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Carbonell C, Adegbulugbe A, Cheung W, Ruff P. Barriers and Challenges to Implementing a Quality Improvement Program: Political and Administrative Challenges. JCO Glob Oncol 2024; 10:e2300455. [PMID: 38935883 DOI: 10.1200/go.23.00455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/17/2024] [Accepted: 04/30/2024] [Indexed: 06/29/2024] Open
Abstract
Quality improvement (QI) programs have rapidly grown in health care over recent years. Despite increasing evidence of successful QI initiatives resulting in improved outcomes, the adoption and implementation of QI programs remain a challenge worldwide. This paper briefly describes political and administrative barriers that impede the implementation of QI programs, including political and ideological factors, socioeconomic and educational barriers, and barriers related to data collection, privacy, and security. Key political and administrative barriers identified include resource limitations due to inadequate public funding, stringent laws, and change resistance. Potential solutions include support and commitment from regional and national authorities, consultation of all involved parties during QI program development, and financial incentives. The barrier of limited resources is starker among low- and middle-income countries (LMICs) compared with high-income countries (HICs) due to the absence of adequate infrastructure, personnel equipped with QI-oriented skills, and analytical technology. Solutions that have facilitated QI programs in some LMICs include outreach and collaboration with other health centers and established QI programs in HICs. The lack of QI-specific training and education in medical curricula challenges QI implementation but can be mitigated through the provision of QI promotion webinars, QI-specific project opportunities, and formalized QI training modules. Finally, barriers related to data collection, privacy, and security include laws hindering the availability of quality data, inefficient data collection and processes, and outdated clinical information systems. Access to high-quality data, organized record-keeping, and alignment of data collection processes will help alleviate these barriers to QI program implementation. The multidimensional nature of these barriers means that proposed solutions will require coordination from multiple stakeholders, government support, and leaders across multiple fields.
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Affiliation(s)
- Chantelle Carbonell
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Abisola Adegbulugbe
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Winson Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Paul Ruff
- Emeritus Professor, Division of Medical Oncology, University of Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
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Li H, Liu X, Huang S, Wen Y. Impacts of continuous quality improvement on wound pain in the puncture site of arteriovenous fistula in haemodialysis patient. Int Wound J 2024; 21:e14697. [PMID: 38468432 PMCID: PMC10928246 DOI: 10.1111/iwj.14697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 03/13/2024] Open
Abstract
This study analyses the effects of a continuous quality improvement nursing model on wound pain at the arteriovenous fistula (AVF) puncture site in patients undergoing haemodialysis. Forty haemodialysis patients from the First Affiliated Hospital of Chongqing Medical University, from September 2020 to December 2022, were selected as study subjects. They were randomly divided into an observation group and a control group. The control group received conventional nursing care, while the observation group was treated with a continuous quality improvement nursing model. The study compared the impact of these nursing approaches on pain intensity post-AVF puncture, wound visual analogue scale scores, self-rating anxiety scale, self-rating depression scale, quality of life scores and patient satisfaction with nursing care. In the observation group, the proportion of patients experiencing moderate to severe pain during AVF puncture was lower than that in the control group, whereas the proportion of patients with no pain or mild pain was higher (P = 0.008). After nursing, the observation group exhibited significantly lower wound visual analogue scale scores, self-rating anxiety scale scores, and self-rating depression scale scores compared to the control group (P < 0.001), with a significantly higher quality of life score (P < 0.05). The nursing satisfaction rate was 95.00% in the observation group, significantly higher than the 65.00% in the control group (P = 0.018). The continuous quality improvement nursing model significantly reduces wound pain at the AVF puncture site in haemodialysis patients, alleviates negative emotions, enhances the quality of life, and achieves high patient satisfaction. It is thus a highly recommendable approach in nursing practice.
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Affiliation(s)
- Hui Li
- Department of NephrologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Xian‐Li Liu
- Department of NephrologyThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Si‐Feng Huang
- Department of NursingThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
| | - Yi‐Jun Wen
- Department of NursingThe First Affiliated Hospital of Chongqing Medical UniversityChongqingChina
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Henderson DAG, Donaghy E, Dozier M, Guthrie B, Huang H, Pickersgill M, Stewart E, Thompson A, Wang HHX, Mercer SW. Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China. BMC Med 2023; 21:319. [PMID: 37620865 PMCID: PMC10463288 DOI: 10.1186/s12916-023-03033-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation. METHODS We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed. RESULTS A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes. CONCLUSIONS Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.
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Affiliation(s)
- D A G Henderson
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Donaghy
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - M Dozier
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - B Guthrie
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - H Huang
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - M Pickersgill
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - E Stewart
- School of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
| | - A Thompson
- School of Social and Political Sciences, University of Edinburgh, Edinburgh, UK
| | - H H X Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - S W Mercer
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.
