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Kagan A, Simmons-Mackie N, Villar-Guerrero E, Chan MT, Turczyn I, Victor JC, Shumway E, Chan L, Cohen-Schneider R, Bayley M. Improving communicative access and patient experience in acute stroke care: An implementation journey. JOURNAL OF COMMUNICATION DISORDERS 2024; 107:106390. [PMID: 38103420 DOI: 10.1016/j.jcomdis.2023.106390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 10/19/2023] [Accepted: 11/09/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Patient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts. METHODS The project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) - an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years. OUTCOMES Examples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products - a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process. CONCLUSIONS This implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.
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Affiliation(s)
- Aura Kagan
- Aphasia Institute, 73 Scarsdale Road, Toronto, Ontario M3B 2R2, Canada; University of Toronto, Faculty of Medicine, Department of Speech-Language Pathology, Rehabilitation Sciences Building, 160-500 University Avenue, Toronto, Ontario M5G 1V7, Canada.
| | - Nina Simmons-Mackie
- Southeastern Louisiana University, Department of Health & Human Sciences, White Hall, Room 206, 310W Dakota Street, SLU Box 10863, Hammond, Louisiana 70402, USA
| | - Elizabeth Villar-Guerrero
- North York General Hospital, General Medicine (7SE) & Neurology / Stroke (8SE), 4001 Leslie Street, Toronto, Ontario M2K 1E1, Canada
| | - Melodie T Chan
- Aphasia Institute, 73 Scarsdale Road, Toronto, Ontario M3B 2R2, Canada.
| | - Ilona Turczyn
- North York General Hospital, 5WEST General Medicine, 4001 Leslie Street, Toronto, Ontario, M2K 1E1, Canada
| | - J Charles Victor
- ICES - Institute for Clinical Evaluative Sciences, 2075 Bayview Ave., Toronto, Ontario M4N 3M5, Canada; University of Toronto, Institute of Health Policy, Management and Evaluation, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6, Canada
| | - Elyse Shumway
- Aphasia Institute, 73 Scarsdale Road, Toronto, Ontario M3B 2R2, Canada
| | - Lisa Chan
- Aphasia Institute, 73 Scarsdale Road, Toronto, Ontario M3B 2R2, Canada
| | | | - Mark Bayley
- Toronto Rehabilitation Institute, The University Centre, Room 3-131, 550 University Avenue, Toronto, Ontario M5G 2A2, Canada
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Ellis LA, Tran Y, Pomare C, Long JC, Churruca K, Saba M, Braithwaite J. Hospital organizational change: The importance of teamwork culture, communication, and change readiness. Front Public Health 2023; 11:1089252. [PMID: 36844850 PMCID: PMC9947780 DOI: 10.3389/fpubh.2023.1089252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
Background Hospital organizational change can be a challenging time, especially when staff do not feel informed and ready for the change to come. A supportive workplace culture can mitigate the negative effects allowing for a smooth transition during hospital organizational change. In this paper, we test an exploratory path model by which teamwork culture influences staff attitudes in feeling informed and ready for change, and which are ultimately related to reduced staff burnout. We also examined different types of change communication, identifying the channels that were perceived as most useful for communicating organizational change. Methods In 2019, a cross-sectional online and paper-based survey of all staff (clinical and non-clinical) was conducted at a hospital undergoing major organizational change in Sydney, Australia. The survey included items regarding teamwork culture, communication (feeling informed, communication channels), change readiness (appropriateness, change efficacy), and burnout. With a sample size of 153 (62% clinical staff), regression and path analyses were used to examine relationships between variables. Results The total effects between teamwork culture and burnout was significant [β (Total) = -0.37, p < 0.001) and explained through a serial mediation. This relationship was found to be mediated by three factors (feeling informed, appropriateness of change and change efficacy) in a full mediation. Further, change readiness (appropriateness of change and change efficacy) mediated the relationship between feeling informed and burnout. The most useful channels of change communication included face-to-face informal communication, emails, and a newsletter specifically about the change. Conclusion Overall, the results supported the predicted hypotheses and were consistent with past research. In the context of large hospital change, staff with a positive teamwork culture who feel informed are more likely to feel change-ready, heightening the chances of successful organizational change and potentially reducing staff burnout. Understanding the pathways on how culture and communication related to burnout during organizational change provides an explanatory pathway that can be used to heighten the chances of a smooth change transition with minimal disruption to staff and patient care.
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Affiliation(s)
| | - Yvonne Tran
- Faculty of Medicine, Health, and Human Sciences, Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie, NSW, Australia
| | - Chiara Pomare
- Faculty of Medicine, Health, and Human Sciences, Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie, NSW, Australia
| | - Janet C. Long
- Faculty of Medicine, Health, and Human Sciences, Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie, NSW, Australia
| | - Kate Churruca
- Faculty of Medicine, Health, and Human Sciences, Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie, NSW, Australia
| | - Maree Saba
- Faculty of Medicine, Health, and Human Sciences, Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie, NSW, Australia
| | - Jeffrey Braithwaite
- Faculty of Medicine, Health, and Human Sciences, Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Macquarie, NSW, Australia
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Pyone T, Mirzoev T. Feasibility of Good Governance at Health Facilities: A Proposed Framework and its Application Using Empirical Insights From Kenya. Int J Health Policy Manag 2022; 11:1102-1111. [PMID: 33619930 PMCID: PMC9808192 DOI: 10.34172/ijhpm.2021.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/02/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Governance is a social phenomenon which permeates throughout systemic, organisational and individual levels. Studies of health systems governance traditionally assessed performance of systems or organisations against principles of good governance. However, understanding key pre-conditions to embed good governance required for healthcare organisations is limited. We explore the feasibility of embedding good governance at healthcare facilities in Kenya. METHODS Our conceptualisation of organisational readiness for embedding good governance stems from a theory of institutional analysis and frameworks for understanding organisational readiness for change. Four inter-related constructs underpin to embed good governance: (i) individual motivations, determined by (ii) mechanisms for encouraging adherence to good governance through (iii) organisation's institutional arrangements, all within (iv) a wider context. We propose a framework, validated through qualitative methods and collected through 39 semi-structured interviews with healthcare providers, county and national-level policy-makers in Kenya. Data was analysed using framework approach, guided by the four constructs of the theoretical framework. We explored each construct in relation to three key principles of good governance: accountability, participation and transparency of information. RESULTS Embedding good governance in healthcare organisations in Kenya is influenced by political and socio-cultural contexts. Individual motivations were a critical element of self-enforcement to embed principles of good governance by healthcare providers within their facilities. Healthcare providers possess strong moral incentives to self-enforce accountability to local populations, but their participation in decision-making was limited. Health facilities lacked effective mechanisms for enforcing good governance such as combating corruption, which led to a proliferation of informal institutional arrangements. CONCLUSION Organisational readiness for good governance is context-specific so future work should recognise different interpretations of acceptable degrees of transparency, accountability and participation. While good governance involves collective social action, organisational readiness relies on individual choices and decisions within the context of organisational rules and cultural and historical environments.
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Affiliation(s)
- Thidar Pyone
- Department of Global Public Health, Public Health England, London, United Kingdom
| | - Tolib Mirzoev
- Leeds Institute of Health Sciences, University of Leeds, United Kingdom
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Wong PKS, Wong YC, Kwan CL. Development and validation of the scale on staff valence under ICF-based practice (SSV-ICF). Disabil Rehabil 2022; 44:1243-1251. [DOI: 10.1080/09638288.2020.1799247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Yu Cheung Wong
- Department of Social Sciences, Caritas Institute of Higher Education, Hong Kong SAR, China
| | - Cheuk Lun Kwan
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong SAR, China
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Assessing Firm Readiness to Adopt Cluster-Based Innovative Projects: A Segmentation Analysis. SUSTAINABILITY 2022. [DOI: 10.3390/su14020947] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As innovation has garnered substantial attention on corporate success and sustainability, organizations must evaluate internal contexts to determine potential innovative practices and benefits. Firms need to investigate the determining factors of innovation preparedness as organizational innovation practices are catalyzed through internal elements. This study evaluates small and medium firms’ readiness to adopt and execute collaborative innovative projects within a future cluster and its impacts on organizational advantages, intentions, and attributes. Thereby, three dimensions were considered in examining organizational preparedness, namely, climate, culture, and motivation. A total of 70 firms operating in the labeled agri-food sector in Morocco were interviewed and homogenously classified using integrated hierarchical and non-hierarchical algorithms, following a segmentation approach. Three segments were identified, stressing the degree of organizational readiness to undertake innovative projects within future service clusters. The segments varied according to the firm’s sub-sector, experience, and resources. Considering the association of readiness with benefits and practical aims, the results broaden firm preparedness understanding to adopt innovative projects. The results also illustrate the relevance of adapting both innovative and beneficial project arrangements for firms with minor to moderate experience while addressing current issues across different segments.
