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Alidina S, Hayirli TC, Amiri A, Barash D, Chwa C, Hellar A, Kengia JT, Kissima I, Mayengo CD, Meara JG, Mwita WC, Staffa SJ, Tibyehabwa L, Wurdeman T, Kapologwe NA. Organizational learning in surgery in Tanzania's health system: a descriptive cross-sectional study. Int J Qual Health Care 2024; 36:mzae048. [PMID: 38814661 DOI: 10.1093/intqhc/mzae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/05/2024] [Accepted: 05/30/2024] [Indexed: 05/31/2024] Open
Abstract
Organizational learning is critical for delivering safe, high-quality surgical care, especially in low- and middle-income countries (LMICs) where perioperative outcomes remain poor. While current investments in LMICs prioritize physical infrastructure, equipment, and staffing, investments in organizational learning are equally important to support innovation, creativity, and continuous improvement of surgical quality. This study aims to assess the extent to which health facilities in Tanzania's Lake Zone perform as learning organizations from the perspectives of surgical providers. The insights gained from this study can motivate future quality improvement initiatives and investments to improve surgical outcomes. We conducted a cross-sectional analysis using data from an adapted survey to explore the key components of organizational learning, including a supportive learning environment, effective learning processes, and encouraging leadership. Our sample included surgical team members and leaders at 20 facilities (health centers, district hospitals, and regional hospitals). We calculated the average of the responses at individual facilities. Responses that were 5+ on a 7-point scale or 4+ on a 5-point scale were considered positive. We examined the variation in responses by facility characteristics using a one-way ANOVA or Student's t-test. We used univariate and multiple regression to assess relationships between facility characteristics and perceptions of organizational learning. Ninety-eight surgical providers and leaders participated in the survey. The mean facility positive response rate was 95.1% (SD 6.1%). Time for reflection was the least favorable domain with a score of 62.5% (SD 35.8%). There was variation by facility characteristics including differences in time for reflection when comparing by level of care (P = .02) and location (P = .01), and differences in trying new approaches (P = .008), capacity building (P = .008), and information transfer (P = .01) when comparing public versus faith-based facilities. In multivariable analysis, suburban centers had less time for reflection than urban facilities (adjusted difference = -0.48; 95% CI: -0.95, -0.01; P = .046). Surgical team members reported more positive responses compared to surgical team leaders. We found a high overall positive response rate in characterizing organizational learning in surgery in 20 health facilities in Tanzania's Lake Zone. Our findings identify areas for improvement and provide a baseline for assessing the effectiveness of change initiatives. Future research should focus on validating the adapted survey and exploring the impact of strong learning environments on surgical outcomes in LMICs. Organizational learning is crucial in surgery and further research, funding, and policy work should be dedicated to improving learning cultures in health facilities.
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Affiliation(s)
- Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Tuna Cem Hayirli
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | - Adam Amiri
- W.P. Carey School of Business, Arizona State University, 1151 S Forest Ave Tempe, AZ 85281 USA
| | - David Barash
- GE Foundation, 41 Farnsworth St, Boston, MA 02210 USA
| | - Cindy Chwa
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
| | | | - James T Kengia
- Department of Health, Social Welfare and Nutrition Services, President's Office Regional Administration and Local Government, P.O. Box 1923, Dodoma 00255, Tanzania
| | | | | | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
- Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue Boston, MA 02115, USA
| | - Winfrida C Mwita
- Kilimanjaro Clinical Research Institute, P. O. Box 2236, Moshi 25116, Tanzania
- Department of Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, P. O. Box 2240, Moshi 25116, Tanzania
| | - Steven J Staffa
- Department of Anesthesiology and Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Leopold Tibyehabwa
- Programs, Pathfinder International, P.O.BOX 77991, Dar es Salaam, Tanzania
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA 02115, USA
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Yue J, Liu J, Zhao Y, Williams S, Zhang B, Zhang L, Zhang Q, Liu X, Wall S, Zhao G. Evaluating factors that influenced the successful implementation of an evidence-based neonatal care intervention in Chinese hospitals using the PARIHS framework. BMC Health Serv Res 2022; 22:104. [PMID: 35078471 PMCID: PMC8787972 DOI: 10.1186/s12913-022-07493-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Evidence based interventions (EBIs) can improve patient care and outcomes. Understanding the process for successfully introducing and implementing EBIs can inform effective roll-out and scale up. The Promoting Action on Research Implementation in Health Services (PARIHS) framework can be used to evaluate and guide the introduction and implementation of EBIs. In this study, we used kangaroo mother care (KMC) as an example of an evidence-based neonatal intervention recently introduced in selected Chinese hospitals, to identify the factors that influenced its successful implementation. We also explored the utility of the PARIHS framework in China and investigated how important each of its constructs (evidence, context and facilitation) and sub-elements were perceived to be to successful implementation of EBIs in a Chinese setting. Method We conducted clinical observations and semi-structured interviews with 10 physicians and 18 nurses in five tertiary hospitals implementing KMC. Interview questions were organized around issues including knowledge and beliefs, resources, culture, implementation readiness and climate. We used directed content analysis to analyze the interview transcript, amending the PARIHS framework to incorporate emerging sub-themes. We also rated the constructs and sub-elements on a continuum from “low (weak)”, “moderate” or “high (strong)” highlighting the ones considered most influential for hospital level implementation by study participants. Results Using KMC as an example, our finding suggest that clinical experience, culture, leadership, evaluation, and facilitation are highly influential elements for EBI implementation in China. External evidence had a moderate impact, especially in the initial awareness raising stages of implementation and resources were also considered to be of moderate importance, although this may change as implementation progresses. Patient experience was not seen as a driver for implementation at hospital level. Conclusion Based on our findings examining KMC implementation as a case example, the PARIHS framework can be a useful tool for planning and evaluating EBI implementation in China. However, it’s sub-elements should be assessed and adapted to the implementation setting. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07493-6.