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Miller L, Shanley DC, Page M, Webster H, Liu W, Reid N, Shelton D, West K, Marshall J, Hawkins E. Preventing Drift through Continued Co-Design with a First Nations Community: Refining the Prototype of a Tiered FASD Assessment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11226. [PMID: 36141498 PMCID: PMC9517247 DOI: 10.3390/ijerph191811226] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/31/2022] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
As part of the broader Yapatjarrathati project, 47 remote health providers and community members attended a two-day workshop presenting a prototype of a culturally-safe, tiered neurodevelopmental assessment that can identify fetal alcohol spectrum disorder (FASD) in primary healthcare. The workshop provided a forum for broad community feedback on the tiered assessment process, which was initially co-designed with a smaller number of key First Nations community stakeholders. Improvement in self-reported attendee knowledge, confidence, and perceived competence in the neurodevelopmental assessment process was found post-workshop, assessed through self-report questionnaires. Narrative analysis described attendee experiences and learnings (extracted from the workshop transcript), and workshop facilitator experiences and learnings (extracted from self-reflections). Narrative analysis of the workshop transcript highlighted a collective sense of compassion for those who use alcohol to cope with intergenerational trauma, but exhaustion at the cyclical nature of FASD. There was a strong desire for a shared responsibility for First Nations children and families and a more prominent role for Aboriginal Health Workers in the assessment process. Narrative analysis from workshop facilitator reflections highlighted learnings about community expertise, the inadvertent application of dominant cultural approaches throughout facilitation, and that greater emphasis on the First Nation's worldview and connection to the community was important for the assessment process to be maintained long-term. This study emphasised the benefit of continued co-design to ensure health implementation strategies match the needs of the community.
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Affiliation(s)
- Luke Miller
- Gold Coast Hospital and Health Service, Gold Coast 4215, Australia
| | - Dianne C. Shanley
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
- School of Applied Psychology, Griffith University, Gold Coast 4222, Australia
| | - Marjad Page
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
| | - Heidi Webster
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
| | - Wei Liu
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
| | - Natasha Reid
- Child Health Research Centre, University of Queensland, Brisbane 4101, Australia
| | - Doug Shelton
- Gold Coast Hospital and Health Service, Gold Coast 4215, Australia
| | - Karen West
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
- Aboriginal and Torres Strait Islander Community, Mount Isa 4825, Australia
| | - Joan Marshall
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
- Aboriginal and Torres Strait Islander Community, Mount Isa 4825, Australia
| | - Erinn Hawkins
- Menzies Health Institute Queensland, Griffith University, Gold Coast 4222, Australia
- School of Applied Psychology, Griffith University, Gold Coast 4222, Australia
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Patel J, Durey A, Naoum S, Kruger E, Slack-Smith L. A scoping review to inform the use of continuous quality improvement in Australian Aboriginal oral health care. AUST HEALTH REV 2022; 46:478-484. [PMID: 35831033 DOI: 10.1071/ah21394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 06/17/2022] [Indexed: 11/23/2022]
Abstract
ObjectiveThe need to improve existing services to Aboriginal communities is prioritised by Australia's National Oral Health Plan. Although only an emerging area in dentistry, continuous quality improvement (CQI) approaches have positively impacted the delivery of primary health services to Aboriginal communities. This scoping review maps the applicability of CQI strategies to Aboriginal Australian oral healthcare services.MethodsA scoping review was conducted and studies that reported using CQI approaches to improve existing oral health services or quality of care deemed relevant to Aboriginal Australian communities were included.ResultsA total of 73 articles were retrieved and eight articles were included in the final synthesis. Several CQI tools were identified, including: plan-do-study-act cycles, dental quality alliance measures, prioritisation matrices, causal mapping and the use of collective impact methodology.ConclusionData exploring CQI in the context of Aboriginal oral health is scarce. The plan-do-study-act cycle and its variations show potential applicability to Aboriginal oral health care. However, for CQI approaches to be adequately implemented, the prevailing model of dental care requires a paradigm shift from quality assurance to quality improvement, acknowledging the impact of structural and process elements on care.