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Samanta D, Landes SJ. Implementation Science to Improve Quality of Neurological Care. Pediatr Neurol 2021; 121:67-74. [PMID: 34153816 PMCID: PMC8842973 DOI: 10.1016/j.pediatrneurol.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 01/12/2023]
Abstract
Neurological disorders are the leading cause of disability and the second leading cause of death globally. To challenge this enormous disease burden, scientists are pursuing innovative solutions to maintain and improve the quality of neurological care. Despite the availability of many effective evidence-based practices, many patients with neurological disorders cannot access these (or receive them inefficiently after a long delay) and may be exposed to unnecessary, expensive, and potentially harmful treatments. To promote the systematic uptake of evidence-based practices into the real world, a new scientific study of methods has been developed: implementation science. In implementation science research, transdisciplinary research teams systematically (using theory, model, and framework) assess local barriers to facilitate the adoption of evidence-based practices and examine potential solutions using implementation strategies (interventions that help adoption of intended practices) targeting multiple levels in the health care system, including patient, provider, clinic, facility, organization, or broader community and policy environment. The success of these strategies (implementation outcomes) is measured by the extent and quality of the implementation. Implementation studies can be either observational or interventional but are distinct from traditional efficacy or effectiveness studies. Traditional neuroscience research and clinical trials, conducted in controlled settings, focus on discovering new insights with little consideration of translating those insights into the everyday practice of a resource-constrained and dynamic health care system. Thus, neurologists should become familiar with implementation science to reduce the knowledge-practice gap, maximize health care value, and improve management of brain disorders affecting public health.
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Affiliation(s)
- Debopam Samanta
- Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Sara J Landes
- University of Arkansas for Medical Sciences, Department of Psychiatry & Central Arkansas Veterans Healthcare System, Behavioral Health QUERI
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Archambault PM, Rivard J, Smith PY, Sinha S, Morin M, LeBlanc A, Couturier Y, Pelletier I, Ghandour EK, Légaré F, Denis JL, Melady D, Paré D, Chouinard J, Kroon C, Huot-Lavoie M, Bert L, Witteman HO, Brousseau AA, Dallaire C, Sirois MJ, Émond M, Fleet R, Chandavong S. Learning Integrated Health System to Mobilize Context-Adapted Knowledge With a Wiki Platform to Improve the Transitions of Frail Seniors From Hospitals and Emergency Departments to the Community (LEARNING WISDOM): Protocol for a Mixed-Methods Implementation Study. JMIR Res Protoc 2020; 9:e17363. [PMID: 32755891 PMCID: PMC7439141 DOI: 10.2196/17363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/17/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Elderly patients discharged from hospital experience fragmented care, repeated and lengthy emergency department (ED) visits, relapse into their earlier condition, and rapid cognitive and functional decline. The Acute Care for Elders (ACE) program at Mount Sinai Hospital in Toronto, Canada uses innovative strategies, such as transition coaches, to improve the care transition experiences of frail elderly patients. The ACE program reduced the lengths of hospital stay and readmission for elderly patients, increased patient satisfaction, and saved the health care system over Can $4.2 million (US $2.6 million) in 2014. In 2016, a context-adapted ACE program was implemented at one hospital in the Centre intégré de santé et de services sociaux de Chaudière-Appalaches (CISSS-CA) with a focus on improving transitions between hospitals and the community. The quality improvement project used an intervention strategy based on iterative user-centered design prototyping and a "Wiki-suite" (free web-based database containing evidence-based knowledge tools) to engage multiple stakeholders. OBJECTIVE The objectives of this study are to (1) implement a context-adapted CISSS-CA ACE program in four hospitals in the CISSS-CA and measure its impact on patient-, caregiver-, clinical-, and hospital-level outcomes; (2) identify underlying mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly; and (3) identify underlying mechanisms by which the Wiki-suite contributes to context-adaptation and local uptake of knowledge tools. METHODS Objective 1 will involve staggered implementation of the context-adapted CISSS-CA ACE program across the four CISSS-CA sites and interrupted time series to measure the impact on hospital-, patient-, and caregiver-level outcomes. Objectives 2 and 3 will involve a parallel mixed-methods process evaluation study to understand the mechanisms by which our context-adapted CISSS-CA ACE program improves care transitions for the elderly and by which our Wiki-suite contributes to adaptation, implementation, and scaling up of geriatric knowledge tools. RESULTS Data collection started in January 2019. As of January 2020, we enrolled 1635 patients and 529 caregivers from the four participating hospitals. Data collection is projected to be completed in January 2022. Data analysis has not yet begun. Results are expected to be published in 2022. Expected results will be presented to different key internal stakeholders to better support the effort and resources deployed in the transition of seniors. Through key interventions focused on seniors, we are expecting to increase patient satisfaction and quality of care and reduce readmission and ED revisit. CONCLUSIONS This study will provide evidence on effective knowledge translation strategies to adapt best practices to the local context in the transition of care for elderly people. The knowledge generated through this project will support future scale-up of the ACE program and our wiki methodology in other settings in Canada. TRIAL REGISTRATION ClinicalTrials.gov NCT04093245; https://clinicaltrials.gov/ct2/show/NCT04093245. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/17363.
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Affiliation(s)
- Patrick Michel Archambault
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Josée Rivard
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Pascal Y Smith
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Samir Sinha
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- Department of Medicine, University Health Network, Toronto, QC, Canada
- Department of Medicine, University of Toronto, Toronto, QC, Canada
| | - Michèle Morin
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Annie LeBlanc
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
| | - Yves Couturier
- Department of Social Work, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Isabelle Pelletier
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - El Kebir Ghandour
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Institut national d'excellence en sante et en services sociaux, Québec, QC, Canada
| | - France Légaré
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN), Québec, QC, Canada
- Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Québec, QC, Canada
| | - Jean-Louis Denis
- Département de gestion, d'évaluation et de politique de santé, École de santé publique, Université de Montréal, Montreal, QC, Canada
| | - Don Melady
- Schwartz-Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Paré
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Josée Chouinard
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Chantal Kroon
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Ste-Marie, QC, Canada
| | - Maxime Huot-Lavoie
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Laetitia Bert
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Nursing, Université Laval, Québec, QC, Canada
| | - Holly O Witteman
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Office of Education and Professional Development, Faculty of Medicine, Université Laval, Québec, QC, Canada
- CHU de Québec-Université Laval, Québec, QC, Canada
| | - Audrey-Anne Brousseau
- Centre intégré universitaire de santé et de services sociaux de l'Estrie - CHUS, Sherbrooke, QC, Canada
| | - Clémence Dallaire
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
- Faculty of Nursing, Université Laval, Québec, QC, Canada
| | - Marie-Josée Sirois
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre d'excellence sur le vieillissement du Québec, Hôpital du Saint-Sacrement, Québec, QC, Canada
- Département de réadaptation, Faculté de médecine, Université Laval, Québec, QC, Canada
| | - Marcel Émond
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- CHU de Québec-Université Laval, Québec, QC, Canada
| | - Richard Fleet
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Sam Chandavong
- Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
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van Teunenbroek CF, Verhagen K, Smalbrugge M, Persoon A, Zuidema SU, Gerritsen DL. The construction of a conceptual framework explaining the relation between barriers to change of management of neuropsychiatric symptoms in nursing homes: a qualitative study using focus groups. BMC Geriatr 2020; 20:163. [PMID: 32375668 PMCID: PMC7201759 DOI: 10.1186/s12877-020-01569-w] [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: 10/25/2019] [Accepted: 04/23/2020] [Indexed: 01/10/2023] Open
Abstract
Background Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. Methods Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. Results We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: ‘organizational barriers’, ‘personal barriers’, ‘deficiency of staff knowledge’, ‘suboptimal communication’, ‘inadequate (multidisciplinary) collaboration’, ‘disorganization of processes’, ‘reactive coping’ and ‘differences in perception’. Addressing ‘organizational barriers’ and ‘deficiency of staff knowledge’ is a precondition for change. ‘Suboptimal communication’ and ‘inadequate (multidisciplinary) collaboration’ play a key role in the extent of change achieved via the themes ‘differences in perception’ and ‘disorganization of processes’. Furthermore, ‘personal barriers’ influence all themes - except ‘organizational barriers’ - and may cause ‘reactive coping’, which in turn may lead to ‘difficulties to structure processes’. Conclusions A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.
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Affiliation(s)
- Charlotte F van Teunenbroek
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD, Groningen, HPC FA21, the Netherlands.
| | - Kim Verhagen
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD, Groningen, HPC FA21, the Netherlands
| | - Martin Smalbrugge
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health research institute, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Anke Persoon
- Radboud Institute for Health Sciences, Department of Primary and Community Care, Radboud Alzheimer Centre, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Sytse U Zuidema
- Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, PO Box 196, 9700 AD, Groningen, HPC FA21, the Netherlands
| | - Debby L Gerritsen
- Radboud Institute for Health Sciences, Department of Primary and Community Care, Radboud Alzheimer Centre, Radboud University Medical Centre, Nijmegen, the Netherlands
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Arthur K, Christofides N, Nelson G. Educators' perceptions of organisational readiness for implementation of a pre-adolescent transdisciplinary school health intervention for inter-generational outcomes. PLoS One 2020; 15:e0227519. [PMID: 31914148 PMCID: PMC6948754 DOI: 10.1371/journal.pone.0227519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 12/19/2019] [Indexed: 01/17/2023] Open
Abstract
Organisational readiness is an implementation pre-requisite to gain its members' appropriate and committed use of the intervention. Implementation climate and organisational readiness for implementing change were evaluated conjointly to assess organisational readiness for an obesity and HIV health intervention that imparts health information directly to Grade 6 learners, and indirectly to their parents/caregivers in their home environment. The study objectives were to assess the level of organisational readiness at schools and to identify organisational factors (facilitators, barriers and contextual factors). A mixed-methods approach collected data from five public schools in Gauteng, South Africa. Forty-six educators and school management answered a self-administered questionnaire and contributed to a focus group discussion at each school. Mean scores with standard deviations, or median scores with interquartile ranges, were calculated to determine levels of organisational readiness. Qualitative data were transcribed and analysed thematically. The overall implementation climate and organisational readiness for implementing change median scores were acceptable, at 3.6 (IQR 3.2-4.1) and 4.3 (IQR 3.8-4.9), respectively. Results indicated that educators collectively valued the change highly enough to commit to its implementation, and that the motivation for the intervention, associated goals and objectives, the realisation for change, and the benefits thereof were well-comprehended by educators. Thirteen barriers and 13 facilitators were identified. The perceived degree of fit between the significance and values attached to the intervention by educators, and how these would be received by the target group (parents and learners) was also beneficial. Key barriers and facilitators indicated that the intervention needed to be a fit with existing workflows and educational systems. Contextual factors such as intervention appropriateness and acceptability as well as sensitivity to HIV were identified. These findings suggested proactive improvements to further improve the intervention and its implementation strategy.
