality Improvement (CQI) programs have been taken up widely by Indigenous primary health care (PHC) services in Australia and there has been national policy commitment to support this. However, international evidence shows that implementing CQI is challenging, impacts are variable and little is known about the factors that impede or enhance effectiveness. A scoping review was undertaken to explore uptake and implementation in Indigenous PHC, including barriers and enablers to embedding CQI in routine practice. We provide guidance on how research and evaluation might be intensified to support implementation.

METHODS

Searches were conducted in MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews. Key websites and publications were handsearched. Studies conducted in Indigenous PHC which demonstrated some combination of CQI characteristics and assessed some aspect of implementation were included. A two stage analysis was undertaken. Stage 1 identified the breadth and focus of literature. Stage 2 investigated barriers and enablers. The Framework for Performance Assessment in PHC (2008) was used to frame the analysis. Data were extracted on the study type, approach, timeframes, CQI strategies, barriers and enablers.

RESULTS

Sixty articles were included in Stage 1 and 21 in Stage 2. Barriers to implementing CQI processes relate primarily to professional and organisational processes and operate at multiple levels (individual, team, service, health system) whereas barriers to improved care relate more directly to knowledge of best practice and team processes that facilitate appropriate care. Few studies described implementation timeframes, number of CQI cycles or improvement strategies implemented and only two applied a change theory.

CONCLUSION

Investigating barriers and enablers that modify implementation and impacts of CQI poses conceptual and methodological challenges. More complete description of CQI processes, implementation strategies, and barriers and enablers could enhance capacity for comparisons across settings and contribute to better understanding of key success factors.

Opportunities for Epidemiologists in Implementation Science: A Primer

The field of epidemiology has been defined as the study of the spread and control of disease. However, epidemiology frequently focuses on studies of etiology and distribution of disease at the cost of understanding the best ways to control disease. Moreover, only a small fraction of scientific discoveries are translated into public health practice, and the process from discovery to translation is exceedingly slow. Given the importance of translational science, the future of epidemiologic training should include competency in implementation science, whose goal is to rapidly move evidence into practice. Our purpose in this paper is to provide epidemiologists with a primer in implementation science, which includes dissemination research and implementation research as defined by the National Institutes of Health. We describe the basic principles of implementation science, highlight key components for conducting research, provide examples of implementation studies that encompass epidemiology, and offer resources and opportunities for continued learning. There is a clear need for greater speed, relevance, and application of evidence into practice, programs, and policies and an opportunity to enable epidemiologists to conduct research that not only will inform practitioners and policy-makers of risk but also will enhance the likelihood that evidence will be implemented.

Performance Measures for Health Care Teams: A Review

Interest in effective health care teamwork has advanced in recent years. To ensure these teams are performing effectively, valid and reliable measurement is necessary. This review identifies and organizes information about measures of health care team performance by addressing the following objectives: (a) identify existing measures of health care team performance ( k = 70), (b) summarize validity evidence (i.e., construct and content validity), (c) summarize reliability information (i.e., interrater/interobserver reliability and internal consistency), (d) summarize information pertaining to the use and implementation of the measures (i.e., generalizability, instrument type, and clarity of language), and (e) identify the teamwork content included in the measures. These findings can aid researchers and practitioners in selecting a measure that is appropriate for a specific context. This review also illuminates areas where future research is needed by identifying types of reliability, validity, and teamwork content that have been largely unaddressed.

The role of organizational structure in readiness for change: A conceptual integration

The purpose of this review is to extend extant conceptualizations of readiness for change as an individual-level phenomenon. This review-of-reviews focuses on existing conceptual frameworks from the dissemination, implementation, quality improvement, and organizational transformation literatures in order to integrate theoretical rationales for how organization structure, a key dimension of the organizational context, may impact readiness for change. We propose that the organization structure dimensions of differentiation and integration impact readiness for change at the individual level of analysis by influencing four key concepts of relevance, legitimacy, perceived need for change, and resource allocation. We identify future research directions that focus on these four key concepts.