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Affiliation(s)
- Jilen Patel
- School of Population and Global Health, The University of Western Australia, Nedlands, WA, Australia; and Dental School, The University of Western Australia, Nedlands, WA, Australia
| | - Angela Durey
- School of Population and Global Health, The University of Western Australia, Nedlands, WA, Australia
| | - Steven Naoum
- Dental School, The University of Western Australia, Nedlands, WA, Australia
| | - Estie Kruger
- School of Human Sciences, The University of Western Australia, WA, Australia
| | - Linda Slack-Smith
- School of Population and Global Health, The University of Western Australia, Nedlands, WA, Australia
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Sebastian S, Thomas DP, Brimblecombe J, Arley B, Cunningham FC. Role of organisational factors on uptake and implementation of the B.strong brief intervention training program in Queensland Indigenous primary health care services. Health Promot J Austr 2021; 33:711-723. [PMID: 34543494 DOI: 10.1002/hpja.542] [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: 06/10/2021] [Revised: 08/26/2021] [Accepted: 09/16/2021] [Indexed: 11/12/2022] Open
Abstract
ISSUE ADDRESSED The B.strong Program was an Indigenous health worker brief intervention (BI) training program delivered in Queensland from 2017-2020. This study examines the organisational factors of participating Indigenous primary health care (PHC) services that impacted on B.strong's uptake and implementation in those services. METHODS Semi-structured interviews were conducted from 2019-2020 with 20 B.strong Program trainees and four health service managers from eight purposively sampled Queensland PHC services, and one Queensland Department of Health manager, to examine their perceptions of uptake and implementation of the B.strong Program. The Consolidated Framework for Implementation Research was used as a framework for the evaluation. Data analysis was conducted using NVivo 11. RESULTS Although strong PHC service support was evident for the uptake of face-to-face workshop training, it was not available to support trainees to complete online modules or for ongoing BI delivery to clients. Key organisational factors associated with both program uptake and implementation of BIs in PHC services were leadership engagement and implementation climate. Within these themes, embedding B.strong into operational practices of health services, having policies, processes and consistent administrative support to facilitate implementation, and addressing gaps in knowledge and skills of health workers were identified as needing to be improved. The study identified the lack of application of continuous quality improvement (CQI) processes to BIs at these health services as a barrier to effective implementation. CONCLUSIONS The study supports the establishment of BI specific CQI initiatives in health services and supports better engagement with organisational leadership in BI training to ensure their ongoing support of both the training and implementation of BI.
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Affiliation(s)
- Saji Sebastian
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - David P Thomas
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | | | - Brian Arley
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Brisbane, QLD, Australia
| | - Frances C Cunningham
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Brisbane, QLD, Australia
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Karthika M, Sureshkumar VK, Bennett A, Noorshe AH, Mallat J, Praveen BM. Quality Management in Respiratory Care. Respir Care 2021; 66:1485-1494. [PMID: 34408082 PMCID: PMC9993877 DOI: 10.4187/respcare.08820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The word "quality" refers to the features of a product or service to which a certain value is ascribed. When it comes to hospital-based practices, quality has often been considered to be specific to the care provided. However, this specific perspective is transitioning toward a broader concept after the evolution of quality-improvement projects and quality frameworks at the organizational level. Respiratory therapy departments have been identified as an essential part of any hospital because the key nature of discipline for respiratory therapists is widely understood. Due to their professional accountability and professional values, respiratory therapists often have administrative roles in infection control practices and quality-improvement projects. Therefore, it would be ideal to have a core team of respiratory therapists trained in quality management and to initiate quality-improvement processes at the departmental level. Every respiratory therapy department should have its own quality-improvement team to assist with the process of training, implementation, and analysis. Thus, this article aimed to discuss the role of respiratory therapists and respiratory therapy departments in quality-improvement processes and projects to set benchmarks and enhance outcomes.
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Affiliation(s)
- Manjush Karthika
- Department of Health and Medical Sciences, Khawarizmi International College, Abu Dhabi, United Arab Emirates.
- Srinivas Institute of Medical Sciences and Research Centre, Srinivas University, Mangalore, India
| | - Vanajakshy Kumaran Sureshkumar
- Department of Healthcare Management, Tata Institute of Social Sciences, Mumbai, India
- Department Critical Care, Quality and Patient Safety, IQRAA Hospital, Calicut, Kerala, India
| | - Adam Bennett
- Respiratory Care, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | | | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio
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Varnfield M, Redd C, Stoney RM, Higgins L, Scolari N, Warwick R, Iedema J, Rundle J, Dutton W. M♡THer, an mHealth System to Support Women with Gestational Diabetes Mellitus: Feasibility and Acceptability Study. Diabetes Technol Ther 2021; 23:358-366. [PMID: 33210954 PMCID: PMC8080933 DOI: 10.1089/dia.2020.0509] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Gestational diabetes mellitus (GDM) is defined as glucose intolerance first identified during pregnancy. Delays in diagnosis and challenges in management can lead to serious adverse outcomes for the mother and child. As rates of GDM diagnosis increase worldwide, health systems and maternity services have become increasingly strained, especially with new restrictions around in-person care due to the current COVID-19 pandemic. Mobile health (mHealth) has increasingly shown promise for management of chronic disease, driven by smartphone adoption and increased internet connectivity. The aim of this work was to evaluate the adoption and multidisciplinary care coordination of an mHealth platform called M♡THer in a cohort of women with first-time diagnosis of GDM. Methods: The mHealth platform for GDM management was developed incorporating a smartphone application, clinician portal, and secure cloud data storage. Forty participants with a first-time diagnosis of GDM were recruited to use the app during their pregnancy. User attitudes from clinicians and women were captured through post-hoc surveys, and app-usage metrics. Results: Clinicians and women indicated satisfaction and ease of use of the mHealth platform, with some technological challenges around wireless connectivity. Blood glucose reviews and antenatal contact were higher with use of the M♡THer app compared with a matched historical sample. Conclusion: The M♡THer mHealth platform is a new comprehensive tool for health care of women with GDM, and may provide an effective new avenue to enhance multidisciplinary care in the face of COVID-19 disruptions and challenges to traditional care pathways.