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Affiliation(s)
- Keshni Arthur
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Nicola Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gill Nelson
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- UCL Institute for Global Health, University College London, London, United Kingdom
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11
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McIlvennan CK, Morris MA, Guetterman TC, Matlock DD, Curry L. Qualitative Methodology in Cardiovascular Outcomes Research: A Contemporary Look. Circ Cardiovasc Qual Outcomes 2019; 12:e005828. [PMID: 31510771 DOI: 10.1161/circoutcomes.119.005828] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Qualitative research offers unique opportunities to contribute to cardiovascular outcomes research. Despite the growth in qualitative research over the last decade, outcomes investigators in cardiology still have relatively little guidance on when and how best to implement these methods in their investigations, leaving the full potential of these methods unrealized. We offer a contemporary look at qualitative methods, including publication trends of qualitative studies in cardiology journals from 1998 to 2018, novel emerging data collection and analytic methods, and current use and examples of cardiovascular outcomes research that apply qualitative methods such as user-centered design, preimplementation evaluation, implementation evaluation, effectiveness evaluation, and policy analysis.
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Affiliation(s)
- Colleen K McIlvennan
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., M.A.M., D.D.M.), University of Colorado School of Medicine, Aurora.,Division of Cardiology (C.K.M.), University of Colorado School of Medicine, Aurora
| | - Megan A Morris
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., M.A.M., D.D.M.), University of Colorado School of Medicine, Aurora
| | | | - Daniel D Matlock
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (C.K.M., M.A.M., D.D.M.), University of Colorado School of Medicine, Aurora.,Veteran Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO (D.D.M.)
| | - Leslie Curry
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (L.C.).,Yale Global Health Leadership Institute, Yale University, New Haven, CT (L.C.)
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12
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Zipfel N, van der Nat PB, Rensing BJWM, Daeter EJ, Westert GP, Groenewoud AS. The implementation of change model adds value to value-based healthcare: a qualitative study. BMC Health Serv Res 2019; 19:643. [PMID: 31492184 PMCID: PMC6728951 DOI: 10.1186/s12913-019-4498-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Value-based healthcare (VBHC) is a concept that focuses on outcome measurement to contribute to quality improvement. However, VBHC does not offer a systematic approach for implementing improvement as implementation science does. The aim is to, firstly, investigate the implementation of improvement initiatives in the context of VBHC and secondly, to explore how implementation science could be of added value for VBHC and vice versa. Methods A case study with two cases in heart care was conducted; one without the explicit use of a systematic implementation method and the other one with the use of the Implementation of Change Model (ICM). Triangulation of data from document research, semi-structured interviews and a focus group was applied to evaluate the degree of method uptake. Interviews were held with experts involved in the implementation of Case 1 (N = 4) and Case 2 (N = 7). The focus group was held with experts also involved in the interviews (N = 4). A theory-driven qualitative analysis was conducted using the ICM as a framework. Results In both cases, outcome measures were seen as an important starting point for the implementation and for monitoring change. Several themes were identified as most important: support, personal importance, involvement, leadership, climate and continuous monitoring. Success factors included intrinsic motivation for the change, speed of implementation, complexity and continuous evaluation. Conclusion Application of the ICM facilitates successful implementation of quality- improvement initiatives within VBHC. However, the practical use of the ICM shows an emphasis on processes. We recommend that monitoring of outcomes be added as an essential part of the ICM. In the discussion, we propose an implementation model that integrates ICM within VBHC. Electronic supplementary material The online version of this article (10.1186/s12913-019-4498-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Zipfel
- Department of Value-based Healthcare, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Nieuwegein, the Netherlands. .,Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Paul B van der Nat
- Department of Value-based Healthcare, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Nieuwegein, the Netherlands
| | - Benno J W M Rensing
- Department of Cardiology, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Nieuwegein, the Netherlands
| | - Edgar J Daeter
- Department of Cardiothoracic Surgery, St. Antonius Hospital, P.O. Box 2500, 3430, EM, Nieuwegein, the Netherlands
| | - Gert P Westert
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - A Stef Groenewoud
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
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13
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Aylin P, Bottle A, Burnett S, Cecil E, Charles KL, Dawson P, D’Lima D, Esmail A, Vincent C, Wilkinson S, Benn J. Evaluation of a national surveillance system for mortality alerts: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSince 2007, Imperial College London has generated monthly mortality alerts, based on statistical process control charts and using routinely collected hospital administrative data, for all English acute NHS hospital trusts. The impact of this system has not yet been studied.ObjectivesTo improve understanding of mortality alerts and evaluate their impact as an intervention to reduce mortality.DesignMixed methods.SettingEnglish NHS acute hospital trusts.ParticipantsEleven trusts were included in the case study. The survey involved 78 alerting trusts.Main outcome measuresRelative risk of mortality and perceived efficacy of the alerting system.Data sourcesHospital Episodes Statistics, published indicators on quality and safety, Care Quality Commission (CQC) reports, interviews and documentary evidence from case studies, and a national evaluative survey.MethodsDescriptive analysis of alerts; association with other measures of quality; associated change in mortality using an interrupted time series approach; in-depth qualitative case studies of institutional response to alerts; and a national cross-sectional evaluative survey administered to describe the organisational structure for mortality governance and perceptions of efficacy of alerts.ResultsA total of 690 mortality alerts generated between April 2007 and December 2014. CQC pursued 75% (154/206) of alerts sent between 2011 and 2013. Patient care was cited as a factor in 70% of all investigations and in 89% of sepsis alerts. Alerts were associated with indicators on bed occupancy, hospital mortality, staffing, financial status, and patient and trainee satisfaction. On average, the risk of death fell by 58% during the 9-month lag following an alert, levelling afterwards and reaching an expected risk within 18 months of the alert. Acute myocardial infarction (AMI) and sepsis alerts instigated institutional responses across all the case study sites, although most sites were undertaking some parallel activities at a more general level to address known problems in care in these and other areas. Responses included case note review and coding improvements, changes in patient pathways, changes in diagnosis of sepsis and AMI, staff training in case note write-up and coding, greater transparency in patient deterioration, and infrastructure changes. Survey data revealed that 86% of responding trusts had a dedicated trust-level lead for mortality reduction and 92% had a dedicated trust-level mortality group or committee in place. Trusts reported that mortality reduction was a high priority and that there was strong senior leadership support for mortality monitoring. The weakest areas reported concerned the accuracy of coding, the quality of specialty-level mortality data and understanding trends in specialty-level mortality data.LimitationsOwing to the correlational nature of our analysis, we could not ascribe a causal link between mortality alerts and reductions in mortality. The complexity of the institutional context and behaviour hindered our capacity to attribute locally reported changes specifically to the effects of the alerts rather than to ongoing institutional strategy.ConclusionsThe mortality alert surveillance system reflects aspects of quality care and is valued by trusts. Alerts were considered a useful focus for identifying problems and implementing interventions around mortality.Future workA further analysis of site visits and survey material, the application of evaluative framework to other interventions, a blinded case note review and the dissemination of findings.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Paul Aylin
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Alex Bottle
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Susan Burnett
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Elizabeth Cecil
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Kathryn L Charles
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Paul Dawson
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Danielle D’Lima
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
| | - Aneez Esmail
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | | | - Samantha Wilkinson
- Dr Foster Unit at Imperial, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jonathan Benn
- Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, London, UK
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14
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Baatiema L, de-Graft Aikins A, Sav A, Mnatzaganian G, Chan CKY, Somerset S. Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals. BMJ Open 2017; 7:e015385. [PMID: 28450468 PMCID: PMC5719663 DOI: 10.1136/bmjopen-2016-015385] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings. DESIGN A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes. SETTING A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana. PARTICIPANTS A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian. RESULTS Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals. CONCLUSION Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, Accra, Legon, Ghana
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, Accra, Legon, Ghana
| | - Adem Sav
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Melbourne, Australia
| | - Carina K Y Chan
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
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15
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Shakoor S, Shafaq H, Hasan R, Qureshi SM, Dojki M, Hughes MA, Zaidi AKM, Khan E. Barriers to Implementation of Optimal Laboratory Biosafety Practices in Pakistan. Health Secur 2016; 14:214-9. [PMID: 27400192 DOI: 10.1089/hs.2016.0031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The primary goal of biosafety education is to ensure safe practices among workers in biomedical laboratories. Despite several educational workshops by the Pakistan Biological Safety Association (PBSA), compliance with safe practices among laboratory workers remains low. To determine barriers to implementation of recommended biosafety practices among biomedical laboratory workers in Pakistan, we conducted a questionnaire-based survey of participants attending 2 workshops focusing on biosafety practices in Karachi and Lahore in February 2015. Questionnaires were developed by modifying the BARRIERS scale in which respondents are required to rate barriers on a 1-4 scale. Nineteen of the original 29 barriers were included and subcategorized into 4 groups: awareness, material quality, presentation, and workplace barriers. Workshops were attended by 64 participants. Among barriers that were rated as moderate to great barriers by at least 50% of respondents were: lack of time to read biosafety guidelines (workplace subscale), lack of staff authorization to change/improve practice (workplace subscale), no career or self-improvement advantages to the staff for implementing optimal practices (workplace subscale), and unclear practice implications (presentation subscale). A lack of recognition for employees' rights and benefits in the workplace was found to be a predominant reason for a lack of compliance. Based on perceived barriers, substantial improvement in work environment, worker facilitation, and enabling are needed for achieving improved or optimal biosafety practices in Pakistan.
