Working under a clinic-level quality incentive: primary care clinicians' perceptions

A Health Care Value Framework for Physical Therapy Primary Health Care Organizations

BACKGROUND AND OBJECTIVE

To develop a health care value framework for physical therapy primary health care organizations including a definition.

METHOD

A scoping review was performed. First, relevant studies were identified in 4 databases (n = 74). Independent reviewers selected eligible studies. Numerical and thematic analyses were performed to draft a preliminary framework including a definition. Next, the feasibility of the framework and definition was explored by physical therapy primary health care organization experts.

RESULTS

Numerical and thematic data on health care quality and context-specific performance resulted in a health care value framework for physical therapy primary health care organizations-including a definition of health care value, namely "to continuously attain physical therapy primary health care organization-centered outcomes in coherence with patient- and stakeholder-centered outcomes, leveraged by an organization's capacity for change."

CONCLUSION

Prior literature mainly discussed health care quality and context-specific performance for primary health care organizations separately. The current study met the need for a value-based framework, feasible for physical therapy primary health care organizations, which are for a large part micro or small. It also solves the omissions of incoherent literature and existing frameworks on continuous health care quality and context-specific performance. Future research is recommended on longitudinal exploration of the HV (health care value) framework.

Diverse community leaders' perspectives about quality primary healthcare and healthcare measurement: Qualitative community-based participatory research

Background

Healthcare quality measurements in the United States illustrate disparities by racial/ethnic group, socio-economic class, and geographic location. Redressing healthcare inequities, including measurement of and reimbursement for healthcare quality, requires partnering with communities historically excluded from decision-making. Quality healthcare is measured according to insurers, professional organizations and government agencies, with little input from diverse communities. This community-based participatory research study aimed to amplify the voices of community leaders from seven diverse urban communities in Minneapolis-Saint Paul Minnesota, view quality healthcare and financial reimbursement based on quality metric scores.

Methods

A Community Engagement Team consisting of one community member from each of seven urban communities —Black/African American, Lesbian-Gay-Bisexual-Transgender-Queer-Two Spirit, Hmong, Latino/a/x, Native American, Somali, and White—and two community-based researchers conducted listening sessions with 20 community leaders about quality primary healthcare. Transcripts were inductively analyzed and major themes were identified.

Results

Listening sessions produced three major themes, with recommended actions for primary care clinics.

#1: Quality Clinics Utilize Structures and Processes that Support Healthcare Equity.

#2: Quality Clinics Offer Effective Relationships, Education, and Health Promotion.

#3: Funding Based on Current Quality Measures Perpetuates Health Inequities.

Conclusion

Community leaders identified ideal characteristics of quality primary healthcare, most of which are not currently measured. They expressed concern that linking clinic payment with quality metrics without considering social and structural determinants of health perpetuates social injustice in healthcare.

More public health service providers are experiencing job burnout than clinical care providers in primary care facilities in China

BACKGROUND

Health workers are at high risk of job burnout. Primary care in China has recently expanded its scope of services to a broader range of public health services in addition to clinical care. This study aims to measure the prevalence of burnout and identify its associated factors among clinical care and public health service providers at primary care facilities.

METHODS

A cross-sectional survey (2018) was conducted among 17,816 clinical care and public health service providers at 701 primary care facilities from six provinces. Burnout was measured by the Chinese version of the Maslach Burnout Inventory-General Scale, and multilevel linear regression analysis was conducted to identify burnout's association with demographics, as well as occupational and organisational factors.

RESULTS

Overall, half of the providers (50.09%) suffered from burnout. Both the presence of burnout and the proportion of severe burnout among public health service providers (58.06% and 5.25%) were higher than among clinical care providers (47.55% and 2.26%, respectively). Similar factors were associated with burnout between clinical care and public health service providers. Younger, male, lower-educated providers and providers with intermediate professional title, permanent contract or higher working hours were related to a higher level of burnout. Organisational environment, such as the presence of a performance-based salary system, affected job burnout.

CONCLUSIONS

Job burnout is prevalent among different types of primary care providers in China, indicating the need for actions that encompass the entirety of primary care. We recommend strengthening the synergy between clinical care and public health services and transforming the performance-based salary system into a more quality-based system that includes teamwork incentives.

Interventions to improve team effectiveness within health care: a systematic review of the past decade

BACKGROUND

A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design.

OBJECTIVES

To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research.

METHODS

Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence.

RESULTS

Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements.

CONCLUSION

Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Provider Perspectives on Quality Payment Programs Targeting Diabetes in Primary Care Settings

Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.

Primary care clinicians' perspectives about quality measurements in safety-net clinics and non-safety-net clinics

BACKGROUND

Quality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare.

METHODS

Qualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes.

RESULTS

Three themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity.

CONCLUSION

Aligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.

Physicians' experiences of SBIRT training and implementation for SUD management in primary care in the UAE: a qualitative study

AimThe objective of this paper is to present a qualitative study of introducing substance misuse screening using the Screening Brief Intervention and Referral to Treatment (SBIRT) model, in primary care in Abu Dhabi.

BACKGROUND

Substance misuse in the UAE is an increasing problem. However religious beliefs and fear of legal consequences have prevented this topic from being openly discussed, risk levels identified through screening and treatment options offered.

METHODS

A controlled trial was undertaken which included a qualitative process study which is reported here. Qualitative interviews with primary care physicians from two intervention clinics were undertaken to explore their views, experiences and attitudes towards substance misuse management in their clinic. Physicians were trained on SBIRT and on the research project process and documentation. At completion of the project, 10 months after the training, physicians (n=17) were invited to participate in an interview to explore their experiences of training and implementation of SBIRT. Interviews were recorded and transcribed. Inductive thematic coding was applied.FindingsIn total, 11 physicians were interviewed and three main themes emerged: (1) The SBIRT screening project, (2) cultural issues and (3) patient follow-up. Findings revealed a general willingness toward the concept of screening and delivering brief interventions in primary care although increased workload and uncertainties about remuneration for the service may be a barrier to future implementation. There was a perceived problem of substance misuse that was not currently being met and a strong perception that patients were not willing to reveal substance use due cultural barriers and fear of police involvement. In conclusion this qualitative process evaluation provided essential insight into implementing SBIRT in the Middle East. In conclusion, despite physician willingness and a clinical need for a substance misuse care pathway, the reluctance among patients to admit to substance use in this culture needs to be addressed to enable successful implementation.