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Affiliation(s)
- Marlien Varnfield
- The Australian e-Health Research Centre, CSIRO, Brisbane, Australia
- Address correspondence to: Marlien Varnfield, MSc, PhD, The Australian e-Health Research Centre, CSIRO, Level 5, UQ Health Sciences Building 901/16, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia
| | - Christian Redd
- The Australian e-Health Research Centre, CSIRO, Brisbane, Australia
| | - Rachel M. Stoney
- Nutrition and Dietetics Department, Redland Hospital, Bayside Health Service, Metro South Health, Brisbane, Australia
| | - Liesel Higgins
- The Australian e-Health Research Centre, CSIRO, Brisbane, Australia
| | - Naomi Scolari
- Nutrition and Dietetics Department, Redland Hospital, Bayside Health Service, Metro South Health, Brisbane, Australia
| | - Roisine Warwick
- Chronic Disease Service, Redland Hospital, Bayside Health Service, Metro South Health, Brisbane, Australia
| | - Joel Iedema
- Department of Medicine, Redland Hospital, Bayside Health Service, Metro South Health, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Jane Rundle
- Women and Birthing Services, Redland Hospital, Bayside Health Service, Metro South Health, Brisbane, Australia
| | - Wendy Dutton
- Obstetrics and Gynaecology Department, Redland Hospital, Bayside Health Service, Metro South Health, Brisbane, Australia
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Sebastian S, Thomas DP, Brimblecombe J, Cunningham FC. Notes From the Field: Applying the Consolidated Framework for Implementation Research in a Qualitative Evaluation of Implementation of the Queensland Aboriginal and Torres Strait Islander Brief Intervention Training Program. Eval Health Prof 2021; 44:395-399. [DOI: 10.1177/0163278721992815] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This paper describes the applicability of the Consolidated Framework for Implementation Research (CFIR) to the qualitative evaluation of the implementation of the Queensland Aboriginal and Torres Strait Islander Brief Intervention Training Program, the B.strong Program. Interviews were conducted with 20 B.strong Program trainees and four health service managers from eight purposively sampled Indigenous primary health care services in Queensland to collect their perceptions of the B.strong Program implementation. The 26 constructs of the CFIR were used to guide data collection and analysis. Additional constructs were developed for two program implementation aspects, “quality improvement” and “cultural suitability.” Findings are presented from the application of the CFIR to the evaluation of the implementation of a brief intervention training program in the Australian Indigenous context. While demonstrating the applicability of the CFIR in this evaluation, this study also highlights that it may require modification, to ensure identification of the different contextual factors that influence program implementation.
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Affiliation(s)
- Saji Sebastian
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - David P. Thomas
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Frances C. Cunningham
- Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Charles Darwin University, Brisbane, Queensland, Australia
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Gaylis F, Nasseri R, Salmasi A, Anderson C, Mohedin S, Prime R, Swift S, Dato P, Cohen E, Catalona W, Topp R, Friedman L, Kane C. Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned. Urology 2021; 153:139-146. [PMID: 33482125 DOI: 10.1016/j.urology.2020.11.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/02/2020] [Accepted: 11/29/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention. MATERIALS AND METHODS The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing. RESULTS For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P < .001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P < .001). CONCLUSION The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.