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Luker JA, Craig LE, Bennett L, Ellery F, Langhorne P, Wu O, Bernhardt J. Implementing a complex rehabilitation intervention in a stroke trial: a qualitative process evaluation of AVERT. BMC Med Res Methodol 2016; 16:52. [PMID: 27164839 PMCID: PMC4862225 DOI: 10.1186/s12874-016-0156-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/05/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The implementation of multidisciplinary stroke rehabilitation interventions is challenging, even when the intervention is evidence-based. Very little is known about the implementation of complex interventions in rehabilitation clinical trials. The aim of study was to better understand how the implementation of a rehabilitation intervention in a clinical trial within acute stroke units is experienced by the staff involved. This qualitative process evaluation was part of a large Phase III stroke rehabilitation trial (AVERT). METHODS A descriptive qualitative approach was used. We purposively sampled 53 allied health and nursing staff from 19 acute stroke units in Australia, New Zealand and Scotland. Semi-structured interviews were conducted by phone, voice-internet, or face to face. Digitally recorded interviews were transcribed and analysed by two researchers using rigorous thematic analysis. RESULTS Our analysis uncovered ten important themes that provide insight into the challenges of implementing complex new rehabilitation practices within complex care settings, plus factors and strategies that assisted implementation. Themes were grouped into three main categories: staff experience of implementing the trial intervention, barriers to implementation, and overcoming the barriers. Participation in the trial was challenging but had personal rewards and improved teamwork at some sites. Over the years that the trial ran some staff perceived a change in usual care. Barriers to trial implementation at some sites included poor teamwork, inadequate staffing, various organisational barriers, staff attitudes and beliefs, and patient-related barriers. Participants described successful implementation strategies that were built on interdisciplinary teamwork, education and strong leadership to 'get staff on board', and developing different ways of working. CONCLUSIONS The AVERT stroke rehabilitation trial required commitment to deliver an intervention that needed strong collaboration between nurses and physiotherapists and was different to current care models. This qualitative process evaluation contributes unique insights into factors that may be critical to successful trials teams, and as AVERT was a pragmatic trial, success factors to delivering complex intervention in clinical practice. TRIAL REGISTRATION AVERT registered with Australian New Zealand Clinical Trials Registry ACTRN12606000185561 .
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Affiliation(s)
- Julie A Luker
- Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia. .,International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia.
| | - Louise E Craig
- Nursing Research Institute, Australian Catholic University, Sydney, Australia
| | - Leanne Bennett
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, Australia
| | - Fiona Ellery
- Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Peter Langhorne
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, UK
| | - Julie Bernhardt
- Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia.,Latrobe University, Melbourne, Australia
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17
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Middleton S, Lydtin A, Comerford D, Cadilhac DA, McElduff P, Dale S, Hill K, Longworth M, Ward J, Cheung NW, D'Este C. From QASC to QASCIP: successful Australian translational scale-up and spread of a proven intervention in acute stroke using a prospective pre-test/post-test study design. BMJ Open 2016; 6:e011568. [PMID: 27154485 PMCID: PMC4861111 DOI: 10.1136/bmjopen-2016-011568] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To embed an evidence-based intervention to manage FEver, hyperglycaemia (Sugar) and Swallowing (the FeSS protocols) in stroke, previously demonstrated in the Quality in Acute Stroke Care (QASC) trial to decrease 90-day death and dependency, into all stroke services in New South Wales (NSW), Australia's most populous state. DESIGN Pre-test/post-test prospective study. SETTING 36 NSW stroke services. METHODS Our clinical translational initiative, the QASC Implementation Project (QASCIP), targeted stroke services to embed 3 nurse-led clinical protocols (the FeSS protocols) into routine practice. Clinical champions attended a 1-day multidisciplinary training workshop and received standardised educational resources and ongoing support. Using the National Stroke Foundation audit collection tool and processes, patient data from retrospective medical record self-reported audits for 40 consecutive patients with stroke per site pre-QASCIP (1 July 2012 to 31 December 2012) were compared with prospective self-reported data from 40 consecutive patients with stroke per site post-QASCIP (1 November 2013 to 28 February 2014). Inter-rater reliability was substantial for 10 of 12 variables. PRIMARY OUTCOME MEASURES Proportion of patients receiving care according to the FeSS protocols pre-QASCIP to post-QASCIP. RESULTS All 36 (100%) NSW stroke services participated, nominating 100 site champions who attended our educational workshops. The time from start of intervention to completion of post-QASCIP data collection was 8 months. All (n=36, 100%) sites provided medical record audit data for 2144 patients (n=1062 pre-QASCIP; n=1082 post-QASCIP). Pre-QASCIP to post-QASCIP, proportions of patients receiving the 3 targeted clinical behaviours increased significantly: management of fever (pre: 69%; post: 78%; p=0.003), hyperglycaemia (pre: 23%; post: 34%; p=0.0085) and swallowing (pre: 42%; post: 51%; p=0.033). CONCLUSIONS We obtained unprecedented statewide scale-up and spread to all NSW stroke services of a nurse-led intervention previously proven to improve long-term patient outcomes. As clinical leaders search for strategies to improve quality of care, our initiative is replicable and feasible in other acute care settings.
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Affiliation(s)
- Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Anna Lydtin
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Daniel Comerford
- NSW Agency for Clinical Innovation, Chatswood, New South Wales, Australia
| | - Dominique A Cadilhac
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Patrick McElduff
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and Australian Catholic University, Sydney, New South Wales, Australia
| | - Kelvin Hill
- National Stroke Foundation, Melbourne, Victoria, Australia
| | - Mark Longworth
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Jeanette Ward
- University of Notre Dame, Broom Campus, Broome, Western Australia, Australia
- University of Ottawa, Ottawa, Canada
| | - N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Cate D'Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australian Capital Territory, Australia
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Alameddine M, Saleh S, Natafgi N. Assessing health-care providers' readiness for reporting quality and patient safety indicators at primary health-care centres in Lebanon: a national cross-sectional survey. HUMAN RESOURCES FOR HEALTH 2015; 13:37. [PMID: 25997430 PMCID: PMC4450474 DOI: 10.1186/s12960-015-0031-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Accepted: 05/09/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Successful endorsement of quality indicators hinges on the readiness and acceptability of care providers for those measures. This paper aims to assess the readiness of care providers in the primary health-care sector in Lebanon for the implementation of quality and patient safety indicators. METHODS A cross-sectional survey methodology was utilized to gather information from 943 clinical care providers working at 123 primary health-care centres in Lebanon. The questionnaire included two sections: the first assessed four readiness dimensions (appropriateness, management support, efficacy, and personal valence) of clinical providers to use quality and safety indicators using the Readiness for Organization Change (ROC) scale, and the second section assessed the safety attitude at the primary care centre utilizing the Agency of Health Research and Quality (AHRQ) Safety Attitude Questionnaire (SAQ)-Ambulatory version. RESULTS Although two thirds (66%) of respondents indicated readiness for implementation of quality and patient safety indicators in their centres, there appear to be differences by professional group. Physicians displayed the lowest scores on all readiness dimensions except for personal valence which was the lowest among nurses (60%). In contrast, allied health professionals displayed the highest scores across all readiness dimensions. Generally, respondents reflected a positive safety attitude climate in the centres. Yet, there remain a few areas of concern related to punitive culture (only 12.8% agree that staff should not be punished for reported errors/incidents), continuity of care (41.1% believe in the negative consequences of lack in continuity of care process), and resources (48.1% believe that the medical equipment they have are adequate). Providers with the highest SAQ score had 2.7, 1.7, 7 and 2.4 times the odds to report a higher readiness on the appropriateness, efficacy, management and personal valence ROC subscales, respectively (P value <0.01). Nurses displayed relatively lower odds of readiness across all other ROC subscales as compared to all other providers. CONCLUSION Health-care providers at the primary health care (PHC) centres in Lebanon are ready to engage in employing quality and patient safety indicators. This is a key finding given the active efforts by the MoPH to strengthen the quality culture in the PHC sector through various strategies.
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Affiliation(s)
- Mohamad Alameddine
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Shadi Saleh
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Nabil Natafgi
- Department of Health Management and Policy, College of Public Health, University of Iowa, CPHB - N277, 145 N. Riverside Dr., Iowa City, IA, 52242, USA.
