Conditions and barriers for quality improvement work: a qualitative study of how professionals and health centre managers experience audit and feedback practices in Swedish primary care

Acceptability and feasibility of using a blended quality improvement strategy among health workers to monitor women engagement in Option B+ program in Lilongwe Malawi

Option B + provides lifelong ART to pregnant and breastfeeding women with HIV to reduce mother-to-child transmission of HIV (eMTCT) and improve maternal health. The effectiveness of Option B + relies on continuous engagement, but suboptimal monitoring of HIV care hinders our measurements of engagement. Process mapping and quality improvement (PROMAQI) is a quality improvement strategy for healthcare workers (HCWs) to optimize complex processes such as monitoring HIV care. We assessed the acceptability and feasibility of the PROMAQI among HCWs and identified barriers and facilitators for PROMAQI implementation. A cross-sectional study using a mixed method approach was conducted from August 2021 to March 2022 across five urban health facilities participating in PROMAQI implementation n the Lilongwe district, Malawi. We assessed PROMAQI acceptability and feasibility at the end of the study. A 5-point Likert (1 = worst to 5 = best) scale tool was administered to 110 HCWs (n = 15-33 per facility) involved in PROMAQI implementationThese data were analysed using descriptive statistics Among the 110 HCWs, twenty-two (QI team (n = 11) and QI implementers (n = 11)) were purposively selected for in-depth interviews. Thematic analysis was conducted using deducted and inductive approaches. The theoretical framework for acceptability (TFA) was used to identify reasons for acceptability. The Consolidated Framework for Implementation Research (CFIR) was used to characterize the barriers and facilitators of PROMAQI implementation. HCWs recruited had a median age of 37 (32-43) years, 82.0% of whom were female. Most (42%) had completed secondary education, and 84% were nurses and community health workers. The median (IQR) acceptability and feasibility scores for the PROMAQI were 5 (IQR 4-5) and 4 (IQR 4-5), respectively. Reasons for high PROMAQI acceptability included addressing a relevant gap and improving performance. Perceived implementation barriers included poor work attitudes, time constraints, resource limitations, knowledge gaps, and workbook difficulties. The facilitators included communication, mentorship, training, and financial incentives. PROMAQI is a highly acceptable and feasible tool for monitoring engagement of women in Option B + . Addressing these barriers may optimize the implementation of PROMAQI. Scaling up PROMAQI may enhance retention in the Option B + program and facilitate eMTCT.

Comparison of two audit and feedback approaches: descriptive analysis of personal and contextual dynamics

INTRODUCTION

Audit and feedback (A&F) is a systematic intervention that can be used to improve the quality of health care. The EASY-NET Network Project proposes an innovative A&F model.

AIM

This study aimed to describe the newly proposed A&F model. An analysis was conducted, examining the participants' attitudes and their individual and interpersonal mechanisms to understand how they influence the work context and vice versa.

METHODS

Two A&F models were compared, involving emergency and rehabilitation health workers, who were divided into two groups. The classic A&F model was compared with a new model, using a desk audit followed by interactive feedback. Communication training was provided to the audit team by psychologists before commencement of the project. The experimental group underwent psychological screening using two standardized tools (COPE-NVI and ProQoL) to evaluate personal and relational dynamics using the context-mechanism-outcome (CMO) paradigm.

RESULTS

The exchange of ideas among health professionals is more effective when using face-to-face feedback than written feedback. The COPE-NVI and ProQoL questionnaires highlighted the difficulties experienced by health care professionals in implementing effective coping strategies to deal with stressful events.

CONCLUSIONS

Identifying signs of stress in health care workers is essential for improvement strategies to be implemented and for establishing new, optimal conditions. Remote feedback makes it possible to overcome logistical barriers and, in the future, this method can be used for inter-organizational collaboration.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A203.

Developing an initial set of quality indicators for chiropractic care: a scoping review

BACKGROUND

Quality indicators are standardized, evidence-based measures of health care quality. Currently, there is no basic set of quality indicators for chiropractic care published in peer-reviewed literature. The goal of this research is to develop a preliminary set of quality indicators, measurable with administrative data.