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Affiliation(s)
- Franklin Gaylis
- Genesis Healthcare Partners, Research Division, San Diego CA; Department of Urology, UC San Diego School of Medicine, La Jolla CA.
| | - Ryan Nasseri
- Department of Urology, UC San Diego School of Medicine, La Jolla CA
| | - Amirali Salmasi
- Genesis Healthcare Partners, Research Division, San Diego CA; Department of Urology, UC San Diego School of Medicine, La Jolla CA
| | | | - Sarah Mohedin
- Genesis Healthcare Partners, Research Division, San Diego CA
| | - Rose Prime
- Genesis Healthcare Partners, Research Division, San Diego CA
| | - Sadie Swift
- Genesis Healthcare Partners, Research Division, San Diego CA
| | - Paul Dato
- Genesis Healthcare Partners, Research Division, San Diego CA
| | - Edward Cohen
- Genesis Healthcare Partners, Research Division, San Diego CA
| | - William Catalona
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago IL
| | - Robert Topp
- College of Nursing, University of Toledo, Toledo OH
| | - Lawrence Friedman
- Department of Medicine, UC Sian Diego School of Medicine, La Jolla CA
| | - Christopher Kane
- Department of Urology, UC San Diego School of Medicine, La Jolla CA
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McCrabb S, Mooney K, Elton B, Grady A, Yoong SL, Wolfenden L. How to optimise public health interventions: a scoping review of guidance from optimisation process frameworks. BMC Public Health 2020; 20:1849. [PMID: 33267844 PMCID: PMC7709329 DOI: 10.1186/s12889-020-09950-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/22/2020] [Indexed: 11/30/2022] Open
Abstract
Background Optimisation processes have the potential to rapidly improve the impact of health interventions. Optimisation can be defined as a deliberate, iterative and data-driven process to improve a health intervention and/or its implementation to meet stakeholder-defined public health impacts within resource constraints. This study aimed to identify frameworks used to optimise the impact of health interventions and/or their implementation, and characterise the key concepts, steps or processes of identified frameworks. Methods A scoping review of MEDLINE, CINAL, PsycINFO, and ProQuest Nursing & Allied Health Source databases was undertaken. Two reviewers independently coded the key concepts, steps or processes involved in each frameworks, and identified if it was a framework aimed to optimise interventions or their implementation. Two review authors then identified the common steps across included frameworks. Results Twenty optimisation frameworks were identified. Eight frameworks were for optimising interventions, 11 for optimising implementation and one covered both intervention and implementation optimisation. The mean number of steps within the frameworks was six (range 3–9). Almost half (n = 8) could be classified as both linear and cyclic frameworks, indicating that some steps may occur multiple times in a single framework. Two meta-frameworks are proposed, one for intervention optimisation and one for implementation strategy optimisation. Steps for intervention optimisation are: Problem identification; Preparation; Theoretical/Literature base; Pilot/Feasibility testing; Optimisation; Evaluation; and Long-term implementation. Steps for implementation strategy optimisation are: Problem identification; Collaborate; Plan/design; Pilot; Do/change; Study/evaluate/check; Act; Sustain/endure; and Disseminate/extend. Conclusions This review provides a useful summary of the common steps followed to optimise a public health intervention or its implementation according to established frameworks. Further opportunities to study and/or validate such frameworks and their impact on improving outcomes exist. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-09950-5.
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Affiliation(s)
- Sam McCrabb
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, 1 University Drive, Callaghan, NSW, 2308, Australia.
| | - Kaitlin Mooney
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, 1 University Drive, Callaghan, NSW, 2308, Australia
| | - Benjamin Elton
- Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, 2287, Australia
| | - Alice Grady
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, 1 University Drive, Callaghan, NSW, 2308, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, 2287, Australia
| | - Sze Lin Yoong
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, 1 University Drive, Callaghan, NSW, 2308, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, 2287, Australia
| | - Luke Wolfenden
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, 1 University Drive, Callaghan, NSW, 2308, Australia.,Hunter New England Population Health, Hunter New England Local Health District, Wallsend, NSW, 2287, Australia
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12
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Percival N, Boucher P, Conte K, Robertson K, Cook J. Could health information systems enhance the quality of Aboriginal health promotion? A retrospective audit of Aboriginal health programs in the Northern Territory of Australia. BMC Med Inform Decis Mak 2020; 20:286. [PMID: 33143691 PMCID: PMC7607732 DOI: 10.1186/s12911-020-01300-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 10/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Australia, health services are seeking innovative ways to utilize data stored in health information systems to report on, and improve, health care quality and health system performance for Aboriginal Australians. However, there is little research about the use of health information systems in the context of Aboriginal health promotion. In 2008, the Northern Territory's publicly funded healthcare system introduced the quality improvement program planning system (QIPPS) as the centralized online system for recording information about health promotion programs. The purpose of this study was to explore the potential for utilizing data stored in QIPPS to report on quality of Aboriginal health promotion, using chronic disease prevention programs as exemplars. We identify the potential benefits and limitations of health information systems for enhancing Aboriginal health promotion. METHODS A retrospective audit was undertaken on a sample of health promotion projects delivered between 2013 and 2016. A validated, paper-based audit tool was used to extract information stored in the QIPPS online system and report on Aboriginal health promotion quality. Simple frequency counts were calculated for dichotomous and categorical items. Text was extracted and thematically analyzed to describe community participation processes and strategies used in Aboriginal health promotion. RESULTS 39 Aboriginal health promotion projects were included in the analysis. 34/39 projects recorded information pertaining to the health promotion planning phases, such as statements of project goals, 'needs assessment' findings, and processes for consulting Aboriginal people in the community. Evaluation findings were reported in approximately one third of projects and mostly limited to a recording of numbers of participants. For almost half of the projects analyzed, community participation strategies were not recorded. CONCLUSION This is the first Australian study to shed light on the feasibility of utilizing data stored in a purposefully designed health promotion information system. Data availability and quality were limiting factors for reporting on Aboriginal health promotion quality. Based on our learnings of QIPPS, strategies to improve the quality and accuracy of data entry together with the use of quality improvement approaches are needed to reap the potential benefits of future health promotion information systems.