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19
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Gonzalez-Suarez CB, Dizon JMR, Grimmer K, Estrada MS, Liao LAS, Malleta ARD, Tan MER, Marfil V, Versales CS, Suarez JL, So KC, Uyehara ED. Protocol for audit of current Filipino practice in rehabilitation of stroke inpatients. J Multidiscip Healthc 2015; 8:127-38. [PMID: 25784814 PMCID: PMC4356451 DOI: 10.2147/jmdh.s61813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Stroke is one of the leading medical conditions in the Philippines. Over 500,000 Filipinos suffer from stroke annually. Provision of evidence-based medical and rehabilitation management for stroke patients has been a challenge due to existing environmental, social, and local health system issues. Thus, existing western guidelines on stroke rehabilitation were contextualized to draft recommendations relevant to the local Philippine setting. Prior to fully implementing the guidelines, an audit of current practice needs to be undertaken, thus the purpose of this audit protocol. Methods A clinical audit of current practices in stroke rehabilitation in the Philippines will be undertaken. A consensus list of data items to be captured was identified by the audit team during a 2-day meeting in 2012. These items, including patient demographics, type of stroke, time to referral for rehabilitation management, length of hospital stay, and other relevant descriptors of stroke management were included as part of the audit. Hospitals in the Philippines will be recruited to take part in the audit activity. Recruitment will be via the registry of the Philippine Academy of Rehabilitation Medicine, where 90% of physiatrists (medical doctors specialized in rehabilitation medicine) are active members and are affiliated with various hospitals in the Philippines. Data collectors will be identified and trained in the audit process. A pilot audit will be conducted to test the feasibility of the audit protocol, and refinements to the protocol will be undertaken as necessary. The comprehensive audit process will take place for a period of 3 months. Data will be encoded using MS Excel®. Data will be reported as means and percentages as appropriate. Subgroup analysis will be undertaken to look into differences and variability of stroke patient descriptors and rehabilitation activities. Conclusion This audit study is an ambitious project, but given the “need” to conduct the audit to identify “gaps” in current practice, and the value it can bring to serve as a platform for implementation of evidence-based stroke management in the Philippines to achieve best patient and health outcomes, the audit team is more than ready to take up the challenge.
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Affiliation(s)
- Consuelo B Gonzalez-Suarez
- University of Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines ; University of Santo Tomas, Manila, Philippines ; International Centre for Allied Health Evidence, University of South Australia, City East Campus, North Terrace, Adelaide, SA, Australia
| | - Janine Margarita R Dizon
- University of Santo Tomas, Manila, Philippines ; International Centre for Allied Health Evidence, University of South Australia, City East Campus, North Terrace, Adelaide, SA, Australia
| | - Karen Grimmer
- International Centre for Allied Health Evidence, University of South Australia, City East Campus, North Terrace, Adelaide, SA, Australia
| | - Myrna S Estrada
- De La Salle University Hospital, Cavite, Dasmariñas, Philippines
| | - Lauren Anne S Liao
- University of Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines
| | | | - Ma Elena R Tan
- Veterans' Memorial Medical Center, Quezon City, Philippines
| | - Vero Marfil
- Veterans' Memorial Medical Center, Quezon City, Philippines
| | - Cristina S Versales
- University of Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines
| | | | - Kleon C So
- University of Santo Tomas Hospital, University of Santo Tomas, Manila, Philippines
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Dale S, Levi C, Ward J, Grimshaw JM, Jammali-Blasi A, D'Este C, Griffiths R, Quinn C, Evans M, Cadilhac D, Cheung NW, Middleton S. Barriers and Enablers to Implementing Clinical Treatment Protocols for Fever, Hyperglycaemia, and Swallowing Dysfunction in the Quality in Acute Stroke Care (QASC) Project-A Mixed Methods Study. Worldviews Evid Based Nurs 2015; 12:41-50. [DOI: 10.1111/wvn.12078] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Simeon Dale
- Clinical Research Fellow, Nursing Research Institute, St Vincent's & Mater Health, Sydney and School of Nursing (NSW & ACT); Australian Catholic University; Darlinghurst NSW Australia
| | - Christopher Levi
- Professor, Senior Staff Neurologist, John Hunter Hospital, Conjoint Professor of Medicine (Neurology) & Director, Centre for Translational Neuroscience and Mental Health; University of Newcastle/Hunter Medical Research Institute
| | - Jeanette Ward
- Professor, Adjunct Professor, Department of Epidemiology and Community Medicine; University of Ottawa; Ottawa ON Canada
| | - Jeremy M. Grimshaw
- Director, Clinical Epidemiology Program, Ottawa Health Research Institute, and Professor, Department of Medicine; University of Ottawa; Ottawa ON Canada
| | - Asmara Jammali-Blasi
- Research Assistant, Nursing Research Institute, St Vincent's & Mater Health Sydney and School of Nursing (NSW & ACT); Australian Catholic University; Darlinghurst NSW Australia
| | - Catherine D'Este
- Professor, Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health; The University of Newcastle; Newcastle NSW Australia
| | - Rhonda Griffiths
- Professor, Head, School of Nursing and Midwifery; University of Western Sydney; Penrith South DC NSW Australia
| | - Clare Quinn
- Speech Pathology Department; Prince of Wales Hospital; Randwick NSW Australia
| | - Malcolm Evans
- Priority Centre for Brain & Mental Health Research; The University of Newcastle; Newcastle NSW Australia
| | - Dominique Cadilhac
- A/Professor, Head, Translational Public Health Unit, Stroke and Ageing Research, Southern Clinical School; Monash University, and Public Heath, Stroke Division, the Florey Institute of Neuroscience and Mental Health; Heidelberg Australia
| | - N. Wah Cheung
- A/Professor, Co-Director, Centre for Diabetes and Endocrinology Research; Westmead Hospital, and University of Sydney; Westmead NSW Australia
| | - Sandy Middleton
- Professor, Director, Nursing Research Institute, St Vincent's & Mater Health Sydney, and School of Nursing (NSW & ACT); Australian Catholic University; Darlinghurst NSW Australia
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Attieh R, Gagnon MP, Estabrooks CA, Légaré F, Ouimet M, Vazquez P, Nuño R. Organizational readiness for knowledge translation in chronic care: a Delphi study. BMC Health Serv Res 2014; 14:534. [PMID: 25380653 PMCID: PMC4226850 DOI: 10.1186/s12913-014-0534-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 10/17/2014] [Indexed: 11/21/2022] Open
Abstract
Background Health-care organizations need to be ready prior to implement evidence-based interventions. In this study, we sought to achieve consensus on a framework to assess the readiness of health-care organizations to implement evidence-based interventions in the context of chronic care. Methods We conducted a web-based modified Delphi study between March and May 2013. We contacted 76 potentially eligible international experts working in the fields of organizational readiness (OR), knowledge translation (KT), and chronic care to comment upon the 76 elements resulting from our proposed conceptual map. This conceptual map was based on a systematic review of the existing frameworks of Organizational Readiness for Change (ORC) in health-care. We developed a conceptual map that proposed a set of core concepts and their associated 17 dimensions and 59 sub-dimensions. Experts rated their agreement concerning the applicability and importance of ORC elements on a 5-point Likert scale, where 1 indicates total disagreement and 5 indicates total agreement. Two rounds were needed to get a consensus from the experts. Consensus was a priori defined as strong (≥75%) or moderate (60-74%). Simple descriptive statistics was used. Results In total, 14 participants completed the first round and 10 completed the two rounds. Panel members reached consensus on the applicability and importance of 6 out of 17 dimensions and 28 out of 59 sub-dimensions to assess OR for KT in the context of chronic care. A strong level of consensus (≥75%) was attained on the Organizational contextual factors, Leadership/participation, Organizational support, and Motivation dimensions. The Organizational climate for change and Change content dimensions reached a moderate consensus (60-74%). Experts also reached consensus on 28 out of 59 sub-dimensions to assess OR for KT. Twenty-one sub-dimensions reached a strong consensus (≥75%) and seven a moderate consensus (60-74%). Conclusion This study results provided the most important and applicable dimensions and sub-dimensions for assessing OR-KT in the context of chronic care. They can be used to guide the design of an assessment tool to improve knowledge translation in the field of chronic care.
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Affiliation(s)
- Randa Attieh
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 45 rue Leclerc, Quebec City, QC, Canada.
| | - Marie-Pierre Gagnon
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 45 rue Leclerc, Quebec City, QC, Canada. .,Faculty of Nursing, Université Laval, Quebec City, QC, Canada.
| | - Carole A Estabrooks
- Faculty of Nursing and School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | - France Légaré
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 45 rue Leclerc, Quebec City, QC, Canada. .,Department of Family Medicine, Université Laval, Quebec City, QC, Canada.
| | - Mathieu Ouimet
- Research Centre of the Centre Hospitalier Universitaire de Québec, Hôpital St-François d'Assise, 45 rue Leclerc, Quebec City, QC, Canada. .,Department of Political Science, Université Laval, Quebec City, QC, Canada.
| | - Patricia Vazquez
- Fundacion Vasca de Innovacion e Investigacion Sanitarias, Bilbao, Spain.
| | - Roberto Nuño
- Fundacion Vasca de Innovacion e Investigacion Sanitarias, Bilbao, Spain.
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Inrig SJ, Tiro JA, Melhado TV, Argenbright KE, Craddock Lee SJ. Evaluating a De-Centralized Regional Delivery System for Breast Cancer Screening and Patient Navigation for the Rural Underserved. TEXAS PUBLIC HEALTH JOURNAL 2014; 66:25-34. [PMID: 28713882 PMCID: PMC5508746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
UNLABELLED Providing breast cancer screening services in rural areas is challenging due to the fractured nature of healthcare delivery systems and complex reimbursement mechanisms that create barriers to access for the under- and uninsured. Interventions that reduce structural barriers to mammography, like patient navigation programs, are effective and recommended, especially for minority and underserved women. Although the literature on rural healthcare is significant, the field lacks studies of adaptive service delivery models and rigorous evaluation of evidence-based programs that facilitate routine screening and appropriate follow-up across large geographic areas. OBJECTIVES To better understand how to implement a decentralized regional delivery "hub & spoke" model for rural breast cancer screening and patient navigation, we have designed a rigorous, structured, multi-level and mixed-methods evaluation based on Glasgow's RE-AIM model (Reach, Effectiveness, Adoption, Implementation, and Maintenance). METHODS AND DESIGN The program is comprised of three core components: 1) Outreach to underserved women by partnering with county organizations; 2) Navigation to guide patients through screening and appropriate follow-up; and 3) Centralized Reimbursement to coordinate funding for screening services through a central contract with Medicaid Breast and Cervical Cancer Services (BCCS). Using Glasgow's RE-AIM model, we will: 1) assess which counties have the resources and capacity to implement outreach and/or navigation components, 2) train partners in each county on how to implement components, and 3) monitor process and outcome measures in each county at regular intervals, providing booster training when needed. DISCUSSION This evaluation strategy will elucidate how the heterogeneity of rural county infrastructure impacts decentralized service delivery as a navigation program expands. In addition to increasing breast cancer screening access, our model improves and maintains time to diagnostic resolution and facilitates timely referral to local cancer treatment services. We offer this evaluation approach as an exemplar for scientific methods to evaluate the translation of evidence-based federal policy into sustainable health services delivery in a rural setting.
