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Howe CJ, Carsey E, Gamboa J, Zhang Y, Lewis B. Communicate to Care: Implementing Health Literacy in a Pediatric Ears, Nose, and Throat Clinic. Health Lit Res Pract 2024; 8:e166-e174. [PMID: 39251191 PMCID: PMC11383560 DOI: 10.3928/24748307-20240819-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Despite positive outcomes in controlled trials, organizations have been slow to adopt health literacy practices. The purpose of the Communicate to CARE (Clear Communication, Achieve Understanding with Teach-Back, Receptive to our patient family needs, Empathetic care delivery) study was to use theories and strategies from implementation science to scale up health literacy practices in a pediatric Ears, Nose, and Throat (ENT) clinic. BRIEF DESCRIPTION OF ACTIVITY Expanding on previous efforts that simply reflected on barriers, the CARE team identified barriers within the local context pre-implementation to select strategies to directly address barriers during health literacy implementation. The RE-AIM framework was used to evaluate the reach, effectiveness, adoption, implementation, and maintenance of health literacy practices. IMPLEMENTATION Over 18 months, the CARE team delivered multiple implementation strategies, including external facilitator, microlessons, preparing champions, audit and feedback, local consensus discussions, and small test of change. We tailored health literacy practices to clinic team roles to accommodate the clinic workflow. RESULTS ENT team mean ratings on acceptability, appropriateness, and feasibility remained >4 indicating a high likelihood of successful implementation. Caregiver always ratings significantly increased from baseline to 12 months for easy-to-understand medication instructions (74%-96%), test results (54%-96%), know what to do if had questions (89%-96%), and encouraged to talk about health problems (76%-90%). Caregiver ratings dropped slightly at 18 months, indicating a need for booster training. While one third of caregivers reported Teach-Back practice across all time periods, the ENT team reported increased practice from baseline (42%), 6 (61%) and 12 months (70%). LESSONS LEARNED Over the first 12 months, the external facilitator delivered implementation strategies with weekly contact, tapering contact over the final 6 months. The local champion became engaged in the CARE study through a quality improvement project with meaningful outcomes for the clinic and an incentivization program for scholarly endeavors. Lunch and learn sessions helped build relationships between the CARE and ENT team to discuss and problem solve issues. The 5-item CAHPS health literacy composite proved to be sensitive to changes during implementation of health literacy practices. Integrating these items into standard follow up surveys with patients and families would help realize the return on investment for health literacy implementation. [HLRP: Health Literacy Research and Practice. 2024;8(3):e166-e174.].
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Metz AJ, Jensen TM, Afkinich JL, Disbennett ME, Farley AB. How the experiences of implementation support recipients contribute to implementation outcomes. FRONTIERS IN HEALTH SERVICES 2024; 4:1323807. [PMID: 38962755 PMCID: PMC11220199 DOI: 10.3389/frhs.2024.1323807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 06/10/2024] [Indexed: 07/05/2024]
Abstract
Introduction There is a growing body of literature on the activities and competencies of implementation support practitioners (ISPs) and the outcomes of engaging ISPs to support implementation efforts. However, there remains limited knowledge about the experiences of implementation support recipients who engage with ISPs and how these experiences shape the trajectory of implementation and contribute to implementation outcomes. This study aimed to extend the research on ISPs by describing the experiences of professionals who received implementation support and inform our understanding of the mechanisms by which ISPs produce behavior change and contribute to implementation outcomes. Methods Thirteen individuals with roles in supporting implementation efforts at a private foundation participated in semi-structured interviews. Data were analyzed using qualitative narrative analysis and episode profile analysis approaches. Iterative diagramming was used to visualize the pathway of experiences of implementation support recipients evidenced by the interview data. Results The majority of recipients described how positive experiences and trusting relationships with ISPs increased acceptance of implementation science throughout the foundation and increased the perception of implementation science as both an appropriate and feasible approach for strengthening the impact of foundation strategies. As perceptions of appropriateness and feasibility increased, recipients of implementation support described increasing knowledge and application of implementation science in their funding engagements and internal foundation strategies. Finally, recipients reported that the application of implementation science across the foundation led to sustained implementation capacity and better outcomes. Discussion The experiences of implementation support recipients described in this paper provide a source for further understanding the mechanisms of change for delivering effective implementation support leading to better implementation quality. Insights from these experiences can enhance our understanding for building implementation capacity and the rationales for evolving approaches that emphasize the dynamic, emotional, and highly relational nature of supporting others to use evidence in practice.
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Affiliation(s)
- Allison J. Metz
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Byrnes A, Flynn R, Watt A, Barrimore S, Young A. Sustainability of enhanced recovery after surgery programmes in gastrointestinal surgery: A scoping review. J Eval Clin Pract 2024; 30:217-233. [PMID: 37957803 DOI: 10.1111/jep.13935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/03/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) is an evidence-based intervention that is well-recognised across multiple surgical specialties as having potential to lead to improved patient and hospital outcomes. Little is known about sustainability of ERAS programmes. AIMS This review aimed to describe available evidence evaluating sustainability of ERAS programmes in gastrointestinal surgery to understand: (a) how sustainability has been defined; (b) examine determinants of sustainability; (c) identify strategies used to facilitate sustainability; (d) identify adaptations to support sustainability; and (e) examine outcomes measured as indicators of sustainability of ERAS programmes. METHODS This scoping review was conducted following the Joanna Briggs Institute's methodology. Research databases (PubMed, Embase, CINHAL) and the grey literature were searched (inception to September 2022) for studies reporting sustainability of ERAS programmes in gastrointestinal surgery. Included articles reported an aspect of sustainability (i.e., definition, determinants, strategies, adaptations, outcomes and ongoing use) at ≥2 years following initial implementation. Aspects of sustainability were categorised according to relevant frameworks to facilitate synthesis. RESULTS The search strategy yielded 1852 records; first round screening excluded 1749, leaving 103 articles for full text review. Overall, 22 studies were included in this review. Sustainability was poorly conceptualised and inconsistently reported across included studies. Provision of adequate resources was the most frequently identified enabler to sustainability (n/N = 9/12, 75%); however, relatively few studies (n = 4) provided a robust report of determinants, with no study reporting determinants of sustainability and strategies and adaptations to support sustainability alongside patient and service delivery outcomes. CONCLUSION Improved reporting, particularly of strategies and adaptations to support sustainability is needed. Refinement of ERAS reporting guidelines should be made to facilitate this, and future implementation studies should plan to document and report changes in context and corresponding programme changes to help researchers and clinicians sustain ERAS programmes locally.
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Affiliation(s)
- Angela Byrnes
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Rachel Flynn
- Health Information and Standards Directorate, Health Information and Quality Authority, Cork, Ireland
| | - Amanda Watt
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Sally Barrimore
- Nutrition and Dietetics Department, Prince Charles Hospital, Chermside, Queensland, Australia
| | - Adrienne Young
- Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Centre for Health Services Research, University of Queensland, St Lucia, Queensland, Australia
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Agulnik A, Boykin D, O'Malley DM, Price J, Yang M, McKone M, Curran G, Ritchie MJ. Virtual facilitation best practices and research priorities: a scoping review. Implement Sci Commun 2024; 5:16. [PMID: 38365878 PMCID: PMC10873989 DOI: 10.1186/s43058-024-00551-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/24/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Facilitation is an implementation strategy that supports the uptake of evidence-based practices. Recently, use of virtual facilitation (VF), or the application of facilitation using primarily video-based conferencing technologies, has become more common, especially since the COVID-19 pandemic. Thorough assessment of the literature on VF, however, is lacking. This scoping review aimed to identify and describe conceptual definitions of VF, evaluate the consistency of terminology, and recommend "best" practices for its use as an implementation strategy. METHODS We conducted a scoping review to identify literature on VF following the PRISMA-ScR guidance. A search of PubMed, Embase, Web of Science, and CINAHL databases was conducted in June 2022 for English language articles published from January 2012 through May 2022 and repeated in May 2023 for articles published from January 2012 through April 2023. Identified articles, including studies and conference abstracts describing VF, were uploaded into Covidence and screened independently by two reviewers. Data extraction was done by two reviewers in Microsoft Excel; additionally, studies were evaluated based on the Proctor et al. (2013) reporting guidelines for specifying details of implementation strategies. RESULTS The search strategy identified 19 articles. After abstract and full-text screening, eight studies described by 10 articles/abstracts were included in analysis. Best practices summarized across studies included (1) stakeholder engagement, (2) understanding the recipient's organization, (3) facilitator training, (4) piloting, (5) evaluating facilitation, (6) use of group facilitation to encourage learning, and (7) integrating novel tools for virtual interaction. Three papers reported all or nearly all components of the Proctor et al. reporting guidelines; justification for use of VF was the most frequently omitted. CONCLUSIONS This scoping review evaluated available literature on use of VF as a primary implementation strategy and identified significant variability on how VF is reported, including inconsistent terminology, lack of details about how and why it was conducted, and limited adherence to published reporting guidelines. These inconsistencies impact generalizability of these methods by preventing replicability and full understanding of this emerging methodology. More work is needed to develop and evaluate best practices for effective VF to promote uptake of evidence-based interventions. TRIAL REGISTRATION N/A.
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Affiliation(s)
- Asya Agulnik
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.
- Division of Critical Care, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Derrecka Boykin
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - Denalee M O'Malley
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Research DivisionNew Brunswick, NJ, USA
| | - Julia Price
- Center for Healthcare Delivery Science, Nemours Children's Health , Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Mia Yang
- Department of Internal Medicine, Section of Gerontology and Geriatric Medicine and the Sticht Center for Healthy Aging and Alzheimer's Prevention, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston Salem, NC, USA
| | - Mark McKone
- Coy C. Carpenter Library, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Geoffrey Curran
- Department of Pharmacy Practice, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mona J Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Baumann AA, Hankins JS, Hsu LL, Gibson RW, Richardson LD, Treadwell M, Glassberg JA, Bourne S, Luo L, Masese RV, Demartino T, Nocek J, Taaffe E, Gollan S, Ruiz OO, Nwosu C, Qashou N, James AS, Tanabe P, King AA. "The project did not come to us with a solution": Perspectives of research teams on implementing a study about electronic health record-embedded individualized pain plans for emergency department treatment of vaso-occlusive episodes in adults with sickle cell disease. BMC Health Serv Res 2023; 23:1245. [PMID: 37953236 PMCID: PMC10641983 DOI: 10.1186/s12913-023-10255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 10/30/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND This study aimed to capture the implementation process of the ALIGN Study, (An individualized Pain Plan with Patient and Provider Access for Emergency Department care of Sickle Cell Disease). ALIGN aimed to embed Individualized Pain Plans in the electronic health record (E-IPP) and provide access to the plan for both adult patients with sickle cell disease (SCD) and emergency department providers when a person with SCD comes to the emergency department in vaso-occlusive crises. METHODS Semi-structured interviews were conducted with research teams from the 8 participating sites from the ALIGN study. Seventeen participants (principal investigators and study coordinators) shared their perspectives about the implementation of ALIGN in their sites. Data were analyzed in three phases using open coding steps adapted from grounded theory and qualitative content analysis. RESULTS A total of seven overarching themes were identified: (1) the E-IPP structure (location and upkeep) and collaboration with the informatics team, (2) the role of ED champion, (3) the role of research coordinators, (4) research team communication, and communication between research team and clinical team, (5) challenges with the study protocol, (6) provider feedback: addressing over-utilizers, patient mistrust, and the positive feedback about the intervention, and (7) COVID-19 and its effects on study implementation. CONCLUSIONS Findings from this study contribute to learning how to implement E-IPPs for adult patients with SCD in ED. The study findings highlight the importance of early engagement with different team members, a champion from the emergency department, study coordinators with different skills and enhancement of communication and trust among team members. Further recommendations are outlined for hospitals aiming to implement E-IPP for patients with SCD in ED.