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Gilmartin HM, Hess E, Mueller C, Plomondon ME, Waldo SW, Battaglia C. A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories. Learn Health Syst 2021; 5:e10227. [PMID: 33889736 PMCID: PMC8051348 DOI: 10.1002/lrh2.10227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 02/26/2020] [Accepted: 03/15/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION A learning health system (LHS) harnesses data and analytics to learn from clinical encounters to implement the best care with high reliability. The 81 Veterans Health Administration (VHA) cardiac catheterization laboratories (cath lab) are a model LHS. The quality and safety of coronary procedures are monitored and reported by the Clinical Assessment, Reporting and Tracking (CART) Program, which has identified variation in care across cath labs. This variation may be due to underappreciated aspects of LHSs, the learning environment and reliability enhancing work practices (REWPs). Learning environments are the educational approaches, context, and settings in which learning occurs. REWPs are the organizational practices found in high reliability organizations. High learning environments and use of REWPs are associated with improved outcomes. This study assessed the learning environments and use of REWPs in VHA cath labs to examine factors supportive of learning and high reliability. METHODS In 2018, the learning organization survey-27 and the REWP survey were administered to 732 cath lab staff. Factor analysis and linear models were computed. Unit-level analyses and site ranking (high, low) were conducted on cath labs with >40% response rate using Bayesian methods. RESULTS Surveys from 40% of cath lab staff (n = 294) at 84% of cath labs (n = 68) were included. Learning environment and REWP strengths across cath labs include the presence of training programs, openness to new ideas, and respectful interaction. Learning environment and REWP gaps include lack of structured knowledge transfer (eg, checklists) and low use of forums for improvement. Survey dimensions matched established factor structures and demonstrated high reliability (Cronbach's alpha >.76). Unit-level analyses were conducted for 29 cath labs. One ranked as high and four as low learning environments. CONCLUSIONS This work demonstrates an approach to assess local learning environments and use of REWPs, providing insights for systems working to become a LHS.