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Affiliation(s)
- Stephen J Inrig
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
| | - Jasmin A Tiro
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
| | - Trisha V Melhado
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
- Moncrief Cancer Institute, Fort Worth, Texas
| | - Simon J Craddock Lee
- University of Texas Southwestern Medical Center, Department of Clinical Sciences, Dallas TX
- University of Texas Southwestern Harold C. Simmons Cancer Center, Dallas TX
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Bach E, Beissner K, Murtaugh C, Trachtenberg M, Reid MC. Implementing a cognitive-behavioral pain self-management program in home health care, part 2: feasibility and acceptability cohort study. J Geriatr Phys Ther 2013; 36:130-7. [PMID: 22976815 DOI: 10.1519/jpt.0b013e31826ef84d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE The prevalence of pain in older adults receiving home health care is high, yet safety concerns for analgesic therapy point to a need for nonpharmacologic approaches to pain management in this population. The purpose of this study was to determine the feasibility and acceptability to physical therapists (PTs) and patients of a cognitive-behavioral pain self-management (CBPSM) program. METHODS Thirty-one PTs volunteered to participate, completed two 4-hour training sessions, and recruited 21 patients with activity-limited pain who consented to participate in the study. Physical therapists completed pre- and posttest assessments of CBPSM knowledge at the first training session, provided structured survey feedback after the second training session, and responded to a phone survey 3 months after training. Patients provided feedback during weekly phone interviews, while receiving the CBPSM program. Treatment sessions were audiotaped during delivery of the self-management pain protocol. Audiotapes were evaluated by independent raters for program fidelity. RESULTS Participating PTs were experienced in physical therapy (average 16.5 years) and in home health care (average 11.0 years). Analysis of pre- and posttest data showed that PTs' CBPSM knowledge increased from a pretest mean of 60.9% to a posttest mean of 85.9%. Audiotape analysis indicated 77.7% therapist adherence to the protocol. At 3-month follow-up, 24.0% of therapists continued to use the entire protocol with their patients presenting with activity-limiting pain. Patient data show high rates of patient recall of being taught protocol components, trying components at least once (ranging from 84.4% to 100.0%) and daily use of protocol components (ranging from 47.3% to 68.4%). The percentage of patients finding a technique helpful for pain management ranged from 71.4% to 81.2%. CONCLUSION This study offers preliminary data on the use of nonpharmacologic pain self-management strategies by PTs in home health setting. Positive feedback from PTs and patients suggests that the translated protocol is both feasible and acceptable.
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Affiliation(s)
- Eileen Bach
- Visiting Nurse Service of New York VNSNY Home Care, New York, NY 10001, USA.
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Drury P, Levi C, D'Este C, McElduff P, McInnes E, Hardy J, Dale S, Cheung NW, Grimshaw JM, Quinn C, Ward J, Evans M, Cadilhac D, Griffiths R, Middleton S. Quality in Acute Stroke Care (QASC): Process Evaluation of an Intervention to Improve the Management of Fever, Hyperglycemia, and Swallowing Dysfunction following Acute Stroke. Int J Stroke 2013; 9:766-76. [DOI: 10.1111/ijs.12202] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Our randomized controlled trial of a multifaceted evidence-based intervention for improving the inpatient management of fever, hyperglycemia, and swallowing dysfunction in the first three-days following stroke improved outcomes at 90 days by 15%. We designed a quantitative process evaluation to further explain and illuminate this finding. Methods Blinded retrospective medical record audits were undertaken for patients from 19 stroke units prior to and following the implementation of three multidisciplinary evidence-based protocols (supported by team-building workshops, and site-based education and support) for the management of fever (temperature ≥37·5°C), hyperglycemia (glucose >11 mmol/l), and swallowing dysfunction in intervention stroke units. Results Data from 1804 patients (718 preintervention; 1086 postintervention) showed that significantly more patients admitted to hospitals allocated to the intervention group received care according to the fever ( n = 186 of 603, 31% vs. n = 74 of 483, 15%, P < 0·001), hyperglycemia ( n = 22 of 603, 3·7% vs. n = 3 of 483,0·6%, P = 0·01), and swallowing dysfunction protocols ( n = 241 of 603, 40% vs. n = 19 of 483, 4·0%, P ≤ 0·001). Significantly more patients in these intervention stroke units received four-hourly temperature monitoring ( n = 222 of 603, 37% vs. n = 90 of 483, 19%, P < 0·001) and six-hourly glucose monitoring (194 of 603, 32% vs. 46 of 483, 9·5%, P < 0·001) within 72 hours of admission to a stroke unit, and a swallowing screen (242 of 522, 46% vs. 24 of 350, 6·8%, P ≤ 0·0001) within the first 24 hours of admission to hospital. There was no difference between the groups in the treatment of patients with fever with paracetamol (22 of 105, 21% vs. 38 of 131, 29%, P = 0·78) or their hyperglycemia with insulin (40 of 100, 40% vs. 17 of 57, 30%, P = 0·49). Interpretation Our intervention resulted in better protocol adherence in intervention stroke units, which explains our main trial findings of improved patient 90-day outcomes. Although monitoring practices significantly improved, there was no difference between the groups in the treatment of fever and hyperglycemia following acute stroke. A significant link between improved treatment practices and improved outcomes would have explained further the success of our intervention, and we are still unable to explain definitively the large improvements in death and dependency found in the main trial results. One potential explanation is that improved monitoring may have led to better overall surveillance of deteriorating patients and faster initiation of treatments not measured as part of the main trial.
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Affiliation(s)
- Peta Drury
- Nursing Research Institute, St. Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery & Paramedicine (NSW & ACT), Australian Catholic University, NSW, Australia
| | - Christopher Levi
- Priority Centre for Brain & Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia
| | - Catherine D'Este
- Centre for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, Faculty of Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Patrick McElduff
- Hunter Medical Research Institute, Clinical Research Design, IT and Statistical Support Unit, School of Medicine and Public Health University of Newcastle, Newcastle, NSW, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St. Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
| | - Jennifer Hardy
- Sydney Nursing School, University of Sydney, Camperdown, NSW, Australia
| | - Simeon Dale
- Nursing Research Institute, St. Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
| | - N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital and University of Sydney, Wentworthville, NSW, Australia
| | | | - Clare Quinn
- Speech Pathology Department, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Jeanette Ward
- Department of Epidemiology & Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Malcolm Evans
- Priority Centre for Brain & Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia
| | - Dominique Cadilhac
- Stroke and Ageing Research Centre, Monash Medical Centre, Southern Clinical School, Monash University, Clayton, VIC, Australia
- National Stroke Research Institute, Florey Neuroscience Institutes, Melbourne Brain Centre, Heidelberg, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Rhonda Griffiths
- School of Nursing and Midwifery, University of Western Sydney, Liverpool, NSW, Australia
| | - Sandy Middleton
- Nursing Research Institute, St. Vincent's & Mater Health Sydney, Australian Catholic University, Sydney, NSW, Australia
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Healthcare reform: implications for knowledge translation in primary care. BMC Health Serv Res 2013; 13:490. [PMID: 24274773 PMCID: PMC3893505 DOI: 10.1186/1472-6963-13-490] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 10/31/2013] [Indexed: 01/11/2023] Open
Abstract
Background The primary care sector represents the linchpin of many health systems. However, the translation of evidence-based practices into patient care can be difficult, particularly during healthcare reform. This can have significant implications for patients, their communities, and the public purse. This is aptly demonstrated in the area of sexual health. The aim of this paper is to determine what works to facilitate evidence-based sexual healthcare within the primary care sector. Methods 431 clinicians (214 general practitioners and 217 practice nurses) in New South Wales, Australia, were surveyed about their awareness, their use, the perceived impact, and the factors that hindered the use of six resources to promote sexual healthcare. Descriptive statistics were calculated from the responses to the closed survey items, while responses to open-ended item were thematically analyzed. Results All six resources were reported to improve the delivery of evidence-based sexual healthcare. Two resources – both double-sided A4-placards – had the greatest reach and use. Barriers that hindered resource-use included limited time, limited perceived need, and limited access to, or familiarity with the resources. Furthermore, the reorganization of the primary care sector and the removal of particular medical benefits scheme items may have hampered clinician capacity to translate evidence-based practices into patient care. Conclusions Findings reveal: (1) the translation of evidence-based practices into patient care is viable despite reform; (2) the potential value of a multi-modal approach; (3) the dissemination of relatively inexpensive resources might influence clinical practices; and (4) reforms to governance and/or funding arrangements may widen the void between evidence-based practices and patient care.
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Pallas SW, Curry L, Bashyal C, Berman P, Bradley EH. Improving health service delivery organisational performance in health systems: a taxonomy of strategy areas and conceptual framework for strategy selection. Int Health 2013; 4:20-9. [PMID: 24030877 DOI: 10.1016/j.inhe.2011.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisation's performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems.