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Grants
- U24 HL133948 NHLBI NIH HHS
- U01 HL134042 NHLBI NIH HHS
- U01 HL133994 NHLBI NIH HHS
- U01 HL133964 NHLBI NIH HHS
- U01 HL134007 NHLBI NIH HHS
- U01 HL133997 NHLBI NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NHLBI NIH HHS
- U01 HL134004 NHLBI NIH HHS
- U01 HL133990 NHLBI NIH HHS
- U01 HL133996 NHLBI NIH HHS
- National Heart, Lung, and Blood Institute
- National Institute on Minority Health and Health Disparities
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Affiliation(s)
- Ana A Baumann
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint Louis, MO, USA.
| | - Jane S Hankins
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
- Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lewis L Hsu
- Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Lynne D Richardson
- Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, New York City, NY, USA
| | - Marsha Treadwell
- Department of Pediatrics, Division of Hematology, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Glassberg
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Bourne
- Addiction Sciences Division, Medical University of South Carolina, Charleston, SC, USA
| | - Lingzi Luo
- School of Global Public Health, New York University, New York City, NY, USA
| | | | | | - Judith Nocek
- Sickle Cell Center, University of Illinois at Chicago, Chicago, IL, USA
| | - Elizabeth Taaffe
- Department of Pediatrics, Washington University in St. Louis, St Louis, MO, USA
| | | | - Ome-Ollin Ruiz
- Department of Pediatrics, Division of Hematology, University of California San Francisco, San Francisco, CA, USA
| | - Chinonyelum Nwosu
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Hematology, St. Jude, Memphis, TN, USA
| | - Nai Qashou
- Department of Pediatrics, Washington University in St. Louis, St Louis, MO, USA
| | - Aimee S James
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint Louis, MO, USA
| | - Paula Tanabe
- Duke University School of Nursing, Durham, NC, USA
| | - Allison A King
- Division of Public Health Sciences, Department of Surgery, Washington University, Saint Louis, MO, USA
- Department of Pediatrics, Washington University in St. Louis, St Louis, MO, USA
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Alagoz E, Saucke M, Balasubramanian P, Lata P, Liebenstein T, Kakumanu S. Barriers to penicillin allergy de-labeling in the inpatient and outpatient settings: a qualitative study. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:88. [PMID: 37821953 PMCID: PMC10568923 DOI: 10.1186/s13223-023-00842-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Penicillin allergy is the most commonly reported drug allergy in the US. Despite evidence demonstrating that up to 90% of labels are incorrect, scalable interventions are not well established. As part of a larger mixed methods investigation, we conducted a qualitative study to describe the barriers to implementing a risk-based penicillin de-labeling protocol within a single site Veteran's hospital. METHODS We conducted individual and group interviews with multidisciplinary inpatient and outpatient healthcare teams. The interview guides were developed using the Theoretical Domains Framework (TDF) to explore workflows and contextual factors influencing identification and evaluation of patients with penicillin allergy. Three researchers iteratively developed the codebook based on TDF domains and coded the data using thematic analysis. RESULTS We interviewed 20 clinicians. Participants included three hospitalists, five inpatient pharmacists, one infectious disease physician, two anti-microbial stewardship pharmacists, four primary care providers, two outpatient pharmacists, two resident physicians, and a nurse case manager for the allergy service. The factors that contributed to barriers to penicillin allergy evaluation and de-labeling were classified under six TDF domains; knowledge, skills, beliefs about capabilities, beliefs about consequences, professional role and identity, and environmental context and resources. Participants from all groups acknowledged the importance of penicillin de-labeling. However, they lacked confidence in their skills to perform the necessary evaluations, such as test dose challenges. The fear of inducing an allergic reaction and adding further complexity to patient care exacerbated their reluctance to de-label patients. The lack of ownership of de-labeling initiative was another significant obstacle in establishing consistent clinical workflows. Additionally, heavy workloads, competing priorities, and ease of access to alternative antibiotics prevented the prioritization of tasks related to de-labeling. Space limitations and nursing staff shortages added to challenges in outpatient settings. CONCLUSION Our findings demonstrated that barriers to penicillin allergy de-labeling fall under multiple behavioral domains. Better role clarification, opportunities to develop necessary skills, and dedicated resources are needed to overcome these barriers. Future interventions will need to employ a systemic approach that addresses each of the behavioral domains influencing penicillin allergy de-labeling with stakeholder engagement of the inpatient and outpatient health care teams.
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Affiliation(s)
- Esra Alagoz
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA.
| | - Megan Saucke
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Paul Lata
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
| | - Tyler Liebenstein
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
| | - Sujani Kakumanu
- William S. Middleton Veterans Memorial Hospital Madison, Madison, WI, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care, University of Wisconsin-Madison, Madison, WI, USA
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Huo Y, Couzner L, Windsor T, Laver K, Dissanayaka NN, Cations M. Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review. Implement Sci Commun 2023; 4:49. [PMID: 37147695 PMCID: PMC10161455 DOI: 10.1186/s43058-023-00428-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 04/05/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Healthcare services can be re-traumatising for trauma survivors where they trigger memories of past distressing events and exert limits to a survivor's sense of autonomy, choice, and control. The benefits of receiving trauma-informed healthcare are well established; however, factors that promote or impede the implementation of trauma-informed care are not yet well characterised and understood. The aim of this review was to systematically identify and synthesise evidence regarding factors that promote or reduce the implementation of TIC in healthcare settings. METHODS This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2.0 guidelines. Scopus, MEDLINE, Proquest, PsycINFO and grey literature were searched for original research or evaluations published between January 2000 and April 2021 reporting barriers and/or facilitating factors for the implementation of trauma-informed care in a healthcare setting. Two reviewers independently assessed the quality of each included study using the Mixed Methods Appraisal Tool (MMAT) Checklist. RESULTS Twenty-seven studies were included, 22 of which were published in the USA. Implementation occurred in a range of health settings, predominantly mental health services. The barriers and facilitators of implementing trauma-informed care were categorised as follows: intervention characteristics (perceived relevance of trauma-informed care to the health setting and target population), influences external to the organisation (e.g. interagency collaboration or the actions of other agencies) and influences within the organisation in which implementation occurred (e.g. leadership engagement, financial and staffing resources and policy and procedure changes that promote flexibility in protocols). Other factors related to the implementation processes (e.g. flexible and accessible training, service user feedback and the collection and review of initiative outcomes) and finally the characteristics of individuals within the service or system such as a resistance to change. CONCLUSIONS This review identifies key factors that should be targeted to promote trauma-informed care implementation. Continued research will be helpful for characterising what trauma-informed care looks like when it is delivered well, and providing validated frameworks to promote organisational uptake for the benefit of trauma survivors. REGISTRATION The protocol for this review was registered on the PROSPERO database (CRD42021242891).
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Affiliation(s)
- Yan Huo
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia
| | - Leah Couzner
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia
| | - Tim Windsor
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia
| | - Kate Laver
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Nadeeka N Dissanayaka
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Psychology, The University of Queensland, Brisbane, QLD, Australia
- Department of Neurology, Royal Brisbane and Woman's Hospital, Brisbane, QLD, Australia
| | - Monica Cations
- College of Education, Psychology and Social Work, Flinders University, Adelaide, SA, Australia.
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Breton M, Gaboury I, Martin E, Green ME, Kiran T, Laberge M, Kaczorowski J, Ivers N, Deville-Stoetzel N, Bordeleau F, Beaulieu C, Descoteaux S. Impact of externally facilitated continuous quality improvement cohorts on Advanced Access to support primary healthcare teams: protocol for a quasi-randomized cluster trial. BMC PRIMARY CARE 2023; 24:97. [PMID: 37038126 PMCID: PMC10088119 DOI: 10.1186/s12875-023-02048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
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.
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Affiliation(s)
- Mylaine Breton
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada.
| | - Isabelle Gaboury
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Elisabeth Martin
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | | | - Tara Kiran
- University of Toronto, Toronto, ON, Canada
| | | | | | - Noah Ivers
- University of Toronto, Toronto, ON, Canada
| | - Nadia Deville-Stoetzel
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Francois Bordeleau
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Christine Beaulieu
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Sarah Descoteaux
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
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Tistad M, Bergström A, Elf M, Eriksson L, Gustavsson C, Göras C, Harvey G, Källberg AS, Rudman A, Unbeck M, Wallin L. Training and support for the role of facilitator in implementation of innovations in health and community care: a scoping review protocol. Syst Rev 2023; 12:15. [PMID: 36721192 PMCID: PMC9887841 DOI: 10.1186/s13643-023-02172-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/13/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Implementing and sustaining innovations in clinical practice, such as evidence-based practices, programmes, and policies, is frequently described as challenging. Facilitation as a strategy for supporting implementation requires a facilitator, i.e. an individual with a designated role to support the implementation process. A growing number of studies report that facilitation can help tackle the challenges in implementation efforts. To optimise the potential contribution of facilitation as a strategy to improve the implementation of new practices, there is a need to enhance understanding about what training and support is required for individuals in the facilitator role. The objective of this scoping review is to map how facilitators have been trained for, and supported in, the facilitator role in implementation studies in health and community care. Specifically, the review aims to examine what is reported on training and support of facilitators in terms of learning outcomes, content, dose, mode of delivery, learning activities, and qualifications of the trainers and how the facilitators perceive training and support. METHODS This scoping review will follow the guidance of the Joanna Briggs Institute and the PRISMA Extension for Scoping Review checklist. We will include articles in which (a) facilitation is deployed as an implementation strategy, with identified facilitator roles targeting staff and managers, to support the implementation of specified innovations in health or community care, and (b) training and/or support of facilitators is reported. We will exclude articles where facilitation is directed to education or training in specific clinical procedures or if facilitation supports the implementation of general quality improvement systems. All types of peer-reviewed studies and study protocols published in English will be included. A systematic search will be performed in MEDLINE (Ovid), Embase (embase.com), Web of Science Core Collection, and CINAHL (Ebsco). DISCUSSION The proposed scoping review will provide a systematic mapping of the literature on the training and support of implementation facilitators and contribute useful knowledge within the field of implementation science to inform future facilitation initiatives. SYSTEMATIC REVIEW REGISTRATION Registered at Open Science Framework (registration https://doi.org/10.17605/OSF.IO/M6NPQ ).
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Affiliation(s)
- Malin Tistad
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Anna Bergström
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women’s and Children’s Health, Uppsala University, Akademiska sjukhuset, Uppsala, SE 751 85 Sweden
| | - Marie Elf
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
| | - Leif Eriksson
- Uppsala Global Health Research on Implementation and Sustainability (UGHRIS), Department of Women’s and Children’s Health, Uppsala University, Akademiska sjukhuset, Uppsala, SE 751 85 Sweden
| | - Catharina Gustavsson
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
- Center for Clinical Research Dalarna–Uppsala University, Nissers väg 3, Falun, SE 791 82 Sweden
- Department of Public Health and Caring Science, Uppsala University, Uppsala, Sweden
| | - Camilla Göras
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
| | - Gill Harvey
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Ann-Sofie Källberg
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
| | - Ann Rudman
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
| | - Maria Unbeck
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Lars Wallin
- School of Health and Welfare, Dalarna University, Falun, SE 791 88 Sweden
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Hasebrook JP, Michalak L, Kohnen D, Metelmann B, Metelmann C, Brinkrolf P, Flessa S, Hahnenkamp K. Digital transition in rural emergency medicine: Impact of job satisfaction and workload on communication and technology acceptance. PLoS One 2023; 18:e0280956. [PMID: 36693080 PMCID: PMC9873191 DOI: 10.1371/journal.pone.0280956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 01/11/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Tele-emergency physicians (TEPs) take an increasingly important role in the need-oriented provision of emergency patient care. To improve emergency medicine in rural areas, we set up the project 'Rural|Rescue', which uses TEPs to restructure professional rescue services using information and communication technologies (ICTs) in order to reduce the therapy-free interval. Successful implementation of ICTs relies on user acceptance and knowledge sharing behavior. METHOD We conducted a factorial design with active knowledge transfer and technology acceptance as a function of work satisfaction (high vs. low), workload (high vs. low) and point in time (prior to vs. after digitalization). Data were collected via machine readable questionnaires issued to 755 persons (411 pre, 344 post), of which 304 or 40.3% of these persons responded (194 pre, 115 post). RESULTS Technology acceptance was higher after the implementation of TEP for nurses but not for other professions, and it was higher when the workload was high. Regarding active communication and knowledge sharing, employees with low work satisfaction are more likely to share their digital knowledge as compared to employees with high work satisfaction. This is an effect of previous knowledge concerning digitalization: After implementing the new technology, work satisfaction increased for the more experienced employees, but not for the less experienced ones. CONCLUSION Our research illustrates that employees' workload has an impact on the intention of using digital applications. The higher the workload, the more people are willing to use TEPs. Regarding active knowledge sharing, we see that employees with low work satisfaction are more likely to share their digital knowledge compared to employees with high work satisfaction. This might be attributed to the Dunning-Kruger effect. Highly knowledgeable employees initially feel uncertain about the change, which translates into temporarily lower work satisfaction. They feel the urge to fill even small knowledge gaps, which in return leads to higher work satisfaction. Those responsible need to acknowledge that digital change affects their employees' workflow and work satisfaction. During such times, employees need time and support to gather information and knowledge in order to cope with digitally changed tasks.