METHODS

We conducted a scoping review searching PubMed/MEDLINE, CINAHL, and Index to Chiropractic Literature databases. Eligible articles were published after 2011, in English, developing/reporting best practices and clinical guidelines specifically developed for, or directly applicable to, chiropractic care. Eligible non-peer-reviewed sources such as quality measures published by the Centers for Medicare and Medicaid Services and the Royal College of Chiropractors quality standards were also included. Following a stepwise eligibility determination process, data abstraction identified specific statements from included sources that can conceivably be measured with administrative data. Once identified, statements were transformed into potential indicators by: 1) Generating a brief title and description; 2) Documenting a source; 3) Developing a metric; and 4) Assigning a Donabedian category (structure, process, outcome). Draft indicators then traversed a 5-step assessment: 1) Describes a narrowly defined structure, process, or outcome; 2) Quantitative data can conceivably be available; 3) Performance is achievable; 4) Metric is relevant; 5) Data are obtainable within reasonable time limits. Indicators meeting all criteria were included in the final set.

RESULTS

Literature searching revealed 2562 articles. After removing duplicates and conducting eligibility determination, 18 remained. Most were clinical guidelines (n = 10) and best practice recommendations (n = 6), with 1 consensus and 1 clinical standards development study. Data abstraction and transformation produced 204 draft quality indicators. Of those, 57 did not meet 1 or more assessment criteria. After removing duplicates, 70 distinct indicators remained. Most indicators matched the Donabedian category of process (n = 35), with 31 structure and 4 outcome indicators. No sources were identified to support indicator development from patient perspectives.

CONCLUSIONS

This article proposes a preliminary set of 70 quality indicators for chiropractic care, theoretically measurable with administrative data and largely obtained from electronic health records. Future research should assess feasibility, achieve stakeholder consensus, develop additional indicators including those considering patient perspectives, and study relationships with clinical outcomes.

TRIAL REGISTRATION

Open Science Framework, https://osf.io/t7kgm.

Access to automated comparative feedback reports in primary care - a study of intensity of use and relationship with clinical performance among Swedish primary care practices

BACKGROUND

Digital applications that automatically extract information from electronic medical records and provide comparative visualizations of the data in the form of quality indicators to primary care practices may facilitate local quality improvement (QI). A necessary condition for such QI to work is that practices actively access the data. The purpose of this study was to explore the use of an application that visualizes quality indicators in Swedish primary care, developed by a profession-led QI initiative ("Primärvårdskvalitet"). We also describe the characteristics of practices that used the application more or less extensively, and the relationships between the intensity of use and changes in selected performance indicators.

METHODS

We studied longitudinal data on 122 primary care practices' visits to pages (page views) in the application over a period up to 5 years. We compared high and low users, classified by the average number of monthly page views, with respect to practice and patient characteristics as well as baseline measurements of a subset of the performance indicators. We estimated linear associations between visits to pages with diabetes-related indicators and the change in measurements of selected diabetes indicators over 1.5 years.

RESULTS

Less than half of all practices accessed the data in a given month, although most practices accessed the data during at least one third of the observed months. High and low users were similar in terms of most studied characteristics. We found statistically significant positive associations between use of the diabetes indicators and changes in measurements of three diabetes indicators.

CONCLUSIONS

Although most practices in this study indicated an interest in the automated feedback reports, the intensity of use can be described as varying and on average limited. The positive associations between the use and changes in performance suggest that policymakers should increase their support of practices' QI efforts. Such support may include providing a formalized structure for peer group discussions of data, facilitating both understanding of the data and possible action points to improve performance, while maintaining a profession-led use of applications.

"If you work alone on this project, you can't reach your target": unpacking the leader's role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19

The South African National Department of Health developed a quality improvement (QI) programme to reduce maternal and neonatal mortality and still births. The programme was implemented between 2018 and 2022 in 21 purposively selected public health facilities. We conducted a process evaluation to describe the characteristics and skills of the QI team leaders of well-performing teams. The evaluation was conducted in 15 of the 21 facilities. Facilities were purposively selected and comprised semi-structured interviews with leaders at three time points; reviewing of QI documentation; and 37 intermittently conducted semi-structured interviews with the QI advisors, being QI technical experts who supported the teams. These interviews focused on participants' experiences and perceptions of how the teams performed, and performance barriers and enablers. Thematic data analysis was conducted using Atlas.ti. Variation in team performance was associated with leaders' attributes and skills. However, the COVID-19 pandemic also affected team functioning. Well-performing teams had leaders who effectively navigated COVID-19 and other challenges, who embraced QI and had sound QI skills. These leaders cultivated trust by taking responsibility for failures, correcting members' mistakes in encouraging ways, and setting high standards of care. Moreover, they promoted programme ownership among members by delegating tasks. Given the critical role leaders play in team performance and thus in the outcomes of QI programmes, efforts should focus on leader selection, training, and support.