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Affiliation(s)
- Nikki Percival
- Faculty of Health, Australian Centre for Public and Population Health Research, University of Technology Sydney, UTS Building 10, Level 8, 235-253 Jones Street, Ultimo, Sydney, NSW, 2007, Australia.
| | - Priscilla Boucher
- Department of Health, Strategic, Policy and Planning, Northern Territory Government, Darwin, NT, Australia
| | - Kathleen Conte
- Faculty of Medicine and Health, School of Public Health, Menzies Centre for Health Policy and University Centre for Rural Health, University of Sydney, Sydney, NSW, Australia
| | - Kate Robertson
- Department of Health, Strategic, Policy and Planning, Northern Territory Government, Darwin, NT, Australia
| | - Julie Cook
- Department of Health, Top End Health Services, Primary Health Care Outreach Team, Northern Territory Government, Katherine, NT, Australia
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Hill JE, Stephani AM, Sapple P, Clegg AJ. The effectiveness of continuous quality improvement for developing professional practice and improving health care outcomes: a systematic review. Implement Sci 2020; 15:23. [PMID: 32306984 PMCID: PMC7168964 DOI: 10.1186/s13012-020-0975-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/19/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Efforts to improve the quality, safety, and efficiency of health care provision have often focused on changing approaches to the way services are organized and delivered. Continuous quality improvement (CQI), an approach used extensively in industrial and manufacturing sectors, has been used in the health sector. Despite the attention given to CQI, uncertainties remain as to its effectiveness given the complex and diverse nature of health systems. This review assesses the effectiveness of CQI across different health care settings, investigating the importance of different components of the approach. METHODS We searched 11 electronic databases: MEDLINE, CINAHL, EMBASE, AMED, Academic Search Complete, HMIC, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trials, LISTA, and NHS EED to February 2019. Also, we searched reference lists of included studies and systematic reviews, as well as checking published protocols for linked papers. We selected randomized controlled trials (RCTs) within health care settings involving teams of health professionals, evaluating the effectiveness of CQI. Comparators included current usual practice or different strategies to manage organizational change. Outcomes were health care professional performance or patient outcomes. Studies were published in English. RESULTS Twenty-eight RCTs assessed the effectiveness of different approaches to CQI with a non-CQI comparator in various settings, with interventions differing in terms of the approaches used, their duration, meetings held, people involved, and training provided. All RCTs were considered at risk of bias, undermining their results. Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process, patient, and other outcomes were limited, with less than half of RCTs showing any effect. Where benefits were evident, it was usually on clinical process measures, with the model used (i.e., Plan-Do-Study-Act, Model of Improvement), the meeting type (i.e., involving leaders discussing implementation) and their frequency (i.e., weekly) having an effect. None considered socio-economic health inequalities. CONCLUSIONS Current evidence suggests the benefits of CQI in improving health care are uncertain, reflecting both the poor quality of evaluations and the complexities of health services themselves. Further mixed-methods evaluations are needed to understand how the health service can use this proven approach. TRIAL REGISTRATION Protocol registered on PROSPERO (CRD42018088309).
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Affiliation(s)
- James E. Hill
- Faculty of Health and Wellbeing, University of Central Lancashire (UCLan), Preston, Lancashire PR1 2HE UK
| | - Anne-Marie Stephani
- Faculty of Health and Wellbeing, University of Central Lancashire (UCLan), Preston, Lancashire PR1 2HE UK
| | | | - Andrew J. Clegg
- Faculty of Health and Wellbeing, University of Central Lancashire (UCLan), Preston, Lancashire PR1 2HE UK
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Fostering Health Literacy Responsiveness in a Remote Primary Health Care Setting: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17082730. [PMID: 32316171 PMCID: PMC7215686 DOI: 10.3390/ijerph17082730] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 01/03/2023]
Abstract
Primary healthcare organisations have an important role in addressing health literacy as this is a barrier to accessing and utilising health care. Until recently, no organisational development tool operationalising health literacy in an Australian context existed. This research evaluated the efficacy of the Organisational Health Literacy Responsiveness (Org-HLR) tool and associated assessment process in a primary healthcare organisation in the Pilbara region of Western Australia. This study utilised a sequential explanatory mixed methods research design incorporating the collection and analysis of data in two phases: (1) Pre- and post-survey data and; (2) seven semi-structured interviews. Survey results showed that participants’ confidence in core health literacy concepts improved from baseline following the intervention. Analysis of the interview data revealed participants’ initial understanding of health literacy was limited, and this impeded organisational responsiveness to health literacy needs. Participants reported the workshop and tool content were relevant to their organisation; they valued involving members from all parts of the organisation and having an external facilitator to ensure the impartiality of the process. External barriers to improving their internal organisational health literacy responsiveness were identified, with participants acknowledging the management style and culture of open communication within the organisation as enablers of change. Participants identified actionable changes to improve their organisational health literacy responsiveness using the process of organisational assessment and change.