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Hampel K, Hajduova Z. Human Resource Management as an Area of Changes in a Healthcare Institution. Risk Manag Healthc Policy 2023; 16:31-41. [PMID: 36636035 PMCID: PMC9831525 DOI: 10.2147/rmhp.s388185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023] Open
Abstract
Purpose The underlying objective of the paper was to investigate the areas that require changes in human resource management in healthcare institutions. The practical objective of the study was to formulate recommendations targeted at the management staff of a healthcare institution, which allow to increase the adaptability and development capacity of medical personnel with the use of appropriate instruments and methods of human resource management. Patients and Methods The quantitative research was conducted among 652 patients using the services of primary health care clinics located in the Silesian province in Poland, in 2019. The share of women in the research sample was 61%, and men - 39%. 11% of the respondents were students, 27% - people of retirement age, and 62% were economically active. An anonymous survey questionnaire was used. Calculations were performed using Statistica software. Mann-Whitney U-test and correlation analysis using Gamma (Γ) coefficients were used. Results The results of the empirical research showed that the respondents positively assessed most of the examined elements (over 70% of positive opinions). Negative opinions did not exceed the error threshold and amounted up to 5%. The presented results allowed to conclude that the expectations and preferences of patients should be constantly monitored, have an impact on the management of medical personnel and imply introducing changes in the weakest areas. Conclusion The conducted research made it possible to identify the needs and expectations of patients and to develop possible solutions to improve human resource management in healthcare entities. In order to improve the operating conditions of the clinic, managers should constantly monitor patient satisfaction and, if necessary, introduce changes to raise service standards. This will allow early detection of shortcomings and the introduction of necessary changes in the clinic.
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Affiliation(s)
- Katarzyna Hampel
- Faculty of Law and Economics, Jan Dlugosz University in Czestochowa, Częstochowa, Poland
| | - Zuzana Hajduova
- Department of Business Finance, Faculty of Business Management, University of Economics in Bratislava, Bratislava, Slovakia,Correspondence: Zuzana Hajduova, University of Economics in Bratislava, Department of Business Finance, Dolnozemská cesta 1, Bratislava, 852 35, Slovakia, Tel + 421 911 404 473, Email
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Aldridge WA, Roppolo RH, Brown J, Bumbarger BK, Boothroyd RI. Mechanisms of change in external implementation support: A conceptual model and case examples to guide research and practice. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231179761. [PMID: 37790181 PMCID: PMC10291867 DOI: 10.1177/26334895231179761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background External implementation support (EIS) is a well-recognized feature of implementation science and practice, often under related terms such as technical assistance and implementation facilitation. Existing models of EIS have gaps related to addressing practice outcomes at both individual and organizational levels, connecting practice activities to intended outcomes, or grounding in well-established theories of behavior and organization change. Moreover, there have been calls to clarify the mechanisms of change through which EIS influences related outcomes. Method In this article, we theorize about mechanisms of change within EIS. Our theorizing process aligns with the approach advocated by Kislov et al. We aim to consolidate prior EIS literature, combining related constructs from previous empirical and conceptual work while drawing on our extensive EIS experience to develop a higher-order, midrange theory of change. Results Our theory of change is empirically and practically informed, conceptually situated within an established grand theory of change, and guided by eight practice principles and social cognitive theory. The theory of change proposes 10 core practice components as mechanisms of change within EIS. When used according to underlying theory and principles, they are believed to contribute to favorable practice outcomes at individual, team, organizational, and system levels. The model offers flexibility by recognizing the need for sequential support processes and the demand to practice in dynamic and responsive ways. Case examples are presented to illustrate major themes and patterns of the model in action. Conclusions The proposed model is intended to support prospective EIS studies by conceptualizing discernable practice components with hypothesized relationships to proximal and distal practice outcomes. The model can be behaviorally operationalized to compliment and extend competency-based approaches to implementation support practitioner (ISP) training and coaching. Over time, the model should be refined based on new empirical findings and contributions from ISPs across the field.
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Affiliation(s)
- William A. Aldridge
- The Impact Center at Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca H. Roppolo
- The Impact Center at Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Brian K. Bumbarger
- Griffith Criminology Institute, Griffith University, Mount Gravatt, Queensland, Australia
| | - Renée I. Boothroyd
- The Impact Center at Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Koh WQ, Hoel V, Casey D, Toomey E. Strategies to Implement Pet Robots in Long-Term Care Facilities for Dementia Care: A Modified Delphi Study. J Am Med Dir Assoc 2023; 24:90-99. [PMID: 36332687 DOI: 10.1016/j.jamda.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/07/2022] [Accepted: 09/24/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Pet robots are technology-based substitutes for live animals that have demonstrated psychosocial benefits for people living with dementia in long-term care. However, little research has been conducted to understand how pet robots should be implemented in routine care. This study aims to identify, contextualize, and achieve expert consensus on strategies to implement pet robots as part of dementia care in long-term care facilities. DESIGN A 2-round modified Delphi study. SETTINGS AND PARTICIPANTS An international panel of 56 experts from 14 countries, involving care professionals, organizational leaders, and researchers. METHODS A list of potentially relevant strategies was identified, contextualized, and revised using empirical data and through stakeholder consultations. These strategies constituted statements for Round 1. Experts rated the relative importance of each statement on a 9-point scale, and free-text fields allowed them to provide justifications. Consensus was predefined as ≥75% agreement. Statements not reaching an agreement were brought forward to Round 2. Quantitative data were analyzed using descriptive statistics, and textual data were analyzed using inductive content analysis. RESULTS Thirteen strategies reached consensus; 11 were established as critical: (1) assess readiness and identify barriers and facilitators, (2) purposely reexamine the implementation, (3) obtain and use residents' and their family's feedback, (4) involve residents and their family, (5) promote adaptability, (6) conduct ongoing training, (7) conduct educational meetings, (8) conduct local consensus discussions, (9) organize clinician implementation team meetings, (10) provide local technical assistance, and (11) access new funding. Other strategies received differing extents of agreement. Reasons for variations included contextual differences, such as resource availability, organizational structures, and staff turnover. CONCLUSIONS AND IMPLICATIONS This study identified the most relevant strategies that can be used by technology developers, care providers, and researchers to implement pet robots in long-term care facilities for dementia care. Further development, specification, and testing in real-world settings are needed.
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Affiliation(s)
| | - Viktoria Hoel
- Institute for Public Health and Nursing Research, University of Bremen, Germany; Leibniz Science Campus Digital Public Health, Bremen, Germany
| | | | - Elaine Toomey
- School of Allied Health, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland
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Sperber NR, Miech EJ, Clary AS, Perry K, Edwards-Orr M, Rudolph JL, Van Houtven CH, Thomas KS. Determinants of inter-organizational implementation success: A mixed-methods evaluation of Veteran Directed Care. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100653. [PMID: 36108526 PMCID: PMC10174078 DOI: 10.1016/j.hjdsi.2022.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/16/2022] [Accepted: 08/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Veteran Directed Care (VDC) aims to keep Veterans at risk for nursing home placement in their communities. VA medical centers (VAMCs) purchase VDC from third-party organizational providers who then partner with them during implementation. Experiences with VDC implementation have varied. OBJECTIVES We sought to identify conditions differentiating partnerships with higher enrollment (implementation success). METHODS We conducted a case-based study with: qualitative data on implementation determinants two and eight months after program start, directed content analysis to assign numerical scores (-2 strong barrier to +2 strong facilitator), and mathematical modeling using Coincidence Analysis (CNA) to identify key determinants of implementation success. Cases consisted of VAMCs and partnering non-VAMC organizations who started VDC during 2017 or 2018. The Consolidated Framework for Implementation Research (CFIR) guided analysis. RESULTS Eleven individual organizations within five partnerships constituted our sample. Two CFIR determinants- Networks & Communication and External Change Agent-uniquely and consistently identified implementation success. At an inter-organizational partnership level, Networks & Communications and External Change Agent +2 (i.e., present as strong facilitators) were both necessary and sufficient. At a within-organization level, Networks & Communication +2 was necessary but not sufficient for the non-VAMC providers, whereas External Change Agent +2 was necessary and sufficient for VAMCs. CONCLUSION Networks & Communication and External Change Agent played difference-making roles in inter-organizational implementation success, which differ by type of organization and level of analysis. IMPLICATIONS This multi-level approach identified crucial difference-making conditions for inter-organizational implementation success when putting a program into practice requires partnerships across multiple organizations.
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Affiliation(s)
- Nina R Sperber
- Center to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, USA; Department of Population Health Sciences, Duke University, USA; Duke-Margolis Center for Health Policy, USA.
| | - Edward J Miech
- VA EXTEND QUERI, VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, USA
| | | | - Kathleen Perry
- Vagelos College of Physicians & Surgeons, Columbia University, USA
| | | | - James L Rudolph
- Brown University School of Public Health, USA; Providence VA Medical Center, USA
| | - Courtney Harold Van Houtven
- Center to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, USA; Department of Population Health Sciences, Duke University, USA; Duke-Margolis Center for Health Policy, USA
| | - Kali S Thomas
- Brown University School of Public Health, USA; Providence VA Medical Center, USA
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Luth EA, Manful A, Weissman JS, Reich A, Ladin K, Semco R, Ganguli I. Practice Billing for Medicare Advance Care Planning Across the USA. J Gen Intern Med 2022; 37:3869-3876. [PMID: 35083654 PMCID: PMC9640523 DOI: 10.1007/s11606-022-07404-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown. OBJECTIVE Examine the role of practices in ACP billing. DESIGN Retrospective cohort study analyzing 2016-2018 national Medicare data. PARTICIPANTS A total of 53,926 practices with at least 10 attributed Medicare beneficiaries. MAIN MEASURES Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix. KEY RESULTS Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ). CONCLUSIONS Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.
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Affiliation(s)
| | - Adoma Manful
- Vanderbilt University, Nashville, TN, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Amanda Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, MA, USA
| | | | - Ishani Ganguli
- Harvard Medical School and Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
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Boerkoel A, Brommels M. The processes involved in the establishment of user-provider partnerships in severe psychiatric illnesses: a scoping review. BMC Psychiatry 2022; 22:660. [PMID: 36289473 PMCID: PMC9608879 DOI: 10.1186/s12888-022-04303-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/11/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE With the rising relevance of person-centred care, initiatives towards user-led decision making and designing of care services have become more frequent. This designing of care services can be done in partnership, but it is unclear how. The aim of this scoping review was to identify for mental health services, what user-provider partnerships are, how they arise in practice and what can facilitate or hinder them. METHODS A scoping review was conducted to obtain a broad overview of user provider partnerships in severe mental illness. Data was inductively analysed using a conventional content analysis approach, in which meaning was found in the texts. RESULTS In total, 1559 titles were screened for the eligibility criteria and the resulting 22 papers found relevant were analysed using conventional content analysis. The identified papers had broad and differing concepts for user-provider partnerships. Papers considered shared decision making and user-involvement as partnerships. Mechanisms such as open communication, organisational top-down support and active participation supported partnerships, but professional identity, power imbalances and stress hindered them. Users can be impeded by their illness, but how to deal with these situations should be formalised through contracts. CONCLUSION The field of research around user-provider partnerships is scattered and lacks consensus on terminology. A power imbalance between a user and a provider is characteristic of partnerships in mental healthcare, which hinders the necessary relationship building allowing partnerships to arise. This power imbalance seems to be closely linked to professional identity, which was found to be difficult to change.
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Affiliation(s)
- Aletta Boerkoel
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany. .,Department for Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden.
| | - Mats Brommels
- grid.465198.7Department for Learning, Informatics, Management and Ethics, Karolinska Institutet, Solna, Sweden
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Stover AM, Wang M, Shea CM, Richman E, Rees J, Cherrington AL, Cummings DM, Nicholson L, Peaden S, Craft M, Mackey M, Safford MM, Halladay JR. The Key Driver Implementation Scale (KDIS) for practice facilitators: Psychometric testing in the “Southeastern collaboration to improve blood pressure control” trial. PLoS One 2022; 17:e0272816. [PMID: 36001592 PMCID: PMC9401114 DOI: 10.1371/journal.pone.0272816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 07/17/2022] [Indexed: 11/19/2022] Open
Abstract
Background Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the “Key Driver Implementation Scale” (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale’s psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial. Methods The KDIS items assess a practice’s progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options. Results PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care. Conclusions The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one.
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Affiliation(s)
- Angela M. Stover
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States of America
- * E-mail:
| | - Mian Wang
- Lineberger Comprehensive Cancer Center, Chapel Hill, NC, United States of America
| | - Christopher M. Shea
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Erica Richman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Jennifer Rees
- NC Tracs Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Andrea L. Cherrington
- University of Alabama Birmingham, School of Medicine, Birmingham, AL, United States of America
| | | | - Liza Nicholson
- Department of Public Health, Samford University, Birmingham, AL, United States of America
| | - Shannon Peaden
- East Carolina University, Greenville, NC, United States of America
| | - Macie Craft
- University of Alabama Birmingham, School of Medicine, Birmingham, AL, United States of America
| | - Monique Mackey
- Area L Area Health Education Center (AHEC)—Part of the NC AHEC Program, Rocky Mount, NC, United States of America
| | | | - Jacqueline R. Halladay
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Dellve L, Williamsson A. Development Work in Swedish Eldercare: Resources for Trustworthy, Integrated Managerial Work During the COVID-19 Pandemic. Front Public Health 2022; 10:864272. [PMID: 35844876 PMCID: PMC9280882 DOI: 10.3389/fpubh.2022.864272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/06/2022] [Indexed: 11/13/2022] Open
Abstract
The extensive needs for developments of eldercare addressing working conditions, care quality, influence, and safety was highlighted during the pandemic. This mixed-method study contribute with knowledge about capability-strengthening development work and its importance for trustworthy managerial work, before and during the COVID-19 pandemic. Questionnaire data and narratives from first-line managers immediately before (n = 284) and 16 months into the pandemic (n = 189), structured interviews with development leaders (n = 25), and documents were analyzed. The results identify different focuses of development work. Strategic-level development leaders focused the strengthening of old adults' capabilities. While operational-level leaders approached strengthening employees' capability. First-line managers' rating of their trustworthy managerial work decreased during the pandemic and was associated with their workload, development support and capability-strengthening projects focusing employees' resources. The study demonstrates the gap between strategic and the operational levels regarding understanding of capability set and needed resources for strengthening capabilities and trustworthy, integrated managerial work regarding safety, influence, and quality conditions for old adults and employees.