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Affiliation(s)
- Sarah W Pallas
- Yale School of Public Health, 60 College St., New Haven, CT 06520, USA
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Curry LA, Krumholz HM, O'Cathain A, Plano Clark VL, Cherlin E, Bradley EH. Mixed methods in biomedical and health services research. Circ Cardiovasc Qual Outcomes 2013; 6:119-23. [PMID: 23322807 DOI: 10.1161/circoutcomes.112.967885] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leslie A Curry
- Section of Health Policy and Administration, Yale School of Public Health, New Haven, CT, USA.
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Albert D, Fortin R, Herrera C, Riley B, Hanning R, Lessio A, Rush B. Strengthening chronic disease prevention programming: the Toward Evidence-Informed Practice (TEIP) Program Evidence Tool. Prev Chronic Dis 2013; 10:E87. [PMID: 23721788 PMCID: PMC3675793 DOI: 10.5888/pcd10.120107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In public health and chronic disease prevention there is increasing priority for effective use of evidence in practice. In Ontario, Canada, despite various models being advanced, public health practitioners are seeking ways to identify and apply evidence in their work in practical and meaningful ways. In a companion article, “Strengthening Chronic Disease Prevention Programming: The Toward Evidence-Informed Practice (TEIP) Program Assessment Tool,” we describe use of a tool to assess and strengthen program planning and implementation processes using 19 criteria derived from best and promising practices literature. In this article, we describe use of a complementary Program Evidence Tool to identify, synthesize, and apply a range of evidence sources to strengthen the content of chronic disease prevention programming. The Program Evidence Tool adapts tools of evidence-based medicine to the unique contexts of community-based health promotion and chronic disease prevention. Knowledge management tools and a guided dialogue process known as an Evidence Forum enable community stakeholders to make appropriate use of evidence in diverse social, political, and structural contexts. Practical guidelines and worksheets direct users through 5 steps: 1) define an evidence question, 2) develop a search strategy, 3) collect and synthesize evidence, 4) interpret and adapt evidence, and 5) implement and evaluate. We describe the Program Evidence Tool’s benefits, strengths, challenges, and what was learned from its application in 4 Ontario public health departments. The Program Evidence Tool contributes to the development and understanding of the complex use of evidence in community-based chronic disease prevention.
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Affiliation(s)
- Dayna Albert
- Ontario Public Health Association, Toronto, Ontario
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Abstract
BACKGROUND AND OBJECTIVES Smoking cessation treatment practices described by the 5 A's (ask, advise, assess, assist, arrange) are not well applied at cardiology wards because of various reasons, such as a lack of time and appropriate skills of the nursing staff. Therefore, a simplified guideline proposing an ask-advise-refer (AAR) strategy was introduced in Dutch cardiac wards. This study aimed to identify factors that determine the intentions of cardiac ward heads in adopting the simplified AAR guideline, as ward heads are key decision makers in the adoption of new guidelines. Ward heads' perceptions of current smoking cessation practices at the cardiac ward were also investigated. METHODS A cross-sectional survey with written questionnaires was conducted among heads of cardiology wards throughout the Netherlands, of whom 117 (64%) responded. RESULTS According to the heads of cardiac wards, smoking cessation practices by cardiologists and nurses were mostly limited to brief practices that are easy to conduct. Only a minority offered intensive counseling or arranged follow-up contact. Heads with strong intentions of adopting the AAR guideline differed significantly on motivational and organizational attributes and perceived more smoking cessation assistance by other health professionals than did heads with weak intentions of adopting. Positive attitudes, social support toward adoption, and perception of much assistance at the ward were significantly associated with increased intentions to adopt the AAR guideline. CONCLUSIONS Brief smoking cessation practices are adequately performed at cardiac wards, but the most effective practices, offering assistance and arranging for follow-up, are less than optimal. The AAR guideline offers a more feasible approach for busy cardiology wards. To ensure successful adoption of this guideline, the heads of cardiac wards should be convinced of its advantages and be encouraged by a supportive work environment. Policies may also facilitate the adoption of the AAR guideline.
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Thornicroft G, Farrelly S, Szmukler G, Birchwood M, Waheed W, Flach C, Barrett B, Byford S, Henderson C, Sutherby K, Lester H, Rose D, Dunn G, Leese M, Marshall M. Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial. Lancet 2013; 381:1634-41. [PMID: 23537606 DOI: 10.1016/s0140-6736(13)60105-1] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The CRIMSON (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study is an individual level, randomised controlled trial that compared the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual for people with severe mental illness. The JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views. We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual. METHODS Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register. The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations (trusts). Hypotheses tested were that, compared with the control group, the intervention group would experience: fewer compulsory admissions (primary outcome); fewer psychiatric admissions; shorter psychiatric stays; lower perceived coercion; improved therapeutic relationships; and improved engagement. We stratified participants by centre. The research team but not participants nor clinical staff were masked to allocation. This study is registered with ClinicalTrials.gov, number ISRCTN11501328. FINDINGS 569 participants were randomly assigned (285 to the intervention group and 284 to the control group). No significant treatment effect was seen for the primary outcome (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0·90 [95% CI 0·58-1·39, p=0·63]) or any secondary outcomes, with the exception of an improved secondary outcome of therapeutic relationships (17·3 [7·6] vs 16·0 [7·1]; adjusted difference -1·28 [95% CI -2·56 to -0·01, p=0·049]). Qualitative data supported this finding. INTERPRETATION Our findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients' preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice. FUNDING Medical Research Council UK and the National Institute for Health Research.
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Affiliation(s)
- Graham Thornicroft
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, UK.
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Implementing clinical guidelines in stroke: a qualitative study of perceived facilitators and barriers. Health Policy 2013; 111:234-44. [PMID: 23643101 DOI: 10.1016/j.healthpol.2013.04.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Revised: 03/07/2013] [Accepted: 04/04/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Clinical guidelines are frequently used as a mechanism for implementing evidence-based practice. However research indicates that health professionals vary in the extent to which they adhere to these guidelines. This study aimed to study the perceptions of stakeholders and health professionals on the facilitators and barriers to implementing national stroke guidelines in Ireland. METHODS Qualitative interviews using focus groups were conducted with stakeholders (n=3) and multidisciplinary team members from hospitals involved in stroke care (n=7). All focus group interviews were semi-structured, using open-ended questions. Data was managed and analysed using NVivo 9 software. RESULTS The main themes to emerge from the focus groups with stakeholders and hospital multidisciplinary teams were very similar in terms of topics discussed. These were resources, national stroke guidelines as a tool for change, characteristics of national stroke guidelines, advocacy at local level and community stroke care challenges. Facilitators perceived by stakeholders and health professionals included having dedicated resources, user-friendly guidelines relevant at local level and having supportive advocates on the ground. Barriers were inadequate resources, poor guideline characteristics and insufficient training and education. CONCLUSIONS This study highlights health professionals' perspectives regarding many key concepts which may affect the implementation of stroke care guidelines. The introduction of stroke clinical guidelines at a national level is not sufficient to improve health care quality as they should be incorporated in a quality assurance cycle with education programmes and feedback from surveys of clinical practice.
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Middleton S. Editorial: Keeping it simple: the power of three clinical protocols. J Clin Nurs 2012; 21:3195-7. [DOI: 10.1111/jocn.12002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Choi NG, Lee A, Goldstein M. Meals on Wheels: exploring potential for and barriers to integrating depression intervention for homebound older adults. Home Health Care Serv Q 2012; 30:214-30. [PMID: 22106903 DOI: 10.1080/01621424.2011.622251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The purpose of this study was to explore Meals on Wheels' (MOW) organizational potential for integrating depression screening, referral, and treatment for homebound older adults. In a survey of 164 MOW administrators, MOW's current practice of depression services was examined, and the administrators' perception of MOW's organizational potential was measured focusing on external environment, financial resources, staffing/skills, and values and goals. Only 20 out of 164 MOWs provide depression screening, and 19 provide in-home counseling for their clients, while 86 provide referral services. About 64-72% of MOWs that are not current providers of screening and/or referrals want to provide the services, and 21% of those that are not current providers of in-home counseling want to provide it.
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Affiliation(s)
- Namkee G Choi
- School of Social Work, University of Texas, Austin, Texas 78712-0358, USA.