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Bradley K, Smith R, Hughson JA, Atkinson D, Bessarab D, Flicker L, Radford K, Smith K, Strivens E, Thompson S, Blackberry I, LoGiudice D. Let's CHAT (community health approaches to) dementia in Aboriginal and Torres Strait Islander communities: protocol for a stepped wedge cluster randomised controlled trial. BMC Health Serv Res 2020; 20:208. [PMID: 32164678 PMCID: PMC7069169 DOI: 10.1186/s12913-020-4985-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Documented rates of dementia and cognitive impairment not dementia (CIND) in older Aboriginal and Torres Strait Islander Peoples is 3-5 times higher than the rest of the population, and current evidence suggests this condition is under-diagnosed and under-managed in a clinical primary care setting. This study aims to implement and evaluate a culturally responsive best practice model of care to optimise the detection and management of people with cognitive impairment and/or dementia, and to improve the quality of life of carers and older Aboriginal and Torres Islander Peoples with cognitive impairment. METHODS/DESIGN The prospective study will use a stepped-wedge cluster randomised controlled trial design working with 12 Aboriginal Community Controlled Health Services (ACCHSs) across four states of Australia. Utilising a co-design approach, health system adaptations will be implemented including (i) development of a best practice guide for cognitive impairment and dementia in Aboriginal and Torres Strait Islander communities (ii) education programs for health professionals supported by local champions and (iii) development of decision support systems for local medical software. In addition, the study will utilise a knowledge translation framework, the Integrated Promoting Action on Research Implementation in Health Services (iPARIHS) Framework, to promote long-term sustainable practice change. Process evaluation will also be undertaken to measure the quality, fidelity and contextual influences on the outcomes of the implementation. The primary outcome measures will be rates of documentation of dementia and CIND, and evidence of improved management of dementia and CIND among older Indigenous peoples attending Aboriginal and Torres Strait Islander primary care services through health system changes. The secondary outcomes will be improvements to the quality of life of older Indigenous peoples with dementia and CIND, as well as that of their carers and families. DISCUSSION The Let's CHAT Dementia project will co-design, implement and evaluate a culturally responsive best practice model of care embedded within current Indigenous primary health care. The best practice model of care has the potential to optimise the timely detection (especially in the early stages) and improve the ongoing management of people with dementia or cognitive impairment. TRIAL REGISTRATION ACTRN12618001485224. Date of registration: 04 of September 2019.