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Affiliation(s)
- Lotta Dellve
- Department of Sociology and Work Science, Faculty of Social Sciences, University of Gothenburg, Gothenburg, Sweden
- *Correspondence: Lotta Dellve
| | - Anna Williamsson
- Department of Biomedical Engineering and Health Systems, School of Chemistry, Biotechnology and Health, Royal Institute of Technology, Stockholm, Sweden
- Production and Work Environment, Methodology, Textiles and Medical Technology, RISE Research Institutes of Sweden, Stockholm, Sweden
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Ye J, Woods D, Bannon J, Bilaver L, Kricke G, McHugh M, Kho A, Walunas T. Identifying Contextual Factors and Strategies for Practice Facilitation in Primary Care Quality Improvement Using an Informatics-Driven Model: Framework Development and Mixed Methods Case Study. JMIR Hum Factors 2022; 9:e32174. [PMID: 35749211 PMCID: PMC9269526 DOI: 10.2196/32174] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/11/2021] [Accepted: 05/01/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives. OBJECTIVE This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world case study. METHODS We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study. RESULTS The proposed framework was used to organize and analyze different stakeholders' perspectives and key factors based on framework domains. The case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients' social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs. CONCLUSIONS Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation-supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.
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Affiliation(s)
- Jiancheng Ye
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Donna Woods
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Jennifer Bannon
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Lucy Bilaver
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Gayle Kricke
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Megan McHugh
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Abel Kho
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Theresa Walunas
- Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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20
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Golan M, Ankori G, Hager T. Non-Cooperation within a School-Based Wellness Program during the COVID-19 Pandemic-A Qualitative Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19116798. [PMID: 35682381 PMCID: PMC9180888 DOI: 10.3390/ijerph19116798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/30/2022] [Accepted: 05/30/2022] [Indexed: 02/04/2023]
Abstract
This paper presents a qualitative analysis of COVID-19′s impact on the development, delivery, and uptake of “Favoring Myself”, a school-based interactive wellness program conducted via Zoom during 2020–2021. “Favoring Myself” targets resilience, self-esteem, body-esteem, self-care behaviors, and media literacy among 5th-grade preadolescents. Data were obtained from meetings, 23 semi-structured interviews with parents, teachers, and principals, and other modes of correspondence. All data were transcribed and thematically analyzed. The analysis highlighted the barriers faced when delivering external programs during COVID-19. Parents’ difficulties in cooperating with the program, distrustful relationships between parents and the education system, as well as teachers’ overload and stress, were identified as barriers to the external program’s sustainability. These challenges are discussed in light of previous studies of school-based programs, the psychological and social contexts of an ongoing crisis and the impact of neoliberalism on education. This study concludes that school-based prevention programs and accompanying research should be more flexible and focus on understanding and relating to parents’ and schools’ fears, uncertainties, and resistance. It is the hope of the authors that knowledge created through this exploration will be helpful in future coping vis-à-vis prevention program teams and recipients in times of unpredictable, unmanageable, and overpowering crises.
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Affiliation(s)
- Moria Golan
- Department of Nutritional Sciences, Tel-Hai College, Upper Galilee 1220800, Israel
- Shahaf, Community Based Facility for Body Image and Eating, Ganey Hadar 7683000, Israel
- Correspondence: ; Tel.: +97-(254)-724-0330
| | - Galia Ankori
- Faculty of Social Sciences and Humanities, Tel-Hai College, Upper Galilee 1220800, Israel; (G.A.); (T.H.)
- Child and Adolescence Mental Health Clinic of Maccabi Health Services, Sderot Binyamin 21, Netanya 4231111, Israel
| | - Tamar Hager
- Faculty of Social Sciences and Humanities, Tel-Hai College, Upper Galilee 1220800, Israel; (G.A.); (T.H.)
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21
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Ballengee LA, Rushton S, Lewinski AA, Hwang S, Zullig LL, Ricks KAB, Ramos K, Brahmajothi MV, Moore TS, Blalock DV, Cantrell S, Kosinski AS, Gordon A, Ear B, Williams JW, Gierisch JM, Goldstein KM. Effectiveness of Quality Improvement Coaching on Process Outcomes in Health Care Settings: A Systematic Review. J Gen Intern Med 2022; 37:885-899. [PMID: 34981354 PMCID: PMC8904663 DOI: 10.1007/s11606-021-07217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A culture of improvement is an important feature of high-quality health care systems. However, health care teams often need support to translate quality improvement (QI) activities into practice. One method of support is consultation from a QI coach. The literature suggests that coaching interventions have a positive impact on clinical outcomes. However, the impact of coaching on specific process outcomes, like adoption of clinical care activities, is unknown. Identifying the process outcomes for which QI coaching is most effective could provide specific guidance on when to employ this strategy. METHODS We searched multiple databases from inception through July 2021. Studies that addressed the effects of QI coaching on process of care outcomes were included. Two reviewers independently extracted study characteristics and assessed risk of bias. Certainty of evidence was assessed using GRADE. RESULTS We identified 1983 articles, of which 23 cluster-randomized trials met eligibility criteria. All but two took place in a primary care setting. Overall, interventions typically targeted multiple simultaneous processes of care activities. We found that coaching probably has a beneficial effect on composite process of care outcomes (n = 9) and ordering of labs and vital signs (n = 6), and possibly has a beneficial effect on changes in organizational process of care (n = 5), appropriate documentation (n = 5), and delivery of appropriate counseling (n = 3). We did not perform meta-analyses because of conceptual heterogeneity around intervention design and outcomes; rather, we synthesized the data narratively. Due to imprecision, inconsistency, and high risk of bias of the included studies, we judged the certainty of these results as low or very low. CONCLUSION QI coaching interventions may affect certain processes of care activities such as ordering of labs and vital signs. Future research that advances the identification of when QI coaching is most beneficial for health care teams seeking to implement improvement processes in pursuit of high-quality care will support efficient use of QI resources. PROTOCOL REGISTRATION This study was registered and followed a published protocol (PROSPERO: CRD42020165069).
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Affiliation(s)
- Lindsay A Ballengee
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA.
- Department of Orthopaedic Surgery, Duke University School of Medicine, Division of Physical Therapy, Duke University, Durham, NC, USA.
| | | | - Allison A Lewinski
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- School of Nursing, Duke University, Durham, NC, USA
| | - Soohyun Hwang
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Leah L Zullig
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Katharine A Ball Ricks
- Cecil G. Sheps Center for Health Service Research, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine Ramos
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Department of Medicine Geriatrics, Duke University, Durham, NC, USA
- Center for the Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Mulugu V Brahmajothi
- Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, NC, USA
| | - Thomasena S Moore
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Dan V Blalock
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Adelaide Gordon
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - Belinda Ear
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
| | - John W Williams
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Department of Population Health Sciences, School of Medicine, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, 411 West Chapel Hill St., Suite 600, Durham, NC, 27701, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
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22
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Jepkosgei J, Nzinga J, Adam MB, English M. Exploring healthcare workers' perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals' newborn units. BMC Health Serv Res 2022; 22:172. [PMID: 35144594 PMCID: PMC8832787 DOI: 10.1186/s12913-022-07572-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits. METHODS This was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach. RESULTS Perceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors. CONCLUSION Our findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.
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Affiliation(s)
- Joyline Jepkosgei
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya.
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
| | | | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, P. O. Box 43640 - 00100, 197 Lenana Place, Lenana Road, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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23
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Poureslami I, FitzGerald JM, Tregobov N, Goldstein RS, Lougheed MD, Gupta S. Health literacy in asthma and chronic obstructive pulmonary disease (COPD) care: a narrative review and future directions. Respir Res 2022; 23:361. [PMID: 36529734 PMCID: PMC9760543 DOI: 10.1186/s12931-022-02290-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Respiratory self-care places considerable demands on patients with chronic airways disease (AD), as they must obtain, understand and apply information required to follow their complex treatment plans. If clinical and lifestyle information overwhelms patients' HL capacities, it reduces their ability to self-manage. This review outlines important societal, individual, and healthcare system factors that influence disease management and outcomes among patients with asthma and chronic obstructive pulmonary disease (COPD)-the two most common ADs. For this review, we undertook a comprehensive literature search, conducted reference list searches from prior HL-related publications, and added insights from international researchers and scientists with an interest in HL. We identified methodological limitations in currently available HL measurement tools in respiratory care. We also summarized the issues contributing to low HL and system-level cultural incompetency that continue to be under-recognized in AD management and contribute to suboptimal patient outcomes. Given that impaired HL is not commonly recognized as an important factor in AD care, we propose a three-level patient-centered model (strategies) designed to integrate HL considerations, with the goal of enabling health systems to enhance service delivery to meet the needs of all AD patients.
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Affiliation(s)
- Iraj Poureslami
- grid.417243.70000 0004 0384 4428Division of Respiratory Medicine, Centre for Lung Health, Vancouver Coastal Health Research Institute, University of British Columbia, 716-828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada ,Canadian Multicultural Health Promotion Society (CMHPS), Vancouver, BC Canada
| | - J. Mark FitzGerald
- grid.417243.70000 0004 0384 4428Division of Respiratory Medicine, Centre for Lung Health, Vancouver Coastal Health Research Institute, University of British Columbia, 716-828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Noah Tregobov
- grid.417243.70000 0004 0384 4428Division of Respiratory Medicine, Centre for Lung Health, Vancouver Coastal Health Research Institute, University of British Columbia, 716-828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada ,grid.17091.3e0000 0001 2288 9830Faculty of Medicine, Vancouver-Fraser Medical Program, University of British Columbia, Vancouver, BC Canada
| | - Roger S. Goldstein
- grid.17063.330000 0001 2157 2938Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada ,Respiratory Medicine, Westpark Healthcare Centre, Toronto, Canada ,grid.17063.330000 0001 2157 2938Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON Canada
| | - M. Diane Lougheed
- grid.410356.50000 0004 1936 8331Asthma Research Unit, Department of Medicine, Kingston Health Sciences Centre, Queen’s University, Kingston, ON Canada ,grid.418647.80000 0000 8849 1617Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | - Samir Gupta
- grid.415502.7Unity Health, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON Canada
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24
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Russell GM, Long K, Lewis V, Enticott JC, Gunatillaka N, Cheng IH, Marsh G, Vasi S, Advocat J, Saito S, Song H, Casey S, Smith M, Harris MF. OPTIMISE: a pragmatic stepped wedge cluster randomised trial of an intervention to improve primary care for refugees in Australia. Med J Aust 2021; 215:420-426. [PMID: 34585377 PMCID: PMC9292802 DOI: 10.5694/mja2.51278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To examine whether primary care outreach facilitation improves the quality of care for general practice patients from refugee backgrounds. DESIGN Pragmatic, cluster randomised controlled trial, with stepped wedge allocation to early or late intervention groups. SETTING, PARTICIPANTS 31 general practices in three metropolitan areas of Sydney and Melbourne with high levels of refugee resettlement, November 2017 - August 2019. INTERVENTION Trained facilitators made three visits to practices over six months, using structured action plans to help practice teams optimise routines of refugee care. MAJOR OUTCOME MEASURE Change in proportion of patients from refugee backgrounds with documented health assessments (Medicare billing). Secondary outcomes were refugee status recording, interpreter use, and clinician-perceived difficulty in referring patients to appropriate dental, social, settlement, and mental health services. RESULTS Our sample comprised 14 633 patients. The intervention was associated with an increase in the proportion of patients with Medicare-billed health assessments during the preceding six months, from 19.1% (95% CI, 18.6-19.5%) to 27.3% (95% CI, 26.7-27.9%; odds ratio, 1.88; 95% CI, 1.42-2.50). The impact of the intervention was greater in smaller practices, practices with larger proportions of patients from refugee backgrounds, recent training in refugee health care, or higher baseline provision of health assessments for such patients. There was no impact on refugee status recording, interpreter use increased modestly, and reported difficulties in refugee-specific referrals to social, settlement and dental services were reduced. CONCLUSIONS Low intensity practice facilitation may improve some aspects of primary care for people from refugee backgrounds. Facilitators employed by local health services could support integrated approaches to enhancing the quality of primary care for this vulnerable population. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12618001970235 (retrospective).
