Team working: the key to implementing guidelines?

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe

INTRODUCTION

Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care.

OBJECTIVES

To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries.

METHODS

A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis.

RESULTS

Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme.

CONCLUSION

Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system.

KNOWLEDGE TRANSFER STATEMENT

The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases.

Barriers and facilitators for prevention in Danish dental care

Objective: To explore barriers and facilitators to oral disease prevention in Danish dental care from a multi-stakeholder perspective. Methods: Eleven semi-structured focus groups and interviews about Danish oral healthcare were conducted with 27 stakeholders (general public, dental teams, dental policy makers) in Copenhagen. Transcripts were analyzed using deductive thematic analysis independently by KR and HL, supervised by JC and KVC. Results: Seven broad themes were identified, including both barriers and facilitators: Knowledge and attitudes, Education and training, Regulation, Incentivization, Multidisciplinary approach, Access to care and the Dental professional-patient relationship. Whilst all themes were relevant to each group of stakeholders, the salient driver within each theme was different for each group. Conclusions: Stakeholder perspectives on the Danish Oral health care system suggest the following are important features for a preventively focused system: (a) Involving all stakeholders in oral healthcare planning. (b) Securing sufficient and ongoing briefing regarding disease prevention for all stakeholders. (c) Regulatory support and creation of incentives to promote and facilitate implementation of disease prevention. (d) Appropriate prevention for disadvantaged groups within society which may be possible to a higher degree by means of multidisciplinary collaboration. (e) Personal relations between the patient and the professional based on mutual trust.

Current use of guidelines, protocols, and care pathways for symptom management in hospice

Evidence-based guidelines or care pathways for symptom management could provide a means to reduce symptom distress in dying patients. We surveyed directors of nursing from hospices affiliated with the Population-based Palliative Care Research Network (PoPCRN) regarding their hospices’ current use of and attitudes toward written symptom management materials. A majority (53/78, 68 percent) of participating hospices reported use of written materials, such as guidelines, protocols, or care pathways, for one or more symptoms. Materials were based on multiple sources and varied from simple medication orders to more comprehensive, multicategory symptom management resources. Regardless of the composition, these materials were perceived as helpful. Given this favorable view, variations in the use and content of written materials may signify an opportunity to decrease symptom distress in hospice through the implementation of evidence-based symptom management resources.

Using informatics to help implement clinical guidelines

Clinical guidelines are a positive contribution to improving the quality of care and assuring its effectiveness. However, clinical guidelines need to be integrated with other quality improvement initiatives to fulfil their potential. We propose a model of how informatics can support the implementation of clinical guidelines and their integration into systems for decision support and clinical audit. Each element of the model is discussed in turn and particular attention is paid to how informatics can also facilitate the involvement of patients in developing and using clinical guidelines. The word ‘patients’ is used to describe all users of health services.

Development of regional guidelines: the way forward for neonatal networks?

Successful development of regional guidelines can help to achieve unified neonatal practice

Clinical practice guidelines: perspectives of clinicians in Queensland public hospitals

BACKGROUND

Clinical practice guidelines (CPG) have been shown to improve processes of care and clinical outcomes. The present study sought to determine how clinicians in Queensland public hospitals view and use such guidelines.

METHODS

A self-administered questionnaire survey was conducted of a convenience sample of medical practitioners, nurses and allied-health professionals in 19 public hospitals.

RESULTS

Of 333 surveyed clinicians, 216 returned questionnaires (65% response rate). Of these, 67% reported guideline use in their clinical area; more so in general than in tertiary hospitals (75% vs. 60%; P = 0.03) or in district hospitals (75% vs. 56%; P= 0.05). The guidelines were considered useful by 85% of respondents; 45% used them at least once a week. Lack of awareness of guidelines (45%) or inability to access them when needed (44%) prevented greater use. Concise, quick-reference formats were preferred to detailed texts (35%vs. 6%; P<0.001). Sixty percent of respondents became acquainted with guideline recommendations through informal discussions with colleagues rather than through organized awareness-raising (27%) or educational forums (41%; P < 0.001). Guideline endorsement by senior colleagues (68%) and peers (53%) was considered essential to maximizing uptake. Barriers to implementing guideline recommendations were encountered by 62% of clinicians, including insufficient clinical resources (29%) or time (24%), and conflict with accepted practice codes (19%).

CONCLUSIONS

In general, clinicians working in public hospitals use CPG and view them positively. Based on free-text comments, a minority of non-medical respondents perceived guidelines and pathways as interchangeable tools. Improved uptake is dependent on increasing access, enhancing user-friendly guideline presentation, deploying local opinion leaders, and mitigating environmental barriers to implementation.

Facilitating the use of evidence in practice: evaluating and adapting clinical practice guidelines for local use by health care organizations

This article describes a framework for evaluating and adapting existing practice guidelines for local use by health care organizations and groups. The framework presents the major issues related to guideline adaptation and breaks them down into manageable steps. Many steps of the framework are illustrated using the process used by the Registered Nurses Association of Ontario to develop best practice guidelines for breastfeeding.