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Middleton S, McElduff P, Ward J, Grimshaw JM, Dale S, D'Este C, Drury P, Griffiths R, Cheung NW, Quinn C, Evans M, Cadilhac D, Levi C. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011; 378:1699-706. [PMID: 21996470 DOI: 10.1016/s0140-6736(11)61485-2] [Citation(s) in RCA: 254] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence-based management of fever, hyperglycaemia, and swallowing dysfunction in acute stroke units (ASUs). METHODS In the Quality in Acute Stroke Care (QASC) study, a single-blind cluster randomised controlled trial, we randomised ASUs (clusters) in New South Wales, Australia, with immediate access to CT and on-site high dependency units, to intervention or control group. Patients were eligible if they spoke English, were aged 18 years or older, had had an ischaemic stroke or intracerebral haemorrhage, and presented within 48 h of onset of symptoms. Intervention ASUs received treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers. Control ASUs received only an abridged version of existing guidelines. We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency (modified Rankin scale [mRS] ≥2), functional dependency (Barthel index), and SF-36 physical and mental component summary scores. Research assistants, the statistician, and patients were masked to trial groups. All analyses were done by intention to treat. This trial is registered at the Australia New Zealand Clinical Trial Registry (ANZCTR), number ACTRN12608000563369. FINDINGS 19 ASUs were randomly assigned to intervention (n=10) or control (n=9). Of 6564 assessed for eligibility, 1696 patients' data were obtained (687 pre-intervention; 1009 post-intervention). Results showed that, irrespective of stroke severity, intervention ASU patients were significantly less likely to be dead or dependent (mRS ≥2) at 90 days than control ASU patients (236 [42%] of 558 patients in the intervention group vs 259 [58%] of 449 in the control group, p=0·002; number needed to treat 6·4; adjusted absolute difference 15·7% [95% CI 5·8-25·4]). They also had a better SF-36 mean physical component summary score (45·6 [SD 10·2] in the intervention group vs 42·5 [10·5] in the control group, p=0·002; adjusted absolute difference 3·4 [95% CI 1·2-5·5]) but no improvement was recorded in mortality (21 [4%] of 558 in intervention group and 24 [5%] of 451 in the control group, p=0·36), SF-36 mean mental component summary score (49·5 [10·9] in the intervention group vs 49·4 [10·6] in the control group, p=0·69) or functional dependency (Barthel Index ≥60: 487 [92%] of 532 patients vs 380 [90%] of 423 patients; p=0·44). INTERPRETATION Implementation of multidisciplinary supported evidence-based protocols initiated by nurses for the management of fever, hyperglycaemia, and swallowing dysfunction delivers better patient outcomes after discharge from stroke units. Our findings show the possibility to augment stroke unit care. FUNDING National Health & Medical Research Council ID 353803, St Vincent's Clinic Foundation, the Curran Foundation, Australian Diabetes Society-Servier, the College of Nursing, and Australian Catholic University.
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Affiliation(s)
- Sandy Middleton
- Nursing Research Institute, St Vincent's & Mater Health Sydney and School of Nursing, Australian Catholic University, NSW, Australia.
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RAWLINGS DEB, HENDRY KATHY, MYLNE SUSAN, BANFIELD MAREE, YATES PATSY. Using Palliative Care Assessment Tools to Influence and Enhance Clinical Practice. ACTA ACUST UNITED AC 2011; 29:139-45; quiz 146-7. [DOI: 10.1097/nhh.0b013e31820ba808] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bouckenooghe D. Positioning Change Recipients’ Attitudes Toward Change in the Organizational Change Literature. JOURNAL OF APPLIED BEHAVIORAL SCIENCE 2010. [DOI: 10.1177/0021886310367944] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article reviews the literature on attitudes toward change. This narrative review of 58 journal articles published between 1993 and 2007 indicates that there is a need for a more complete typology of attitudes toward change that also fully captures the core essence of this concept. By means of content analysis we first examined the conceptual overlap between the eight attitude-related constructs included in this review and the working definition of attitudes toward change. Second, the concept “attitudes toward change” was described along four major theoretical lenses: (a) nature of change, (b) level of change, (c) positive—negative view on change, and (d) research perspective. This conceptual review not only summarizes the current state of research but also offers a more complete typology of attitudes toward change, and highlights directions for possible future inquiry.
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Leaver CA, Guttmann A, Zwarenstein M, Rowe BH, Anderson G, Stukel T, Golden B, Bell R, Morra D, Abrams H, Schull MJ. Development of a minimization instrument for allocation of a hospital-level performance improvement intervention to reduce waiting times in Ontario emergency departments. Implement Sci 2009; 4:32. [PMID: 19505308 PMCID: PMC2706789 DOI: 10.1186/1748-5908-4-32] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Accepted: 06/08/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rigorous evaluation of an intervention requires that its allocation be unbiased with respect to confounders; this is especially difficult in complex, system-wide healthcare interventions. We developed a short survey instrument to identify factors for a minimization algorithm for the allocation of a hospital-level intervention to reduce emergency department (ED) waiting times in Ontario, Canada. METHODS Potential confounders influencing the intervention's success were identified by literature review, and grouped by healthcare setting specific change stages. An international multi-disciplinary (clinical, administrative, decision maker, management) panel evaluated these factors in a two-stage modified-delphi and nominal group process based on four domains: change readiness, evidence base, face validity, and clarity of definition. RESULTS An original set of 33 factors were identified from the literature. The panel reduced the list to 12 in the first round survey. In the second survey, experts scored each factor according to the four domains; summary scores and consensus discussion resulted in the final selection and measurement of four hospital-level factors to be used in the minimization algorithm: improved patient flow as a hospital's leadership priority; physicians' receptiveness to organizational change; efficiency of bed management; and physician incentives supporting the change goal. CONCLUSION We developed a simple tool designed to gather data from senior hospital administrators on factors likely to affect the success of a hospital patient flow improvement intervention. A minimization algorithm will ensure balanced allocation of the intervention with respect to these factors in study hospitals.
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Affiliation(s)
- Chad Andrew Leaver
- Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Canada.
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Clarke P. Understanding the experience of stroke: a mixed-method research agenda. THE GERONTOLOGIST 2009; 49:293-302. [PMID: 19386828 DOI: 10.1093/geront/gnp047] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The use of both quantitative and qualitative strategies to examine a single research question has been a subject of considerable controversy and still remains a largely uncommon practice in the sociology of health and illness. Yet, when seeking to understand the meaning of a chronic disabling condition in later life from a social psychological perspective, a mixed-method approach is likely to provide the most comprehensive picture. This article provides an overview of the usefulness and appropriateness of a mixed-method approach to understanding the stroke experience. I comment on the current state of research on the experience of stroke, including epistemological and ontological orientations. Using real data examples, I address paradigmatic assumptions, methods of integration, as well as challenges and pitfalls in integrating methods. I conclude by considering future directions in this field of research.
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Affiliation(s)
- Philippa Clarke
- Institute for Social Research, University of Michigan, Ann Arbor, MI 48106, USA.
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Crites GE, McNamara MC, Akl EA, Richardson WS, Umscheid CA, Nishikawa J. Evidence in the learning organization. Health Res Policy Syst 2009; 7:4. [PMID: 19323819 PMCID: PMC2667412 DOI: 10.1186/1478-4505-7-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 03/26/2009] [Indexed: 11/29/2022] Open
Abstract
Background Organizational leaders in business and medicine have been experiencing a similar dilemma: how to ensure that their organizational members are adopting work innovations in a timely fashion. Organizational leaders in healthcare have attempted to resolve this dilemma by offering specific solutions, such as evidence-based medicine (EBM), but organizations are still not systematically adopting evidence-based practice innovations as rapidly as expected by policy-makers (the knowing-doing gap problem). Some business leaders have adopted a systems-based perspective, called the learning organization (LO), to address a similar dilemma. Three years ago, the Society of General Internal Medicine's Evidence-based Medicine Task Force began an inquiry to integrate the EBM and LO concepts into one model to address the knowing-doing gap problem. Methods During the model development process, the authors searched several databases for relevant LO frameworks and their related concepts by using a broad search strategy. To identify the key LO frameworks and consolidate them into one model, the authors used consensus-based decision-making and a narrative thematic synthesis guided by several qualitative criteria. The authors subjected the model to external, independent review and improved upon its design with this feedback. Results The authors found seven LO frameworks particularly relevant to evidence-based practice innovations in organizations. The authors describe their interpretations of these frameworks for healthcare organizations, the process they used to integrate the LO frameworks with EBM principles, and the resulting Evidence in the Learning Organization (ELO) model. They also provide a health organization scenario to illustrate ELO concepts in application. Conclusion The authors intend, by sharing the LO frameworks and the ELO model, to help organizations identify their capacities to learn and share knowledge about evidence-based practice innovations. The ELO model will need further validation and improvement through its use in organizational settings and applied health services research.
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Affiliation(s)
- Gerald E Crites
- Wright State University Boonshoft School of Medicine, Dayton, OH, USA.
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Smith MW, Barnett PG. The role of economics in the QUERI program: QUERI Series. Implement Sci 2008; 3:20. [PMID: 18430199 PMCID: PMC2390584 DOI: 10.1186/1748-5908-3-20] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2006] [Accepted: 04/22/2008] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The United States (U.S.) Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has implemented economic analyses in single-site and multi-site clinical trials. To date, no one has reviewed whether the QUERI Centers are taking an optimal approach to doing so. Consistent with the continuous learning culture of the QUERI Program, this paper provides such a reflection. METHODS We present a case study of QUERI as an example of how economic considerations can and should be integrated into implementation research within both single and multi-site studies. We review theoretical and applied cost research in implementation studies outside and within VA. We also present a critique of the use of economic research within the QUERI program. RESULTS Economic evaluation is a key element of implementation research. QUERI has contributed many developments in the field of implementation but has only recently begun multi-site implementation trials across multiple regions within the national VA healthcare system. These trials are unusual in their emphasis on developing detailed costs of implementation, as well as in the use of business case analyses (budget impact analyses). CONCLUSION Economics appears to play an important role in QUERI implementation studies, only after implementation has reached the stage of multi-site trials. Economic analysis could better inform the choice of which clinical best practices to implement and the choice of implementation interventions to employ. QUERI economics also would benefit from research on costing methods and development of widely accepted international standards for implementation economics.
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Affiliation(s)
- Mark W Smith
- Health Economics Resource Center, US Department of Veterans Affairs, Menlo Park, California, USA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, USA
| | - Paul G Barnett
- Health Economics Resource Center, US Department of Veterans Affairs, Menlo Park, California, USA
- Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Health Research and Policy, Stanford University School of Medicine, Palo Alto, California, USA
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Affiliation(s)
- Renée F Lyons
- Atlantic Health Promotion Research Centre, Dalhousie University, Halifax NS Canada.
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