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Affiliation(s)
| | | | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, VIC
| | - Joanne C Enticott
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC.,Southern Synergy, Monash University, Melbourne, VIC
| | - Nilakshi Gunatillaka
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, VIC
| | | | - Geraldine Marsh
- Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne, VIC
| | | | | | - Shoko Saito
- Centre for Primary Health Care and Equity, UNSW, Sydney, NSW
| | - Hyun Song
- Centre for Primary Health Care and Equity, UNSW, Sydney, NSW.,NSW Agency for Clinical Innovation, Sydney, NSW
| | - Sue Casey
- Victorian Foundation for Survivors of Torture, Melbourne, VIC
| | - Mitchell Smith
- NSW Refugee Health Service, South Western Sydney Local Health District, Sydney, NSW
| | - Mark F Harris
- Centre for Primary Health Care and Equity, UNSW, Sydney, NSW
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25
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Heidenreich PA, Lin S, Gholami P, Moore VR, Burk ML, Glassman PA, Cunningham FE, Sahay A. Interventions to Increase Leukocyte Testing during Treatment with Dimethyl Fumarate. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910312. [PMID: 34639610 PMCID: PMC8507868 DOI: 10.3390/ijerph181910312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 11/27/2022]
Abstract
Dimethyl fumarate (DMF), a treatment for multiple sclerosis, may cause leukopenia and infection. Accordingly, periodic white blood cell (WBC) monitoring is recommended. We sought to evaluate the US Department of Veteran Affairs’ safety program which provides facilities with a list of patients prescribed DMF therapy without a documented white blood cell count (WBC). We identified 118 sites with patients treated with DMF from 1 January 2016 through 30 September 2016. Each site was asked if any of seven interventions were used to improve WBC monitoring (academic detailing, provider education without academic detailing, electronic clinical reminders, request for provider action plan, draft orders for WBC monitoring, patient mailings, and patient calls). The survey response rate was 78%. For the 92 responding sites (78%) included sites (1115 patients) the mean rate of WBC monitoring was 54%. In multivariate analysis, academic detailing increased the rate by 17% (95% CI 4 to 30%, p = 0.011) and provider education increased the rate by 9% (95% CI 0.6 to 18%, p = 0.037). The WBC monitoring rate increased by 3.8% for each additional intervention used (95% CI 1.2–6.4%, p = 0.005). Interventions focused on the physician, including academic detailing, were associated with improved WBC monitoring for patients at risk for leukopenia from DMF treatment.
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Affiliation(s)
- Paul A. Heidenreich
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA; (S.L.); (P.G.); (A.S.)
- Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
- Correspondence: ; Tel.: +1-650-849-1205
| | - Shoutzu Lin
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA; (S.L.); (P.G.); (A.S.)
| | - Parisa Gholami
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA; (S.L.); (P.G.); (A.S.)
| | - Von R. Moore
- Veterans Affairs Center for Medication Safety Pharmacy Benefits Management Services, Hines, IL 60141, USA; (V.R.M.); (M.L.B.); (F.E.C.)
| | - Muriel L. Burk
- Veterans Affairs Center for Medication Safety Pharmacy Benefits Management Services, Hines, IL 60141, USA; (V.R.M.); (M.L.B.); (F.E.C.)
| | - Peter A. Glassman
- Veterans Affairs VA Pharmacy Benefits Management Services, Washington, DC 20004, USA;
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - Francesca E. Cunningham
- Veterans Affairs Center for Medication Safety Pharmacy Benefits Management Services, Hines, IL 60141, USA; (V.R.M.); (M.L.B.); (F.E.C.)
| | - Anju Sahay
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA; (S.L.); (P.G.); (A.S.)
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26
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Kerins C, Kelly C, Reardon CM, Houghton C, Toomey E, Hayes CB, Geaney F, Perry IJ, McSharry J, McHugh S. Factors Influencing Fidelity to a Calorie Posting Policy in Public Hospitals: A Mixed Methods Study. Front Public Health 2021; 9:707668. [PMID: 34485232 PMCID: PMC8414889 DOI: 10.3389/fpubh.2021.707668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/14/2021] [Indexed: 12/04/2022] Open
Abstract
Background: Labelling menus with nutrition information has increasingly become an important obesity policy option. While much research to-date has focused on determining its effectiveness, few studies report the extent to which menu labelling is implemented as designed. The aim of this study was to explore factors influencing fidelity to a calorie posting policy in Irish acute public hospitals. Methods: A mixed methods sequential explanatory study design was employed, with a nested case study for the qualitative component. Quantitative data on implementation fidelity at hospitals were analysed first and informed case sampling in the follow-on qualitative phase. Maximum variation sampling was used to select four hospitals with high and low levels of implementation and variation in terms of geographic location, hospital size, complexity of care provided and hospital type. Data were collected using structured observations, unstructured non-participant observations and in-depth semi-structured interviews. The Consolidated Framework for Implementation Research guided qualitative data collection and analysis. Using framework analysis, factors influencing implementation were identified. A triangulation protocol was used to integrate fidelity findings from multiple sources. Data on influencing factors and fidelity were then combined using joint displays for within and cross-case analysis. Results: Quantitative fidelity data showed seven hospitals were categorised as low implementers and 28 hospitals were high implementers of the policy. Across the four hospitals selected as cases, qualitative analysis revealed factors influencing implementation and fidelity were multiple, and operated independently and in combination. Factors were related to the internal hospital environment (e.g., leadership support, access to knowledge and information, perceived importance of calorie posting implementation), external hospital environment (e.g., national policy, monitoring), features of the calorie posting policy (e.g., availability of supporting materials), and the implementation process (e.g., engaging relevant stakeholders). Integrated analysis of fidelity indicated a pattern of partial adherence to the calorie posting policy across the four hospitals. Across all hospitals, there was a consistent pattern of low adherence to calorie posting across all menu items on sale, low adherence to calorie information displayed per standard portion or per meal, low adherence to standardised recipes/portions, and inaccurate calorie information. Conclusion: Efforts to maximise fidelity require multi-level, multi-component strategies in order to reduce or mitigate barriers and to leverage facilitators. Future research should examine the relative importance of calorie posting determinants and the association between implementation strategies and shifts in fidelity to intervention core components.
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Affiliation(s)
- Claire Kerins
- Discipline of Health Promotion, School of Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - Colette Kelly
- Discipline of Health Promotion, School of Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - Caitlin M Reardon
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Elaine Toomey
- Faculty of Education and Health Sciences, School of Allied Health, University of Limerick, Limerick, Ireland.,Health Research Institute, University of Limerick, Limerick, Ireland
| | - Catherine B Hayes
- Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Fiona Geaney
- School of Public Health, University College Cork, Cork, Ireland
| | - Ivan J Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
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27
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Gaboury I, Breton M, Perreault K, Bordeleau F, Descôteaux S, Maillet L, Hudon C, Couturier Y, Duhoux A, Vachon B, Cossette B, Rodrigues I, Poitras ME, Loignon C, Vasiliadis HM. Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services. BMC Health Serv Res 2021; 21:812. [PMID: 34388996 PMCID: PMC8361639 DOI: 10.1186/s12913-021-06839-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/30/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.
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Affiliation(s)
- Isabelle Gaboury
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada.
| | - Mylaine Breton
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Kathy Perreault
- GMF-U Saint-Jean-sur-Richelieu, Saint-Jean-sur-Richelieu, Canada
| | - François Bordeleau
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Sarah Descôteaux
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Lara Maillet
- École Nationale d'Administration Publique, Montreal, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Yves Couturier
- School of social work, Faculty of letters and social sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montreal, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Benoit Cossette
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Isabel Rodrigues
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Marie-Eve Poitras
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Christine Loignon
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Helen-Maria Vasiliadis
- Department of community health sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
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Penney LS, Damush TM, Rattray NA, Miech EJ, Baird SA, Homoya BJ, Myers LJ, Bravata DM. Multi-tiered external facilitation: the role of feedback loops and tailored interventions in supporting change in a stepped-wedge implementation trial. Implement Sci Commun 2021; 2:82. [PMID: 34315540 PMCID: PMC8317410 DOI: 10.1186/s43058-021-00180-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 06/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Facilitation is a complex, relational implementation strategy that guides change processes. Facilitators engage in multiple activities and tailor efforts to local contexts. How this work is coordinated and shared among multiple, external actors and the contextual factors that prompt and moderate facilitators to tailor activities have not been well-described. METHODS We conducted a mixed methods evaluation of a trial to improve the quality of transient ischemic attack care. Six sites in the Veterans Health Administration received external facilitation (EF) before and during a 1-year active implementation period. We examined how EF was employed and activated. Data analysis included prospective logs of facilitator correspondence with sites (160 site-directed episodes), stakeholder interviews (a total of 78 interviews, involving 42 unique individuals), and collaborative call debriefs (n=22) spanning implementation stages. Logs were descriptively analyzed across facilitators, sites, time periods, and activity types. Interview transcripts were coded for content related to EF and themes were identified. Debriefs were reviewed to identify instances of and utilization of EF during site critical junctures. RESULTS Multi-tiered EF was supported by two groups (site-facing quality improvement [QI] facilitators and the implementation support team) that were connected by feedback loops. Each site received an average of 24 episodes of site-directed EF; most of the EF was delivered by the QI nurse. For each site, site-directed EF frequently involved networking (45%), preparation and planning (44%), process monitoring (44%), and/or education (36%). EF less commonly involved audit and feedback (20%), brainstorming solutions (16%), and/or stakeholder engagement (5%). However, site-directed EF varied widely across sites and time periods in terms of these facilitation types. Site participants recognized the responsiveness of the QI nurse and valued her problem-solving, feedback, and accountability support. External facilitators used monitoring and dialogue to intervene by facilitating redirection during challenging periods of uncertainty about project direction and feasibility for sites. External facilitators, in collaboration with the implementation support team, successfully used strategies tailored to diverse local contexts, including networking, providing data, and brainstorming solutions. CONCLUSIONS Multi-tiered facilitation capitalizing on emergent feedback loops allowed for tailored, site-directed facilitation. Critical juncture cases illustrate the complexity of EF and the need to often try multiple strategies in combination to facilitate implementation progress. TRIAL REGISTRATION The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) is a registered trial ( NCT02769338 ), May 11, 2016-prospectively registered.
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Affiliation(s)
- Lauren S. Penney
- grid.280682.60000 0004 0420 5695VA HSR&D Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System, San Antonio, TX USA ,grid.267309.90000 0001 0629 5880School of Medicine, University of Texas Health at San Antonio, San Antonio, TX USA
| | - Teresa M. Damush
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA
| | - Nicholas A. Rattray
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Anthropology, Indiana University-Purdue University, Indianapolis, IN USA
| | - Edward J. Miech
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA
| | - Sean A. Baird
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Barbara J. Homoya
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Laura J. Myers
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA
| | - Dawn M. Bravata
- grid.280828.80000 0000 9681 3540VA HSR&D Center for Health Information and Communication (CHIC), Richard L. Roudebush VA Medical Center, Indianapolis, IN USA ,grid.448342.d0000 0001 2287 2027Regenstrief Institute, Inc., Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN USA ,grid.257413.60000 0001 2287 3919Department of Neurology, Indiana University School of Medicine, Indianapolis, IN USA
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Impact of a statewide computed tomography scan educational campaign on radiation dose and repeat CT scan rates for transferred injured children. J Clin Transl Sci 2021; 5:e129. [PMID: 34367674 PMCID: PMC8327550 DOI: 10.1017/cts.2021.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign's impact on injured children received radiation dose. Methods All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. Results Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). Conclusion A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.
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Ritchie MJ, Parker LE, Kirchner JE. From novice to expert: methods for transferring implementation facilitation skills to improve healthcare delivery. Implement Sci Commun 2021; 2:39. [PMID: 33832549 PMCID: PMC8033694 DOI: 10.1186/s43058-021-00138-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is substantial evidence that facilitation can address the challenges of implementing evidence-based innovations. However, facilitators need a wide variety of complex skills; lack of these can have a negative effect on implementation outcomes. Literature suggests that novice and less experienced facilitators need ongoing support from experts to develop these skills. Yet, no studies have investigated the transfer process. During a test of a facilitation strategy applied at 8 VA primary care clinics, we explored the techniques and processes an expert external facilitator utilized to transfer her skills to two initially novice internal facilitators who became experts. METHODS In this qualitative descriptive study, we conducted monthly debriefings with three facilitators over a 30-month period and documented these in detailed notes. Debriefings with the expert facilitator focused on how she trained and mentored facilitation trainees. We also conducted, recorded, and transcribed two semi-structured qualitative interviews with each facilitator and queried them about training content and process. We used a mix of inductive and deductive approaches to analyze data; our analysis was informed by a review of mentoring, coaching, and cognitive apprenticeship literature. We also used a case comparison approach to explore how the expert tailored her efforts. RESULTS The expert utilized 21 techniques to transfer implementation facilitation skills. Techniques included both active (providing information, modeling, and coaching) and participatory ones. She also used techniques to support learning, i.e., cognitive supports (making thinking visible, using heuristics, sharing experiences), psychosocial supports, strategies to promote self-learning, and structural supports. Additionally, she transferred responsibility for facilitation through a dynamic process of interaction with trainees and site stakeholders. Finally, the expert varied the level of focus on particular skills to tailor her efforts to trainee and local context. CONCLUSIONS This study viewed the journey from novice to expert facilitator through the lens of the expert who transferred facilitation skills to support implementation of an evidence-based program. It identified techniques and processes that may foster transfer of these skills and build organizational capacity for future implementation efforts. As the first study to document the implementation facilitation skills transfer process, findings have research and practical implications.