Quality in neonatal mortality audits: Results of pilot study from district of Dhule, Maharashtra

Introduction

As per WHO guidelines, it is important to have quality among mortality audit documents to improve outcome in health services.

Objective

To assess quality of facility-based neonatal mortality audits implementation.

Methodology

Mixed-method descriptive analysis was conducted. Totally, 96 death review documents were reviewed. The 25 healthcare workers were interviewed in depth. Observation analysis done for audit meetings using WHO modified checklist for quality in audit toolkit.

Results

The observation of audit meetings highlighted that almost half of the members were not communicated regarding vision of audit and framework of audit and review meetings. In quantitative analysis, it was found that secondary care hospitals were not having accuracy and consistency in audit documentation.

Conclusion

The quality of neonatal death audit was poor due to challenges faced by the hospitals in creating an enabling atmosphere, which can be overcome by sharing the vision of audit with the whole staff of the hospital. A standard operating procedure for audit committee to be adopted to implement action plans. Commitment, investment, and intentional leadership from everyone, including all healthcare workers, can make these ambitious goals attainable.

BeTTer Outcomes Workgroup Health Quality Initiative to optimize bone health for prostate cancer patients in the British Columbia Cancer System

INTRODUCTION

Bone-targeted therapies (BTTs) are integral to the management of bone metastases in metastatic castration-resistant prostate cancer (mCRPC). BTTs vary considerably in referral and drug access pathways and optimal BTT use requires multi-specialty consultation and supervision. Health quality improvement (HQI) has become the predominant framework to improve patient care in multidisciplinary settings.

METHODS

HQI initiatives on use of BTT in mCRPC were developed and evaluated in five centers of a provincial cancer center network using Plan-Do-Study-Act (PDSA) methodology. Multidisciplinary teams (MDTs) completed a common quality assessment form and an HQI template and then implemented an HQI initiative. Feedback and findings were shared and discussed at regional events. It was subsequently determined whether to adopt, adapt, or abandon initiatives.

RESULTS

Patterns of unmet needs varied across type of BTT. Gaps in use of radium-223 were mostly referral and education issues that could be directly addressed at the local level by participating clinician teams. Conversely, most supportive BTT gaps were related to coverage and resourcing support. HQI initiatives selected by each site consisted of implementation or expansion of local MDT meetings, referral documents, databases, and improvement charters. The main HQI initiative was completed in four sites and was adapted or adopted in three. Improvements in BTT use were observed in two of three centers with data on HQI process measures.

CONCLUSIONS

Despite the overall heterogenous structure of the groups and metrics used, this study demonstrated that the PDSA framework provides the needed structure for improvements in BTT use in mCRPC across multiple sites.

Better with GPs as managers? - Variation in perceptions of feedback messages, goal-clarity and performance across manager´s in Swedish primary care

BACKGROUND

Primary care in several countries is developing towards team-based and multi-professional care, requiring leadership and management capabilities at the primary care practice level. This article reports findings from a study of primary care managers in Sweden, focusing variation in performance and perceptions of feedback messages and goal-clarity, depending on managers' professional background.

METHODS

The study was designed as a cross-sectional analysis of primary care practice managers' perceptions combined with registered data on patient-reported performance. Managers perceptions was collected through a survey to all 1 327 primary care practice managers in Sweden. Data about patient-reported performance was collected from the 2021 National Patient Survey in primary care. We used bivariate (Pearson correlation) and multivariate (ordinary least square regression analysis) statistical methods to describe and analyse the possible association between managers' background, responses to survey statements and patient-reported performance.

RESULTS

Both GP and non-GP managers had positive perceptions of the quality and support of feedback messages from professional committees focusing medical quality indicators, although managers perceived that the feedback facilitated improvement work to a lower degree. Feedback from the regions as payers scored consistently lower in all dimensions, especially among GP-managers. Results from regression analysis indicate that GP-managers correlate with better patient-reported performance when controlling for selected primary care practice and managerial characteristics. A significant positive relationship with patient-reported performance was also found for female managers, a smaller size of the primary care practice and a good staffing situation of GPs.