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Affiliation(s)
- Kate Bradley
- The University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Royal Melbourne Hospital, Royal Park Campus, Administration Building 21, 34 -54 Poplar Road, Melbourne, Victoria 3052 Australia
| | - Robyn Smith
- The University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Royal Melbourne Hospital, Royal Park Campus, Administration Building 21, 34 -54 Poplar Road, Melbourne, Victoria 3052 Australia
| | - Jo-anne Hughson
- The University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Royal Melbourne Hospital, Royal Park Campus, Administration Building 21, 34 -54 Poplar Road, Melbourne, Victoria 3052 Australia
| | - David Atkinson
- The University of Western Australia, Rural Clinical School of Western Australia , PO Box 1377, Broome, 6725 Australia
| | - Dawn Bessarab
- The University of Western Australia, M303, 35 Stirling Highway, Perth, 6009 Australia
| | - Leon Flicker
- The University of Western Australia, Rural Clinical School of Western Australia , PO Box 1377, Broome, 6725 Australia
| | - Kylie Radford
- Neuroscience Research Australia, 139 Barker Street, Sydney, NSW 2031 Australia
- The School of Medical Sciences, University of New South Wales, Sydney, NSW Australia
| | - Kate Smith
- University of Western Australia, 35 Stirling Highway, Perth, 6009 Australia
| | | | - Sandra Thompson
- The University of Western Australia, 167 Fitzgerald St, Geraldton, WA 6530 Australia
| | | | - Dina LoGiudice
- The University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Royal Melbourne Hospital, Royal Park Campus, Administration Building 21, 34 -54 Poplar Road, Melbourne, Victoria 3052 Australia
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Dzidowska M, Lee KSK, Wylie C, Bailie J, Percival N, Conigrave JH, Hayman N, Conigrave KM. A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement. BMC FAMILY PRACTICE 2020; 21:33. [PMID: 32054450 PMCID: PMC7020510 DOI: 10.1186/s12875-020-1101-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/29/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Unhealthy alcohol use involves a spectrum from hazardous use (exceeding guidelines but no harms) through to alcohol dependence. Evidence-based management of unhealthy alcohol use in primary health care has been recommended since 1979. However, sustained and systematic implementation has proven challenging. The Continuing Quality Improvement (CQI) process is designed to enable services to detect barriers, then devise and implement changes, resulting in service improvements. METHODS We conducted a systematic review of literature reporting on strategies to improve implementation of screening and interventions for unhealthy alcohol use in primary care (MEDLINE EMBASE, PsycINFO, CINAHL, the Australian Indigenous Health InfoNet). Additional inclusion criteria were: (1) pragmatic setting; (2) reporting original data; (3) quantitative outcomes related to provision of service or change in practice. We investigate the extent to which the three essential elements of CQI are being used (data-guided activities, considering local conditions; iterative development). We compare characteristics of programs that include these three elements with those that do not. We describe the types, organizational levels (e.g. health service, practice, clinician), duration of strategies, and their outcomes. RESULTS Fifty-six papers representing 45 projects were included. Of these, 24 papers were randomized controlled trials, 12 controlled studies and 20 before/after and other designs. Most reported on strategies for improving implementation of screening and brief intervention. Only six addressed relapse prevention pharmacotherapies. Only five reported on patient outcomes and none showed significant improvement. The three essential CQI elements were clearly identifiable in 12 reports. More studies with three essential CQI elements had implementation and follow-up durations above the median; utilised multifaceted designs; targeted both practice and health system levels; improved screening and brief intervention than studies without the CQI elements. CONCLUSION Utilizing CQI methods in implementation research would appear to be well-suited to drive improvements in service delivery for unhealthy alcohol use. However, the body of literature describing such studies is still small. More well-designed research, including hybrid studies of both implementation and patient outcomes, will be needed to draw clearer conclusions on the optimal approach for implementing screening and treatment for unhealthy alcohol use. (PROSPERO registration ID: CRD42018110475).
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Affiliation(s)
- Monika Dzidowska
- Faculty of Medicine and Health, Discipline of Addiction Medicine, NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, The University of Sydney, Lev 6, King George V Building (C39), The University of Sydney, NSW 2006 Australia
| | - K. S. Kylie Lee
- Faculty of Medicine and Health, Discipline of Addiction Medicine, NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, The University of Sydney, Lev 6, King George V Building (C39), The University of Sydney, NSW 2006 Australia
- Centre for Alcohol Policy Research, La Trobe University, Level 5, HS2, Bundoora, VIC 3086 Australia
| | - Claire Wylie
- Faculty of Medicine and Health, Translational Australian Clinical Toxicology Program, The University of Sydney, Lev3, 1-3 Ross Street (K06), The University of Sydney, NSW 2006 Australia
| | - Jodie Bailie
- The University of Sydney, Faculty of Medicine and Health, University Centre for Rural Health, 61 Uralba Street, Lismore, NSW 2480 Australia
| | - Nikki Percival
- Faculty of Health, Australian Centre for Public and Population Health Research, University of Technology Sydney, UTS Building 10, 235-253 Jones Street, Ultimo, NSW 2007 Australia
| | - James H. Conigrave
- Faculty of Medicine and Health, Discipline of Addiction Medicine, NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, The University of Sydney, Lev 6, King George V Building (C39), The University of Sydney, NSW 2006 Australia
| | - Noel Hayman
- Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care (Inala Indigenous Health Service), 37 Wirraway Parade, Inala, QLD 4077 Australia
- School of Medicine, Griffith University, Griffith Health Centre (G40), Gold Coast campus, Gold Coast, QLD 4222 Australia
- School of Medicine, University of Queensland, Herston Road, Herston, QLD 4006 Australia
| | - Katherine M. Conigrave
- Faculty of Medicine and Health, Discipline of Addiction Medicine, NHMRC Centre of Research Excellence in Indigenous Health and Alcohol, The University of Sydney, Lev 6, King George V Building (C39), The University of Sydney, NSW 2006 Australia
- Sydney Local Health District, Royal Prince Alfred Hospital, Drug Health Service, King George V Building, 83-117 Missenden Road, Camperdown, NSW 2050 Australia
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