A human factors systems approach to understanding team-based primary care: a qualitative analysis

BACKGROUND

Research shows that high-functioning teams improve patient outcomes in primary care. However, there is no consensus on a conceptual model of team-based primary care that can be used to guide measurement and performance evaluation of teams.

OBJECTIVE

To qualitatively understand whether the Systems Engineering Initiative for Patient Safety (SEIPS) model could serve as a framework for creating and evaluating team-based primary care.

METHODS

We evaluated qualitative interview data from 19 clinicians and staff members from 6 primary care clinics associated with a large Midwestern university. All health care clinicians and staff in the study clinics completed a survey of their communication connections to team members. Social network analysis identified key informants for interviews by selecting the respondents with the highest frequency of communication ties as reported by their teammates. Semi-structured interviews focused on communication patterns, team climate and teamwork.

RESULTS

Themes derived from the interviews lent support to the SEIPS model components, such as the work system (Team, Tools and Technology, Physical Environment, Tasks and Organization), team processes and team outcomes.

CONCLUSIONS

Our qualitative data support the SEIPS model as a promising conceptual framework for creating and evaluating primary care teams. Future studies of team-based care may benefit from using the SEIPS model to shift clinical practice to high functioning team-based primary care.

Organizational Capabilities for Integrating Care: A Review of Measurement Tools

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes.

Interacting factors associated with Low antibiotic prescribing for respiratory tract infections in primary health care - a mixed methods study in Sweden

Background

Prescribing of antibiotics for common infections varies widely, and there is no medical explanation. Systematic reviews have highlighted factors that may influence antibiotic prescribing and that this is a complex process. It is unclear how factors interact and how the primary care organization affects diagnostic procedures and antibiotic prescribing. Therefore, we sought to explore and understand interactions between factors influencing antibiotic prescribing for respiratory tract infections in primary care.

Methods

Our mixed methods design was guided by the Triangulation Design Model according to Creswell. Quantitative and qualitative data were collected in parallel. Quantitative data were collected by prescription statistics, questionnaires to patients, and general practitioners’ audit registrations. Qualitative data were collected through observations and semi-structured interviews.

Results

From the analysis of the data from the different sources an overall theme emerged: A common practice in the primary health care centre is crucial for low antibiotic prescribing in line with guidelines. Several factors contribute to a common practice, such as promoting management and leadership, internalized guidelines including inter-professional discussions, the general practitioner’s diagnostic process, nurse triage, and patient expectation. These factors were closely related and influenced each other. The results showed that knowledge must be internalized and guidelines need to be normative for the group as well as for every individual.

Conclusions

Low prescribing is associated with adapted and transformed guidelines within all staff, not only general practitioners. Nurses’ triage and self-care advice played an important role. Encouragement from the management level stimulated inter-professional discussions about antibiotic prescribing. Informal opinion moulders talking about antibiotic prescribing was supported by the managers. Finally, continuous professional development activities were encouraged for up-to-date knowledge.

Preliminary testing of the Swedish version of the Assessment of Interprofessional Team Collaboration Scale (AITCS-S)

Interprofessional collaboration might improve healthcare processes and outcomes; however, it has been found that most instruments that aim to measure collaboration have undergone limited testing. The assessment of interprofessional team collaboration scale (AITCS) is one questionnaire that aims to evaluate collaboration, but it has not yet been extensively tested. The aim of this study was to translate and to cross-culturally adapt the AITCS for use in Sweden, to describe floor and ceiling values, and to investigate the AITCS in terms of reliability, face, and content validity. The study included a total of 349 participants working in team-based pain rehabilitation. The participants were asked to fill in the Swedish version of the AITCS (AITCS-S) at baseline. Of these, 73 participants also completed the AITCS-S two weeks later. The results showed that the content and face validity were good. Internal consistency varied from 0.79 to 0.96 and judged to be acceptable to excellent. Test–retest stability showed excellent stability with intraclass correlation values above 0.75 for all subscales. This study concludes that the Swedish version of the AITCS is a reliable and valid questionnaire. Further psychometric investigations might be undertaken in order to attempt to develop shorter versions of the AITCS-S.

Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams

Introduction:

Teamwork between healthcare providers is conditional for the delivery of integrated care. This study aimed to assess the usefulness of the conceptual framework Integrated Team Effectiveness Model for developing and testing of the Integrated Team Effectiveness Instrument.

Theory and methods:

Focus groups with healthcare providers in an integrated care setting for people with chronic obstructive pulmonary disease (COPD) were conducted to examine the recognisability of the conceptual framework and to explore critical success factors for collaborative COPD practice out of this framework. The resulting items were transposed into a pilot instrument. This was reviewed by expert opinion and completed 153 times by healthcare providers. The underlying structure and internal consistency of the instrument were verified by factor analysis and Cronbach’s alpha.

Results:

The conceptual framework turned out to be comprehensible for discussing teamwork effectiveness. The pilot instrument measures 25 relevant aspects of teamwork in integrated COPD care. Factor analysis suggested three reliable components: teamwork effectiveness, team processes and team psychosocial traits (Cronbach’s alpha between 0.76 and 0.81).

Conclusions and discussion:

The conceptual framework Integrated Team Effectiveness Model is relevant in developing a practical full-spectrum instrument to facilitate discussing teamwork effectiveness. The Integrated Team Effectiveness Instrument provides a well-founded basis to self-evaluate teamwork effectiveness in integrated COPD care by healthcare providers. Recommendations are provided for the improvement of the instrument.

Same-level peer-assisted learning in medical clinical placements: a narrative systematic review

BACKGROUND

Peer-assisted learning (PAL) is increasingly used in medical education, and the benefits of this approach have been reported. Previous reviews have focused on the benefits of peer tutoring of junior students by senior students. Forms of PAL such as discussion groups and role-playing have been neglected, as have alternative teacher-learner configurations (e.g. same-level PAL) and the effects on other stakeholders, including clinician educators and patients. This review examines the benefits of same-level PAL for students, clinician educators and patients in pre-registration clinical medical education.

METHODS

Medline, PsycINFO, CINAHL and ERIC were searched in March 2014. A total of 1228 abstracts were retrieved for review; 64 full-text papers were assessed. Data were extracted from empirical studies describing a same-level PAL initiative in a clinical setting, focusing on effects beyond academic performance and student satisfaction. Qualitative thematic analysis was employed to identify types of PAL and to cluster the reported PAL effects.

RESULTS

Forty-three studies were included in the review. PAL activities were categorised into role-play, discussion, teaching and assessment. Only 50% of studies reported information beyond self-report and satisfaction with the PAL intervention. Benefits for students (including development of communication and professional skills) and clinician educators (developing less-used facilitation skills) were reported. Direct patient outcomes were not identified. Caveats to the use of PAL emerged, and guidelines for the use of PAL were perceived as useful.

CONCLUSION

Many student-related benefits of PAL were identified. PAL contributes to the development of crucial skills required for a doctor in the workplace. Vertical integration of learning and teaching skills across the curriculum and tools such as feedback checklists may be required for successful PAL in the clinical environment. Benefits for patients and educators were poorly characterised within the included studies. Future work should evaluate the use of PAL with regards to student, clinician educator and patient outcomes.

Effects of a Longitudinal Interprofessional Educational Outreach Program on Collaboration

INTRODUCTION

Interprofessional education (IPE) interventions lack clarity regarding development and implementation, impeding a clear understanding of their role and effectiveness. The aim of this study was to identify whether and how an outreach program targeting interprofessional health care teams can improve self-efficacy and interprofessional collaboration (IPC).

METHODS

A cohort study was conducted to explore the effect of the program on individual self-efficacy and perceived IPC and investigate factors affecting interprofessional learning and collaboration. The program was a two-year IPE program consisting of workshops, educational materials, and interworkshop support. Participants were physicians, nurses, dietitians, pharmacists, and social workers at two primary care teams in Toronto. Self-efficacy and team function were measured five times throughout the program. We used analysis of variance and t-tests to compare between teams and used Pearson correlations to estimate the relationship between self-efficacy and team function. One-on-one interviews investigated factors affecting IPC and the program's effect on IPC.