CONCLUSIONS

Both GP and non-GP managers rated the quality and support of feedback messages from professional committees higher than feedback from regions as payers. Differences in perceptions were especially striking among GP-managers. Patient-reported performance was significantly better in primary care practices managed by GPs and female managers. Variables reflecting structural and organizational, rather than managerial, characteristics contributed with additional explanations behind the variation in patient-reported performance across primary care practices. As we cannot exclude reversed causality, the findings may reflect that GPs are more likely to accept being a manager of a primary care practice with favourable characteristics.

Developing a Questionnaire Evaluating Knowledge, Attitudes and Behaviors on Audit & Feedback among General Practitioners: A Mixed Methods Study

BACKGROUND

Audit and Feedback (A&F) is one of the most common strategies used to improve quality in healthcare. However, there is still lack of awareness regarding the enabling factors and barriers that could influence its effectiveness. The aim of this study was to develop a questionnaire to measure the knowledge, attitudes and behaviors of general practitioners (GPs) regarding A&F. The study was performed in the context of the EASY-NET program (project code NET-2016-02364191).

METHODS

The survey was developed according to two steps. Firstly, a scoping review was performed in order to map the literature on the existing similar instruments with the aim of identifying the sub-domains and possible items to include in a preliminary version of the questionnaire. In the second phase, the questionnaire was reviewed by a multidisciplinary group of experts and administrated to a convenience sample in a pilot survey.

RESULTS

Ten papers were included in the scoping review. The survey target and development methodology were heterogenous among the studies. The knowledge, attitudes and behaviors domains were assessed in six, nine and seven studies, respectively. In the first step, 126 pertinent items were extracted and categorized as follows: 8 investigated knowledge, 93 investigated attitudes, and 25 investigated behaviors. Then, 2 sub-domains were identified for knowledge, 14 for attitudes and 7 for behavior. Based on these results, a first version of the survey was developed via consensus among two authors and then revised by the multidisciplinary group of experts in the field of A&F. The final version of the survey included 36 items: 8 in the knowledge domain, 19 in the attitudes domain and 9 in the behaviors domain. The results of the pilot study among 15 GPs suggested a good acceptability and item relevance and accuracy, with positive answers totaling 100% and 93.3% in the proposed questions.

CONCLUSIONS

The methodology used has shown to be a good strategy for the development of the survey. The survey will be administrated before and after the implementation of an A&F intervention to assess both baseline characteristics and changes after the intervention.

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.

Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury

Introduction

The rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions.

Purpose

We employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions.

Methods

This study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews.

Results

There were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives.

Conclusion

This study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.

Audit as a Tool for Improving the Quality of Stroke Care: A Review

INTRODUCTION

A clinical audit is a tool that allows the evaluation of and improvement in the quality of stroke care processes. Fast, high-quality care and preventive interventions can reduce the negative impact of stroke.

OBJECTIVE

This review was conducted on studies investigating the effectiveness of clinical audits to improve the quality of stroke rehabilitation and stroke prevention.

METHOD

We reviewed clinical trials involving stroke patients. Our search was performed on PubMed databases, Web of Science, and Cochrane library databases. Of the 2543 initial studies, 10 studies met the inclusion criteria.

RESULTS

Studies showed that an audit brought an improvement in rehabilitation processes when it included a team of experts, an active training phase with facilitators, and short-term feedback. In contrast, studies looking at an audit in stroke prevention showed contradictory results.

CONCLUSIONS

A clinical audit highlights any deviations from clinical best practices in order to identify the causes of inefficient procedures so that changes can be implemented to improve the care system. In the rehabilitation phase, the audit is effective for improving the quality of care processes.

Characterizing the Gaps Between Best-Practice Implementation Strategies and Real-world Implementation: Qualitative Study Among Family Physicians Who Engaged With Audit and Feedback Reports

BACKGROUND

In Ontario, Canada, a government agency known as Ontario Health is responsible for making audit and feedback reports available to all family physicians to encourage ongoing quality improvement. The confidential report provides summary data on 3 key areas of practice: safe prescription, cancer screening, and diabetes management.