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Affiliation(s)
- Mona J. Ritchie
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
| | - Louise E. Parker
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Management, College of Management, University of Massachusetts, 100 Morrissey Blvd, Boston, MA 02125 USA
| | - JoAnn E. Kirchner
- VA Behavioral Health Quality Enhancement Research Initiative (QUERI), Department of Veterans Affairs, 2200 Ft Roots Dr, Building 58, North Little Rock, AR 72114 USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W Markham St, #755, Little Rock, AR 72205 USA
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Using Lean-Facilitation to Improve Quality of Hepatitis C Testing in Primary Care. J Gen Intern Med 2021; 36:349-357. [PMID: 32930938 PMCID: PMC7878607 DOI: 10.1007/s11606-020-06210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Lean management has been successfully employed in healthcare to improve outcomes and efficiencies. Facilitation is increasingly being used to support evidence-based practice uptake in healthcare. However, while both Lean and Facilitation are used in healthcare quality improvement, limited research has explored their integration and the sustainability of their combined effects. OBJECTIVE To improve hepatitis C virus (HCV) screening rates among persons born between 1945 and 1965 through the design and evaluation of a multi-modal Lean-Facilitation intervention (LFI) for Department of Veterans Affairs primary care community clinics. DESIGN We conducted a mixed methods quasi-experimental evaluation in eight clinics, guided by the integrated Promoting Action on Research Implementation in Health Services framework. PARTICIPANTS We engaged regional and local leadership (N = 9), implemented our LFI with clinicians and staff (N = 68), and conducted summative interviews with participants (N = 13). INTERVENTION The LFI included six implementation strategies: (1) external facilitation, (2) stakeholder engagement, (3) champion activation, (4) rapid process improvement sessions, (5) Plan-Do-Study-Act cycles, and (6) audit-feedback. MEASURES The primary outcome was rate of new HCV screening among previously untested patients with a primary care visit. Using interrupted time series, we analyzed intervention and time effects on HCV testing rates, and administered organizational readiness surveys, conducted summative qualitative interviews, and tracked facilitation events. RESULTS The LFI was associated with significant, immediate, and sustained increases in HCV testing. No change was detected at matched comparison clinics. Staff accepted the LFI and the philosophy of "bottom-up" solution development yet had mixed feedback on its appropriateness and feasibility. Enablers of implementation and early sustainment included lower satisfaction with baseline HCV testing processes and staff culture, while later sustainment was related to implementation climate support, measurement, and evaluation. CONCLUSIONS High-reach and relatively low effort, but persistent intervention led to significant improvement in guideline-concordant HCV testing rates which were sustained. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02936648.
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Piat M, Wainwright M, Sofouli E, Albert H, Casey R, Rivest MP, Briand C, Kasdorf S, Labonté L, LeBlanc S, O'Rourke JJ. The CFIR Card Game: a new approach for working with implementation teams to identify challenges and strategies. Implement Sci Commun 2021; 2:1. [PMID: 33413699 PMCID: PMC7791817 DOI: 10.1186/s43058-020-00099-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 11/29/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The Consolidated Framework for Implementation Research (CFIR) and the ERIC compilation of implementation strategies are key resources for identifying implementation barriers and strategies. However, their respective density and complexity make their application to implementation planning outside of academia challenging. We developed the CFIR Card Game as a way of working with multi-stakeholder implementation teams that were implementing mental health recovery into their services, to identify barriers and strategies to overcome them. The aim of this descriptive evaluation is to describe how the game was prepared, played, used and received by teams and researchers and their perception of the clarity of the CFIR constructs. METHODS We used the new CFIR-ERIC Matching Tool v.1 to design the game. We produced a deck of cards with each of the CFIR-ERIC Matching Tool barrier narratives representing all 39 CFIR constructs. Teams played the game at the pre-implementation stage at a time when they were actively engaged in a planning process for implementing their selected recovery-oriented innovation. The teams placed each card in either the YES or NO column of the board in response to whether they anticipated experiencing this barrier in their setting. Teams were also asked about the clarity of the barrier narratives and were provided with plain language versions if unclear. Researchers completed a reflection form following the game, and participants completed an open-added questionnaire that included questions specific to the CFIR Card Game. We applied a descriptive coding approach to analysis. RESULTS Four descriptive themes emerged from this analysis: (1) the CFIR Card Game as a useful and engaging process, (2) difficulties understanding CFIR construct barrier narratives, (3) strengths of the game's design and structure and room for improvement and (4) mediating factors: facilitator preparation and multi-stakeholder dynamics. Quantitative findings regarding the clarity of the barrier narratives were integrated with qualitative data under theme 2. Only seven of the 39 original barrier narratives were judged to be clear by all teams. CONCLUSIONS The CFIR Card Game can be used to enhance implementation planning. Plain language versions of CFIR construct barrier narratives are needed. Our plain language versions require further testing and refining.
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Affiliation(s)
- Myra Piat
- Department of Psychiatry, McGill University, Douglas Hospital Research Centre, Montreal, Quebec, Canada.
| | | | - Eleni Sofouli
- Department of Psychiatry, McGill University, Douglas Hospital Research Centre, Montreal, Quebec, Canada
| | - Hélène Albert
- École de Travail Social, Université de Moncton, Moncton, New Brunswick, Canada
| | - Regina Casey
- Department of Psychology, Douglas College, New Westminster, British Columbia, Canada
| | - Marie-Pier Rivest
- École de Travail Social, Université de Moncton, Moncton, New Brunswick, Canada
| | - Catherine Briand
- Department of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Sarah Kasdorf
- Department of Anthropology, Durham University, Durham, UK
| | - Lise Labonté
- Department of Anthropology, Durham University, Durham, UK
| | - Sébastien LeBlanc
- École de Travail Social, Université de Moncton, Moncton, New Brunswick, Canada
| | - Joseph J O'Rourke
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, British Columbia, Canada
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Tsang JY, Brown B, Peek N, Campbell S, Blakeman T. Mixed methods evaluation of a computerised audit and feedback dashboard to improve patient safety through targeting acute kidney injury (AKI) in primary care. Int J Med Inform 2021; 145:104299. [PMID: 33099183 DOI: 10.1016/j.ijmedinf.2020.104299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/03/2020] [Accepted: 10/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Reducing the harms associated with acute kidney injury (AKI) requires addressing a wide range of patient safety issues, including polypharmacy and transitions of care, particularly for vulnerable patient groups. Computerised audit and feedback can transform the way healthcare organisations measure, analyse and learn from quality and safety data across different care settings, potentially improving patient safety. OBJECTIVE To implement and evaluate an audit and feedback dashboard targeting AKI to improve patient safety, focusing on factors affecting a range of user characteristics in primary care. METHODS We performed a mixed methods study in three stages. Semi-structured interviews were initially performed with both primary (n = 10) and secondary care (n = 5) staff to gather user requirements for six quality indicators extracted from national guidance on post-discharge AKI care. Modified indicators were implemented in the Performance Improvement plaN GeneratoR (PINGR) audit and feedback dashboard for six months, across 45 general practices in Salford. Primary care professionals were then interviewed again (n = 7) and completed usability questionnaires. This was triangulated with an interrupted time series analysis on indicator performance, alongside software usage statistics. RESULTS Improvements were observed for the indicators for medication review (+9.01 %; 95 % Confidence Interval (CI), +6.95 % to +11.06 %) and blood pressure measurement (+5.20 %; 95 % CI + 3.61 % to +6.78 %). Variable performance and engagement were observed for other indicators including AKI coding (+0.39 %; 95 % CI -1.88 % to +2.65 %), serum creatinine (-3.40 %; 95 % CI -7.66 % to +0.85 %), proteinuria (-1.08 %; 95 % CI -1.47 % to +0.32 %) and providing patient information (+0.16 %; 95 % CI -0.41 % to +0.73 %). A key facilitator to engagement was the development of 'champions of change', achieved through a raised awareness of high-risk patients, guidelines, inconsistencies in coding practice and evidence for quality and safety performance. Barriers related to the specificity and perceived achievability of indicators, and limitations in resources. CONCLUSION In a six-month, quasi-experimental evaluation of an electronic audit and feedback dashboard targeting AKI, we found improvements for two out of six quality indicators. While information technology can facilitate improvements in patient safety, further allocation of protected staff time and investment into shared learning are needed to realise those improvements in practice.
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Affiliation(s)
- Jung Yin Tsang
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK; Centre for Health Informatics, The University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK.
| | - Benjamin Brown
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK; Centre for Health Informatics, The University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK
| | - Niels Peek
- Centre for Health Informatics, The University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK
| | - Thomas Blakeman
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK; NIHR Greater Manchester Patient Safety Translational Research Centre (GMPSTRC), University of Manchester, Manchester, UK
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Zoellner J, Porter K, Thatcher E, Kennedy E, Werth JL, Grossman B, Roatsey T, Hamilton H, Anderson R, Cohn W. A Multilevel Approach to Understand the Context and Potential Solutions for Low Colorectal Cancer (CRC) Screening Rates in Rural Appalachia Clinics. J Rural Health 2020; 37:585-601. [PMID: 33026682 DOI: 10.1111/jrh.12522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To explore system/staff- and patient-level opportunities to improve colorectal cancer (CRC) screening within an 11-clinic Federally Qualified Health Center (FQHC) in rural Appalachia with CRC screening rates around 22%-30%. METHODS Using a convergent parallel mixed-methods design, staff (n = 26) and patients (n = 60, age 50-75, 67% female, 83% <college, 47% Medicare, 23% Medicaid) were interviewed about CRC-related screening practices. Staff and patient interviews were guided by the Consolidated Framework for Implementation Research and Health Belief Model, respectively, and analyzed using a hybrid inductive-deductive approach. RESULTS Among staff, inner setting factors that could promote CRC screening included high workplace satisfaction, experiences tracking other cancer screenings, and a highly active Performance Improvement Committee. Inner setting hindering factors included electronic medical record inefficiencies and requiring patients to physically return fecal tests to the clinic. Outer setting CRC screening promoting factors included increased Medicaid access, support from outside organizations, and reporting requirements to external regulators, while hindering factors included poor social determinants of health, inadequate colonoscopy access, and lack of patient compliance. Among patients, perceived screening benefits were rated relatively higher than barriers. Top barriers included cost, no symptoms, fear, and transportation. Patients reported high likelihood of getting a stool-based test and colonoscopy if recommended, yet self-efficacy to prevent CRC was considerably lower. CONCLUSIONS Contextualized perceptions of barriers and practical opportunities to improve CRC screening rates were identified among staff and patients. To optimize multilevel CRC screening interventions in rural Appalachia clinics, future quality improvement, research, and policy efforts are needed to address identified challenges.
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Affiliation(s)
- Jamie Zoellner
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Kathleen Porter
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Esther Thatcher
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Erin Kennedy
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - James L Werth
- Stone Mountain Health Services, Damascus, Virginia.,Tri-Area Community Health, Laurel Fork, Virginia
| | - Betsy Grossman
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | | | | | - Roger Anderson
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Wendy Cohn
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
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Geerligs L, Shepherd HL, Rankin NM, Masya L, Shaw JM, Price MA, Dhillon H, Dolan C, Prest G, Butow P. The value of real-world testing: a qualitative feasibility study to explore staff and organisational barriers and strategies to support implementation of a clinical pathway for the management of anxiety and depression in adult cancer patients. Pilot Feasibility Stud 2020; 6:109. [PMID: 32742718 PMCID: PMC7388211 DOI: 10.1186/s40814-020-00648-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 07/07/2020] [Indexed: 01/17/2023] Open
Abstract
Background Effective translation of evidence-based research into clinical practice requires assessment of the many factors that can impact implementation success. Research methods that draw on recognised implementation frameworks, such as the Promoting Action Research in Health Services (PARiHS) framework, and that test feasibility to gain information prior to full-scale roll-out, can support a more structured approach to implementation. Objective This paper presents qualitative findings from a feasibility study in one cancer service of an online portal to operationalise a clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients. The aim of this study was to explore staff perspectives on the feasibility and acceptance of a range of strategies to support implementation in order to inform the full-scale roll-out. Methods Semi-structured interviews were conducted with fifteen hospital staff holding a range of clinical, administrative and managerial roles, and with differing levels of exposure to the pathway. Qualitative data were analysed thematically, and themes were subsequently organised within the constructs of the PARiHS framework. Results Barriers and facilitators that affected the feasibility of the online portal and implementation strategies were organised across eight key themes: staff perceptions, culture, external influences, attitudes to psychosocial care, intervention fit, familiarity, burden and engagement. These themes mapped to the PARiHS framework's three domains of evidence, context and facilitation. Conclusions Implementation success may be threatened by a range of factors related to the real-world context, perceptions of the intervention (evidence) and the process by which it is introduced (facilitation). Feasibility testing of implementation strategies can provide unique insights into issues likely to influence full-scale implementation, allowing for early tailoring and more effective facilitation which may save time, money and effort in the long-term. Use of a determinant implementation framework can assist researchers to synthesise and effectively respond to barriers as they arise. While the current feasibility study related to a specific implementation, strategies such as regular engagement with local stakeholders, and discussion of barriers arising in real-time during early testing is likely to be of benefit to all researchers and clinicians seeking to maximise the likelihood of long-term implementation success.