RESULTS

Team function improved as the program progressed (P = .02); although it did not affect self-efficacy, there was an increasing correlation between self-efficacy and team function as the program progressed (P < .01 for workshop 5). Interviews revealed that trust, liability concerns, and geographic proximity were mediators of IPC. The workshops were perceived to enable trust building by increasing knowledge and allowing nonphysician team members to showcase their expertise.

DISCUSSION

Our findings demonstrate that an IPE workshop, through role clarification, cultivation of trust, and a community of practice, can promote these elements. Trust in team members and geographic proximity are potential facilitators to IPC developed during an interprofessional program.

Relationship of organizational culture, teamwork and job satisfaction in interprofessional teams

BACKGROUND

Team effectiveness is often explained on the basis of input-process-output (IPO) models. According to these models a relationship between organizational culture (input = I), interprofessional teamwork (process = P) and job satisfaction (output = O) is postulated. The aim of this study was to examine the relationship between these three aspects using structural analysis.

METHODS

A multi-center cross-sectional study with a survey of 272 employees was conducted in fifteen rehabilitation clinics with different indication fields in Germany. Structural equation modeling (SEM) was carried out using AMOS software version 20.0 (maximum-likelihood method).

RESULTS

Of 661 questionnaires sent out to members of the health care teams in the medical rehabilitation clinics, 275 were returned (41.6%). Three questionnaires were excluded (missing data greater than 30%), yielding a total of 272 employees that could be analyzed. The confirmatory models were supported by the data. The results showed that 35% of job satisfaction is predicted by a structural equation model that includes both organizational culture and teamwork. The comparison of this predictive IPO model (organizational culture (I), interprofessional teamwork (P), job satisfaction (O)) and the predictive IO model (organizational culture (I), job satisfaction (O)) showed that the effect of organizational culture is completely mediated by interprofessional teamwork. The global fit indices are a little better for the IO model (TLI: .967, CFI: .972, RMSEA .052) than for the IPO model (TLI: .934, CFI: .943, RMSEA: .61), but the prediction of job satisfaction is better in the IPO model (R(2) = 35%) than in the IO model (R(2) = 24%).

CONCLUSIONS

Our study results underpin the importance of interprofessional teamwork in health care organizations. To enhance interprofessional teamwork, team interventions can be recommended and should be supported. Further studies investigating the organizational culture and its impact on interprofessional teamwork and team effectiveness in health care are important.

Development and validation of the primary care team dynamics survey

OBJECTIVE

To develop and validate a survey instrument designed to measure team dynamics in primary care.

DATA SOURCES/STUDY SETTING

We studied 1,080 physician and nonphysician health care professionals working at 18 primary care practices participating in a learning collaborative aimed at improving team-based care.

STUDY DESIGN

We developed a conceptual model and administered a cross-sectional survey addressing team dynamics, and we assessed reliability and discriminant validity of survey factors and the overall survey's goodness-of-fit using structural equation modeling.

DATA COLLECTION

We administered the survey between September 2012 and March 2013.

PRINCIPAL FINDINGS

Overall response rate was 68 percent (732 respondents). Results support a seven-factor model of team dynamics, suggesting that conditions for team effectiveness, shared understanding, and three supportive processes are associated with acting and feeling like a team and, in turn, perceived team effectiveness. This model demonstrated adequate fit (goodness-of-fit index: 0.91), scale reliability (Cronbach's alphas: 0.71-0.91), and discriminant validity (average factor correlations: 0.49).

CONCLUSIONS

It is possible to measure primary care team dynamics reliably using a 29-item survey. This survey may be used in ambulatory settings to study teamwork and explore the effect of efforts to improve team-based care. Future studies should demonstrate the importance of team dynamics for markers of team effectiveness (e.g., work satisfaction, care quality, clinical outcomes).