OBJECTIVE

This report was redesigned to improve its usability in line with evidence. The objective of this study was to explore how the redesign was perceived, with an emphasis on recipients' understanding of the report and their engagement with it.

METHODS

We conducted qualitative semistructured interviews with family physicians who had experience with both versions of the report recruited through purposeful and snowball sampling. We analyzed the transcripts following an emergent and iterative approach.

RESULTS

Saturation was reached after 17 family physicians participated. In total, 2 key themes emerged as factors that affected the perceived usability of the report: alignment between the report and the recipients' expectations and capacity to engage in quality improvement. Family physicians expected the report and its quality indicators to reflect best practices and to be valid and accurate. They also expected the report to offer feedback on the clinical activities they perceived to be within their control to change. Furthermore, family physicians expected the goal of the report to be aligned with their perspective on feasible quality improvement activities. Most of these expectations were not met, limiting the perceived usability of the report. The capacity to engage with audit and feedback was hindered by several organizational and physician-level barriers, including the lack of fit with the existing workflow, competing priorities, time constraints, and insufficient skills for bridging the gaps between their data and the corresponding desired actions.

CONCLUSIONS

Despite recognized improvements in the design of the report to better align with best practices, it was not perceived as highly usable. Improvements in the presentation of the data could not overcome misalignment with family physicians' expectations or the limited capacity to engage with the report. Integrating iterative evaluations informed by user-centered design can complement evidence-based guidance for implementation strategies. Creating a space for bringing together audit and feedback designers and recipients may help improve usability and effectiveness.

Swedish Child Health Services Register: a quality register for child health services and children's well-being

BACKGROUND

Swedish child health services (CHS) is a free-of-charge healthcare system that reaches almost all children under the age of 6. The aim for the CHS is to improve children's physical, psychological and social health by promoting health and development, preventing illness and detecting emerging problems early in the child's life. The services are defined in a national programme divided into three parts: universal interventions, targeted interventions and indicated interventions.The Swedish Child Health Services Register (BHVQ) is a national Quality Register developed in 2013. The register extracts data from the child's health record and automatically presents current data in real time. At present, the register includes 21 variables.

AIM

We aim to describe data available in the BHVQ and the completeness of data in BHVQ across variables.

METHODS

Child-specific data were exported from the register, and data for children born in the regions were retrieved from Statistics Sweden to calculate coverage.

RESULTS

The register includes over 110 000 children born between 2011 and 2022 from 221 child healthcare centres in eight of Sweden's 21 regions. In seven of the eight regions, 100% of centres report data.The completeness of data differs between participating regions and birth cohorts. The average coverage for children born in 2021 is 71%.

CONCLUSIONS

The BHVQ is a valuable resource for evaluating Child Health Services nationally, with high coverage for the youngest children. As a result of continuous improvement of the services, the possibility to follow the development of children's health in Sweden is possible through the register. When fully expanded, the register will be a natural and essential part of developing preventive services, improving healthcare for children below 6 years of age and a tool for developing evidence-based child health interventions.

Fifteen years with patient choice and free establishment in Swedish primary healthcare: what do we know?

Background:

In 2007, a reform of Swedish primary healthcare began when some regions implemented enhanced patient choice in combination with free establishment for private providers. Although heavily debated, in 2010 it became mandatory for all regions to implement this choice system.

Aim:

The aim of this article was to review all published research articles related to the primary healthcare choice reform in Sweden, to investigate what has been published about the reform and summarise its first 15 years.

Methods:

A scoping review was performed to cover the breadth of research on the reform. Searches were made in Scopus, Web of Science and PubMed for articles published between 2007 and 2021, resulting in 217 unique articles. In total, 52 articles were included.

Results:

The articles were summarised and presented in relation to six overarching themes: arguments about the primary healthcare choice reform; governance and financial reimbursements; choice of provider and use of information; effects on equity and access; effects on quality; and differences between private and public primary healthcare centres.

Conclusions:

The articles show that the reform has led to an increase in access to primary healthcare, but most studies indicate that the increase is inequitably distributed in terms of socioeconomy and geographical location. The effects on quality are unclear but several studies show that the mechanisms supposed to lead to quality improvements do not work as intended. Furthermore, from a population health perspective, it is time to discuss how such a responsibility can be reintegrated into primary healthcare and function with the choice system.