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Affiliation(s)
- Liesbeth Geerligs
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia
| | - Heather L Shepherd
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | - Nicole M Rankin
- Faculty of Health Sciences, The University of Sydney, Sydney, NSW Australia
| | - Lindy Masya
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia
| | - Joanne M Shaw
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | - Melanie A Price
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | - Haryana Dhillon
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | | | | | | | - Phyllis Butow
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
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Hatch B, Tillotson C, Huguet N, Marino M, Baron A, Nelson J, Sumic A, Cohen D, E DeVoe J. Implementation and adoption of a health insurance support tool in the electronic health record: a mixed methods analysis within a randomized trial. BMC Health Serv Res 2020; 20:428. [PMID: 32414376 PMCID: PMC7227079 DOI: 10.1186/s12913-020-05317-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/11/2020] [Indexed: 11/10/2022] Open
Abstract
Background In addition to delivering vital health care to millions of patients in the United States, community health centers (CHCs) provide needed health insurance outreach and enrollment support to their communities. We developed a health insurance enrollment tracking tool integrated within the electronic health record (EHR) and conducted a hybrid implementation-effectiveness trial in a CHC-based research network to assess tool adoption using two implementation strategies. Methods CHCs were recruited from the OCHIN practice-based research network. Seven health center systems (23 CHC clinic sites) were recruited and randomized to receive basic educational materials alone (Arm 1), or these materials plus facilitation (Arm 2) during the 18-month study period, September 2016–April 2018. Facilitation consisted of monthly contacts with clinic staff and utilized audit and feedback and guided improvement cycles. We measured total and monthly tool utilization from the EHR. We conducted structured interviews of CHC staff to assess factors associated with tool utilization. Qualitative data were analyzed using an immersion-crystallization approach with barriers and facilitators identified using the Consolidated Framework for Implementation Research. Results The majority of CHCs in both study arms adopted the enrollment tool. The rate of tool utilization was, on average, higher in Arm 2 compared to Arm 1 (20.0% versus 4.7%, p < 0.01). However, by the end of the study period, the rate of tool utilization was similar in both arms; and observed between-arm differences in tool utilization were largely driven by a single, large health center in Arm 2. Perceived relative advantage of the tool was the key factor identified by clinic staff as driving tool utilization. Implementation climate and leadership engagement were also associated with tool utilization. Conclusions Using basic education materials and low-intensity facilitation, CHCs quickly adopted an EHR-based tool to support critical outreach and enrollment activities aimed at improving access to health insurance in their communities. Though facilitation carried some benefit, a CHC’s perceived relative advantage of the tool was the primary driver of decisions to implement the tool. Trial registration ClinicalTrials.gov: NCT02355262, Posted February 4, 2015.
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Affiliation(s)
- Brigit Hatch
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA. .,OCHIN, 1881 SW Naito Parkway, Portland, OR, 97201, USA.
| | | | - Nathalie Huguet
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Miguel Marino
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Andrea Baron
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Joan Nelson
- OCHIN, 1881 SW Naito Parkway, Portland, OR, 97201, USA
| | | | - Deborah Cohen
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA
| | - Jennifer E DeVoe
- Oregon Health & Science University, 3405 SW Perimeter Court, Portland, OR, 97239, USA.,OCHIN, 1881 SW Naito Parkway, Portland, OR, 97201, USA
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Albers B, Metz A, Burke K. Implementation support practitioners - a proposal for consolidating a diverse evidence base. BMC Health Serv Res 2020; 20:368. [PMID: 32357877 PMCID: PMC7193379 DOI: 10.1186/s12913-020-05145-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/24/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Workforce development for implementation practice has been identified as a grand challenge in health services. This is due to the embryonic nature of the existing research in this area, few available training programs and a general shortage of frontline service staff trained and prepared for practicing implementation in the field. The interest in the role of "implementation support" as a way to effectively build the implementation capacities of the human service sector has therefore increased. However, while frequently used, little is known about the skills and competencies required to effectively provide such support. MAIN BODY To progress the debate and the research agenda on implementation support competencies, we propose the role of the "implementation support practitioner" as a concept unifying the multiple streams of research focused on e.g. consultation, facilitation, or knowledge brokering. Implementation support practitioners are professionals supporting others in implementing evidence-informed practices, policies and programs, and in sustaining and scaling evidence for population impact. They are not involved in direct service delivery or management and work closely with the leadership and staff needed to effectively deliver direct clinical, therapeutic or educational services to individuals, families and communities. They may be specialists or generalists and be located within and/or outside the delivery system they serve. To effectively support the implementation practice of others, implementation support practitioners require an ability to activate implementation-relevant knowledge, skills and attitudes, and to operationalize and apply these in the context of their support activities. In doing so, they aim to trigger both relational and behavioral outcomes. This thinking is reflected in an overarching logic outlined in this article. CONCLUSION The development of implementation support practitioners as a profession necessitates improved conceptual thinking about their role and work and how they enable the uptake and integration of evidence in real world settings. This article introduces a preliminary logic conceptualizing the role of implementation support practitioners informing research in progress aimed at increasing our knowledge about implementation support and the competencies needed to provide this support.
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Affiliation(s)
- Bianca Albers
- European Implementation Collaborative, Søborg, Denmark
- University of Melbourne, Melbourne, Australia
| | - Allison Metz
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Katie Burke
- Centre for Effective Services, Dublin, Ireland
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Shelley DR, Gepts T, Siman N, Nguyen AM, Cleland C, Cuthel AM, Rogers ES, Ogedegbe O, Pham-Singer H, Wu W, Berry CA. Cardiovascular Disease Guideline Adherence: An RCT Using Practice Facilitation. Am J Prev Med 2020; 58:683-690. [PMID: 32067871 DOI: 10.1016/j.amepre.2019.12.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 12/18/2019] [Accepted: 12/19/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. STUDY DESIGN The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. SETTING/PARTICIPANTS A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. INTERVENTION The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. MAIN OUTCOME MEASURES The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). RESULTS The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). CONCLUSIONS Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT02646488.
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Affiliation(s)
- Donna R Shelley
- Department of Policy and Public Health Management, College of Global Public Health, New York University, New York, New York.
| | - Thomas Gepts
- University of California Berkeley, Department of Sociology, Berkeley, California
| | - Nina Siman
- Department of Population Health, NYU Langone Health, New York, New York
| | - Ann M Nguyen
- Department of Population Health, NYU Langone Health, New York, New York
| | - Charles Cleland
- Department of Population Health, NYU Langone Health, New York, New York
| | - Allison M Cuthel
- Ronald O. Perelman Department of Emergency Medicine, NYU Langone Health, New York, New York
| | - Erin S Rogers
- Department of Population Health, NYU Langone Health, New York, New York
| | | | - Hang Pham-Singer
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Winfred Wu
- New York City Department of Health and Mental Hygiene, New York, New York
| | - Carolyn A Berry
- Department of Population Health, NYU Langone Health, New York, New York
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Quanbeck A, Almirall D, Jacobson N, Brown RT, Landeck JK, Madden L, Cohen A, Deyo BMF, Robinson J, Johnson RA, Schumacher N. The Balanced Opioid Initiative: protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care. Implement Sci 2020; 15:26. [PMID: 32334632 PMCID: PMC7183389 DOI: 10.1186/s13012-020-00990-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rates of opioid prescribing tripled in the USA between 1999 and 2015 and were associated with significant increases in opioid misuse and overdose death. Roughly half of all opioids are prescribed in primary care. Although clinical guidelines describe recommended opioid prescribing practices, implementing these guidelines in a way that balances safety and effectiveness vs. risk remains a challenge. The literature offers little help about which implementation strategies work best in different clinical settings or how strategies could be tailored to optimize their effectiveness in different contexts. Systems consultation consists of (1) educational/engagement meetings with audit and feedback reports, (2) practice facilitation, and (3) prescriber peer consulting. The study is designed to discover the most cost-effective sequence and combination of strategies for improving opioid prescribing practices in diverse primary care clinics. METHODS/DESIGN The study is a hybrid type 3 clustered, sequential, multiple-assignment randomized trial (SMART) that randomizes clinics from two health systems at two points, months 3 and 9, of a 21-month intervention. Clinics are provided one of four sequences of implementation strategies: a condition consisting of educational/engagement meetings and audit and feedback alone (EM/AF), EM/AF plus practice facilitation (PF), EM/AF + prescriber peer consulting (PPC), and EM/AF + PF + PPC. The study's primary outcome is morphine-milligram equivalent (MME) dose by prescribing clinicians within clinics. The study's primary aim is the comparison of EM/AF + PF + PPC versus EM/AF alone on change in MME from month 3 to month 21. The secondary aim is to derive cost estimates for each of the four sequences and compare them. The exploratory aim is to examine four tailoring variables that can be used to construct an adaptive implementation strategy to meet the needs of different primary care clinics. DISCUSSION Systems consultation is a practical blend of implementation strategies used in this case to improve opioid prescribing practices in primary care. The blend offers a range of strategies in sequences from minimally to substantially intensive. The results of this study promise to help us understand how to cost effectively improve the implementation of evidence-based practices. TRIAL REGISTRATION NCT04044521 (ClinicalTrials.gov). Registered 05 August 2019.
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Affiliation(s)
- Andrew Quanbeck
- Department of Family Medicine and Community Health, University of Wisconsin–Madison, 800 University Bay Drive, Suite 210, Madison, WI 53705-2278 USA
| | - Daniel Almirall
- Department of Statistics and Institute for Social Research, University of Michigan, 2448 Institute for Social Research, 426 Thompson St., Ann Arbor, MI 48104-2321 USA
| | - Nora Jacobson
- Institute for Clinical and Translational Research and School of Nursing, University of Wisconsin, Madison, 5130 Signe Skott Cooper Hall, 701 Highland Ave, Madison, WI 53705-2202 USA
| | - Randall T. Brown
- Department of Family Medicine and Community Health, University of Wisconsin–Madison, 1100 Delaplaine Ct, Madison, WI 53705-1840 USA
| | - Jillian K. Landeck
- Department of Family Medicine and Community Health, University of Wisconsin–Madison, 1100 Delaplaine Ct, Madison, WI 53705-1840 USA
| | - Lynn Madden
- APT Foundation, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511-5991 USA
| | - Andrew Cohen
- Bellin Health Systems, Inc., 744 S. Webster Ave, Green Bay, WI 54305 USA
| | - Brienna M. F. Deyo
- Department of Family Medicine and Community Health, University of Wisconsin–Madison, 1100 Delaplaine Ct, Madison, WI 53705-1840 USA
| | - James Robinson
- Forward Data Analytic Services, LLC, 6700 Cross Country Road, Verona, WI 53593 USA
| | - Roberta A. Johnson
- Department of Family Medicine and Community Health, University of Wisconsin–Madison, 800 University Bay Drive, Suite 210, Madison, WI 53705-2278 USA
| | - Nicholas Schumacher
- Department of Family Medicine and Community Health, University of Wisconsin–Madison, 800 University Bay Drive, Suite 210, Madison, WI 53705-2278 USA
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Tahkola A, Korhonen P, Kautiainen H, Niiranen T, Mäntyselkä P. Lifetime risk assessment in cholesterol management among hypertensive patients: observational cross-sectional study based on electronic health record data. BMC FAMILY PRACTICE 2020; 21:62. [PMID: 32290820 PMCID: PMC7155316 DOI: 10.1186/s12875-020-01138-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 04/06/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND In hypertensive patients, reducing plasma low-density lipoprotein cholesterol level (LDL-C) is one of the main interventions for preventing chronic cardiovascular diseases (CVD). However, LDL-C control remains generally insufficient, also in patients with hypertension. We analyzed Electronic Health Record (EHR) data of 7117 hypertensive patients to find the most potential age and sex subgroups in greatest need for improvement in real life dyslipidemia treatment. Taking into account the current discussion on lifetime CVD risk, we focused on the age dependence in LDL-C control. METHODS In this observational cross-sectional study, based on routine electronic health record (EHR) data, we investigated LDL-C control of hypertensive, non-diabetic patients without renal dysfunction or CVD, aged 30 years or more in Finnish primary care setting. RESULTS More than half (54% of women and 53% of men) of untreated patients did not meet the LDL-C target of < 3 mmol/l and one third (35% of women and 33% of men) of patients did not reach the target even with the lipid-lowering medication (LLM). Furthermore, higher age was strongly associated with better LDL-C control (p < 0.001) and lower LDL-C level (p < 0.001) in individuals with and without LLM. Higher age was also strongly associated with LLM prescription (p < 0.001). In total, about half of the patients were on LLM (53% of women and 51% of men). CONCLUSIONS Our findings indicate that dyslipidemia treatment among Finnish primary care hypertensive patients is generally insufficient, particularly in younger age groups who might benefit the most from CVD risk reduction over time. Clinicians should probably rely more on the lifetime risk of CVD, especially when treating working age hypertensive patients.