Planned and reported implementation of clinical practice guidelines

The aim of this project was to compare the intentions with reported action of Health Trusts in Scotland to prioritise and implement published SIGN clinical guidelines. All health Trusts in Scotland were asked about plans for implementation, and resurveyed 15-18 months later for confirmation. Specific guideline implementation groups led by medical doctors were the most common implementation structure. Implementation usually consisted of baseline audit, development of a local version, and reaudit. In one case a successful link between acute and primary care through an area level GP audit facilitator was thought to increase implementation. More research is required to: find out what influences the ability of an organisation to implement guidelines; identify particular facilitating factors or barriers; and on factors influencing the ability of a health organisation to implement guidelines.

Trauma emergency unit: long-term evaluation of a quality assurance programme

OBJECTIVE

Long-term evaluation of a quality assurance programme (after an assessment in 1993).

DESIGN

Review of medical records.

SETTING

Emergency area of an orthopaedic, trauma, and plastic surgery unit in a French teaching hospital (Besancon).

SUBJECTS

1187 consecutive ambulatory patients' records, from July 1995.

MAIN MEASURES

Occurrence of near adverse events (at risk events causing situations which could lead to the occurrence of an adverse event).

RESULTS

71 near adverse events were identified (5.9% of the ambulatory visits). There was a significant decrease in the rate of near adverse events between 1993 (9.9% (2056 ambulatory visits, 204 near adverse events)), and 1995 (5.9% (1187 ambulatory visits, 71 near adverse events)), and significant change in the proportion of each category of adverse event (decrease in departures from prevention protocols).

CONCLUSIONS

Despite their limitations, the effectiveness and efficiency of quality assurance programmes seem to be real and valuable. Maintaining quality improvement requires conditions which include some of the basic principles of total quality management (leadership, participatory management, openness, continuous feed back). The organisation of this unit as a specialised trauma centre was also a determining factor in the feasibility of a quality assurance programme (specialisation and small size, high activity volume, management of the complete care process). Quality assurance is an important initial step towards quality improvement, that should precede consideration of a total quality management programme.

The managerial and clinical implications of patient-focused care

Discusses five elements of patient-focused care (PFC). Clarifies issues surrounding the first element--aggregating patients--and debates the strengths and weaknesses of the second element--centralizing services in PFC units. Explores arguments for and against the third element--multiskilling and cross-training--including staff activity in conventional hospitals and PFC units, in depth. Discusses the structure of PFC teams and their management. Describes the main components of the fourth PFC element--integrated carepaths--and explores their role in clinical audit, computerization and seamless care. Examines the costs of PFC by comparing actual with expected costs. Makes managerial, clinical, educational and research implications throughout for staff working in or with PFC units.

Use facilitated case discussions for significant event auditing

An important type of review undertaken routinely in health care teams is analysis of individual cases. This informal process can be turned into a structured and effective form of audit by using an adaptation of the "critical incident" technique in facilitated case discussions. Participants are asked to recall personal situations that they feel represent either effective or ineffective practice. From such review of individual cases arise general standards to improve the quality of care. On the basis of a study of audit of deaths in general practice, we describe how to implement such a system, including forming and maintaining the discussion group, methodology, and guidelines for facilitators. Problems that may arise during the case discussions are outlined and their management discussed, including problems within the team and with the process of the discussions.

Palliative care in the community: setting practice guidelines for primary care teams

BACKGROUND

Previous studies have demonstrated deficiencies in palliative care in the community. One method of translating the results of research into clinical practice, in order to produce more effective health care, is the development of clinical guidelines. Setting standards for such care has been performed by care teams in both hospital and hospice settings but not in primary care.

AIM

This study set out to develop guidelines for primary care teams to follow in the provision of palliative care in the community using facilitated case discussions with the members of such teams, as a form of internal audit.

METHOD

Five practices were randomly chosen from the family health services authority medical list. Meetings between the facilitators and primary care teams were held over a period of one year. The teams were asked to describe good aspects of care, areas of concern and suggestions to improve these, in recent cases of patient deaths.

RESULTS

In total 56 cases were discussed. All practices felt that cohesive teamwork, coordinated management, early involvement of nursing staff and the identification of a key worker were essential for good terminal care. Concerns arose in clinical and administrative areas but the majority were linked to poor communication, either between patient and professionals within the primary care team or between primary and secondary care. All the positive aspects of care, concerns and suggestions were collated by the facilitators into guidelines for teams to refer to from the initial diagnosis of a terminal illness through to the patient's death and care of the relatives afterwards.

CONCLUSION

Developing multidisciplinary as opposed to medical guidelines for palliative care allows primary health care teams to create standards that are acceptable to them and stimulates individuals within the teams to accept responsibility for initiating the change necessary for more effective care. The process of facilitating teams to discuss their work allows for recognition and respect of individuals' roles and more importantly provides shared ownership, an important contributory factor in the implementation of guidelines.