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Affiliation(s)
- Aapo Tahkola
- University of Eastern Finland, Institute of Public Health and Clinical Nutrition, Kuopio, Finland
- Health Centre of Jyväskylä Cooperation Area, Jyväskylä, Finland
| | | | | | - Teemu Niiranen
- National Institute for Health and Welfare, Helsinki, Finland
- Department of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Pekka Mäntyselkä
- University of Eastern Finland, Institute of Public Health and Clinical Nutrition, Kuopio, Finland
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland
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Ritchie MJ, Kirchner JE, Townsend JC, Pitcock JA, Dollar KM, Liu CF. Time and Organizational Cost for Facilitating Implementation of Primary Care Mental Health Integration. J Gen Intern Med 2020; 35:1001-1010. [PMID: 31792866 PMCID: PMC7174254 DOI: 10.1007/s11606-019-05537-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 07/18/2019] [Accepted: 09/30/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Integrating mental health services into primary care settings is complex and challenging. Although facilitation strategies have successfully supported implementation of primary care mental health integration and other complex innovations, we know little about the time required or its cost. OBJECTIVE To examine the time and organizational cost of facilitating implementation of primary care mental health integration. DESIGN Descriptive analysis. PARTICIPANTS One expert external facilitator and two internal regional facilitators who helped healthcare system stakeholders, e.g., leaders, managers, clinicians, and non-clinical staff, implement primary care mental health integration at eight clinics. INTERVENTION Implementation facilitation tailored to the needs and resources of the setting and its stakeholders. MAIN MEASURES We documented facilitators' and stakeholders' time and types of activities using a structured spreadsheet collected from facilitators on a weekly basis. We obtained travel costs and salary information. We conducted descriptive analysis of time data and estimated organizational cost. KEY RESULTS The external facilitator devoted 263 h (0.09 FTE), including travel, across all 8 clinics over 28 months. Internal facilitator time varied across networks (1792 h versus 1169 h), as well as clinics. Stakeholder participation time was similar across networks (1280.6 versus 1363.4 person hours) but the number of stakeholders varied (133 versus 199 stakeholders). The organizational cost of providing implementation facilitation also varied across networks ($263,490 versus $258,127). Stakeholder participation accounted for 35% of the cost of facilitation activities in one network and 47% of the cost in the other. CONCLUSIONS Although facilitation can improve implementation of primary care mental health integration, it requires substantial organizational investments that may vary by site and implementation effort. Furthermore, the cost of using an external expert to transfer facilitation skills and build capacity for implementation efforts appears to be minimal.
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Affiliation(s)
- Mona J Ritchie
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA.
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - JoAnn E Kirchner
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James C Townsend
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA
- Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Jeffery A Pitcock
- VA Quality Enhancement Research Initiative (QUERI) Program for Team-Based Behavioral Health, U.S. Department of Veterans Affairs, North Little Rock, AR, USA
| | | | - Chuan-Fen Liu
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
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Kunstler BE, Lennox A, Bragge P. Changing prescribing behaviours with educational outreach: an overview of evidence and practice. BMC MEDICAL EDUCATION 2019; 19:311. [PMID: 31412928 PMCID: PMC6693161 DOI: 10.1186/s12909-019-1735-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/26/2019] [Indexed: 05/28/2023]
Abstract
BACKGROUND General practitioners (GPs), or family practitioners, are tasked with prescribing medications that can be harmful to the community if they are inappropriately prescribed or used (e.g. opioids). Educational programs, such as educational outreach (EO), are designed to change the behaviour of health professionals. The purpose of this study was to identify the efficacy of EO programs at changing the prescribing behaviour of GPs. METHODS This study included an evidence and practice review, comprising a rapid review supplemented by interviews with people who are familiar with EO implementation for regulation purposes. Seven databases were searched using terms related to health professionals and prescribing. Systematic and narrative reviews published in English after 2007 were included. Non-statistical analysis was used to report intervention efficacy. Three government representatives participated in semi-structured interviews to aid in understanding the relevance of review findings to the Victorian context. Interviews were transcribed verbatim and thematically analysed for emerging themes. RESULTS Fourteen reviews were identified for the evidence review. Isolated (e.g. EO program delivered by itself) and multifaceted (e.g. EO program supplemented by other interventions) programs were found to change prescribing behaviours. However, limited evidence suggests that EO can successfully change prescribing behaviours specific to GPs. Isolated EO can successfully change health professional prescribing behaviours, although cheaper alternatives such as letters might be just as effective. Multifaceted EO can also successfully change health professional prescribing behaviours, especially in older adults, but it remains unclear as to what combination of interventions works best. Success factors for EO reported by government representatives included programs having practical rather than didactic foci; making EO compulsory; focussing EO on preventing adverse events; using monetary or professional development incentives; and in-person delivery. CONCLUSIONS Educational outreach can successfully change prescribing behaviours but evidence specific to GPs is lacking. Key characteristics of EO that could optimise success include ensuring the EO program is tailored, involves practical learning and uses incentives that are meaningful to clinicians.
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Affiliation(s)
- Breanne E. Kunstler
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
| | - Alyse Lennox
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton, Melbourne, VIC 3800 Australia
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Algurén B, Nordin A, Andersson-Gäre B, Peterson A. In-depth comparison of two quality improvement collaboratives from different healthcare areas based on registry data-possible factors contributing to sustained improvement in outcomes beyond the project time. Implement Sci 2019; 14:74. [PMID: 31337394 PMCID: PMC6647054 DOI: 10.1186/s13012-019-0926-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 07/09/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality improvement collaboratives (QICs) are widely used to improve healthcare, but there are few studies of long-term sustained improved outcomes, and inconsistent evidence about what factors contribute to success. The aim of the study was to open the black box of QICs and compare characteristics and activities in detail of two differing QICs in relation to their changed outcomes from baseline and the following 3 years. METHODS Final reports of two QICs-one on heart failure care with five teams, and one on osteoarthritis care with seven teams, including detailed descriptions of improvement projects from each QIC's team, were analysed and coded by 18 QIC characteristics and four team characteristics. Goal variables from each team routinely collected within the Swedish Heart Failure Registry (SwedeHF) and the Better Management of Patients with OsteoArthritis Registry (BOA) at year 2013 (baseline), 2014, 2015 and 2016 were analysed with univariate statistics. RESULTS The two QICs differed greatly in design. The SwedeHF-QIC involved eight experts and ran for 12 months, whereas the BOA-QIC engaged three experts and ran for 6 months. There were about twice as many activities in the SwedeHF-QIC as in the BOA-QIC and they ranged from standardisation of team coordination to better information and structured follow-ups. The outcome results were heterogeneous within teams and across teams and QICs. Both QICs were highly appreciated by the participants and contributed to their learning, e.g. of improvement methods; however, several teams had already reached goal values when the QICs were launched in 2013. CONCLUSIONS Even though many QI activities were carried out, it was difficult to see sustained improvements on outcomes. Outcomes as specific measurable aspects of care in need of improvement should be chosen carefully. Activities focusing on adherence to standard care programmes and on increased follow-up of patients seemed to lead to more long-lasting improvements. Although earlier studies showed that data follow-up and measurement skills as well as well-functioning data warehouses contribute to sustained improvements, the present registries' functionality and QICs at this time did not support those aspects sufficiently. Further studies on QICs and their impact on improvement beyond the project time should investigate the effect of those elements in particular.
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Affiliation(s)
- Beatrix Algurén
- Department of Food and Nutrition, and Sport Science, University of Gothenburg, Faculty of Education, Box 300, 405 30, Gothenburg, Sweden. .,School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden.
| | - Annika Nordin
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Boel Andersson-Gäre
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden.,Futurum, Region Jönköping County, Jönköping, Sweden
| | - Anette Peterson
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden.,Futurum, Region Jönköping County, Jönköping, Sweden
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Fritz J, Wallin L, Söderlund A, Almqvist L, Sandborgh M. Implementation of a behavioral medicine approach in physiotherapy: impact and sustainability. Disabil Rehabil 2019; 42:3467-3474. [PMID: 30999779 DOI: 10.1080/09638288.2019.1596170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: To explore the effects on and sustainability of physiotherapists' clinical behavior when using facilitation to support the implementation of a behavioral medicine approach in primary health care for patients with persistent musculoskeletal pain.Methods: A quasi-experimental pre-/post-test trial was conducted. Fifteen physiotherapists were included in the experimental group, and nine in the control group. Based on social cognitive theory and the Promoting Action on Research Implementation in Health Services framework, facilitation with multifaceted implementation methods was used during a six-month period. Clinical behaviors were investigated with a study-specific questionnaire, structured observations, self-reports and patient records. Descriptive and non-parametric statistical methods were used for analyzing differences over time and effect size.Results: A sustained increase in self-efficacy for applying the behavioral medicine approach was found. Clinical actions and verbal expressions changed significantly, and the effect size was large; however, changes were not sustained at follow-ups. The behavioral changes were mainly related to the goal setting, self-monitoring and functional behavioral analysis components. No changes in clinical behavior were found in the control group.Conclusion: Tailored multifaceted facilitation can support the implementation of a behavioral medicine approach in physiotherapy in primary health care, but more comprehensive actions targeting sustainability are needed.Implications for rehabilitationTailored multifaceted facilitation can support the implementation of an evidence based behavioral medicine approach in physiotherapy.Facilitation can be useful for increasing self-efficacy beliefs for using behavioral medicine approach in physiotherapist's clinical practice.Further research is required to establish strategies that are effective in sustaining behavioral changes.
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Affiliation(s)
- Johanna Fritz
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Lars Wallin
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden.,Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.,Department of Health and Care Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anne Söderlund
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Lena Almqvist
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
| | - Maria Sandborgh
- School of Health, Care and Social Welfare, Mälardalen University, Västerås, Sweden
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Lugo-Palacios DG, Hammond J, Allen T, Darley S, McDonald R, Blakeman T, Bower P. The impact of a combinatorial digital and organisational intervention on the management of long-term conditions in UK primary care: a non-randomised evaluation. BMC Health Serv Res 2019; 19:159. [PMID: 30866917 PMCID: PMC6416963 DOI: 10.1186/s12913-019-3984-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 03/01/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Better management of long-term conditions remains a policy priority, with a focus on improving outcomes and reducing use of expensive hospital services. A number of interventions have been tested, but many have failed to show benefit in rigorous comparative research. In 2016, the NHS Test Beds scheme was launched to implement and test interventions combining digital technologies and pathway redesign in routine health care settings, with each intervention comprising multiple innovations to better realise benefit from their 'combinatorial' effect. We present the evaluation of one of the NHS Test Beds, which combined risk stratification algorithms, practice-based quality improvement and health monitoring and coaching to improve management of long-term conditions in a single health economy in the north-west of England. METHODS The NHS Test Bed was implemented in one clinical commissioning group in the north-west of England (patient population 235,800 served by 36 general practices). Routine administrative data on hospital use (the primary outcome) and a selection of secondary outcomes (data from both hospital and primary care) were collected in the intervention site, and from a comparator area in the same region. We used difference-in-differences analysis to compare outcomes in the NHS Test Bed area and the comparator after initiation of the combinatorial intervention. RESULTS Tests confirmed the existence of parallel trends in the intervention and comparator sites for hospital outcomes for the period April 2016 to March 2017, and for some of the planned primary care outcomes. Based on 10 months of post-intervention secondary care data and 13 months post-intervention primary care data, we found no significant impact on primary outcomes between the intervention and comparator site, and a significant impact on only one secondary outcome. CONCLUSION A combinatorial digital and organisational intervention to improve the management of long-term conditions was implemented across a whole health economy, but we found no evidence of a positive impact on health care utilisation outcomes in hospital and primary care.
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Affiliation(s)
- David G. Lugo-Palacios
- Manchester Centre for Health Economics, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL UK
| | - Jonathan Hammond
- Centre for Primary Care and Health Services Research, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL UK
| | - Thomas Allen
- Manchester Centre for Health Economics, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL UK
| | - Sarah Darley
- Centre for Primary Care and Health Services Research, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL UK
| | - Ruth McDonald
- Centre for Primary Care and Health Services Research and Alliance Manchester Business School, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 9PL UK
| | - Thomas Blakeman
- NIHR Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, M13 9PL UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL UK
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