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Affiliation(s)
- Heather M. Gilmartin
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Health Systems, Management, and PolicyUniversity of Colorado, School of Public HealthAuroraColoradoUSA
| | - Edward Hess
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Candice Mueller
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Clinical Assessment Reporting and Tracking ProgramVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Mary E. Plomondon
- Health Systems, Management, and PolicyUniversity of Colorado, School of Public HealthAuroraColoradoUSA
- Clinical Assessment Reporting and Tracking ProgramVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Stephen W. Waldo
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Clinical Assessment Reporting and Tracking ProgramVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
| | - Catherine Battaglia
- Denver/Seattle Center of Innovation for Veteran‐Centered and Value Driven CareVHA Eastern Colorado Healthcare SystemAuroraColoradoUSA
- Health Systems, Management, and PolicyUniversity of Colorado, School of Public HealthAuroraColoradoUSA
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Wang X, Du X, Yang H, Bucholz E, Downing N, Spertus JA, Masoudi FA, Li J, Guan W, Gao Y, Hu S, Bai X, Krumholz HM, Li X. Use of intravenous magnesium sulfate among patients with acute myocardial infarction in China from 2001 to 2015: China PEACE-Retrospective AMI Study. BMJ Open 2020; 10:e033269. [PMID: 32220910 PMCID: PMC7170603 DOI: 10.1136/bmjopen-2019-033269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE In 2001, Chinese guidelines for the care of acute myocardial infarction (AMI) included a new recommendation against the routine use of magnesium. We studied temporal trends and institutional variation in the use of intravenous magnesium sulfate in nationally representative samples of individuals hospitalised with AMI in China between 2001 and 2015. METHODS In an observational study (China PEACE-Retrospective Study) of AMI care, we used a two-stage, random sampling strategy to create a nationally representative sample of 28 208 patients with AMI at 162 Chinese hospitals in 2001, 2006, 2011 and 2015. The main outcome is use of intravenous magnesium sulfate over time. RESULTS We identified 24 418 patients admitted for AMI, without hypokalaemia, in the four study years. Over time, there was a significant initial decrease in intravenous magnesium sulfate use, from 32.1% in 2001 to 17.1% in 2015 (p<0.001 for trend). The decline was greater in the Eastern (from 33.3% to 16.5%) and Western (from 34.8% to 17.2%) regions, as compared with the Central region (from 25.9% to 18.1%), with little difference between rural and urban areas. The proportion of hospitals using intravenous magnesium sulfate did not change over time (from 81.3% to 77.9%). The median ORs, representing hospital-level variation, were 6.03 in 2001, 3.86 in 2006, 4.26 in 2011 and 4.72 in 2015. Intravenous magnesium sulfate use was associated with cardiac arrest at admission and receipt of reperfusion therapy, but no hospital-specific characteristics. CONCLUSIONS Despite recommendations against its use, intravenous magnesium sulfate is used in about one in six patients with AMI in China. Our findings highlight the need for more efficient mechanisms to stop using ineffective therapies to improve patients' outcomes and reduce medical waste. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT01624883).
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Affiliation(s)
- Xianqiang Wang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue Du
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Emily Bucholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Nicholas Downing
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - John A Spertus
- Cardiovascular Outcomes Research, St. Luke's Mid America Heart Institute and the University of Missouri, Kansas City, Missouri, USA
| | - Fredrick A Masoudi
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jing Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenchi Guan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Hu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueke Bai
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Xi Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lyman B, Jacobs JD, Hammond EL, Gunn MM. Organizational learning in hospitals: A realist review. J Adv Nurs 2019; 75:2352-2377. [PMID: 31162704 DOI: 10.1111/jan.14091] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/15/2019] [Accepted: 04/09/2019] [Indexed: 11/26/2022]
Abstract
AIM To establish a middle-range theory of organizational learning in hospitals. DESIGN A realist review of the literature, conducted according to established standards for realist and meta-narrative evidence syntheses. Middle-range theory development was performed according to Smith and Liehr's recommendations. DATA SOURCES Two comprehensive scientific databases and six discipline-focused databases spanning health care, life sciences, business, sociology, and psychology were searched from inception to 12 May 2016. REVIEW METHODS Citations meeting the inclusion criteria were appraised using the Mixed Methods Appraisal Tool. Data extraction was guided by a focus on the contextual factors, mechanisms, and outcomes associated with organizational learning. RESULTS The initial search yielded 2,332 citations, 147 of which were ultimately included in the review. The included citations were generally of high quality. Reviewed evidence indicates certain aspects of organizational context can be conducive to mechanisms of organizational learning, leading to a range of positive organizational outcomes. CONCLUSION This review updates and expands on a previous review of the literature on organizational learning in hospitals, refines the concept of organizational learning in hospitals, and provides a middle-range theory of organizational learning in hospitals. IMPACT This updated review provides a strong evidence base for future work on the topic of organizational learning in hospitals. The refined concept of organizational learning makes it possible to develop reliable, valid research instruments that better reflect of the full scope of organizational learning. Finally, the middle-range theory guides researchers and clinical leaders as they advance the science and practice of organizational learning.
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Affiliation(s)
- Bret Lyman
- College of Nursing, Brigham Young University, Provo, Utah
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Wang H, Gao Y, Ji L, Bai W. Soleus muscle H-reflex monitoring in endoscopic surgery under general anesthesia percutaneous interlaminar approach. Exp Ther Med 2018; 15:4409-4413. [PMID: 29725381 PMCID: PMC5920342 DOI: 10.3892/etm.2018.5979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 11/29/2022] Open
Abstract
The clinical value of soleus muscle H-reflex monitoring in general anesthesia percutaneous interlaminar approach was investigated. A total of 80 cases with unilateral L5-S1 disc herniation between January 2015 and October 2016 were randomly divided into control group (without soleus muscle H-reflex monitoring, n=40) and observation group (with soleus muscle H-reflex monitoring, n=40). Results showed that the operation time of the observation group was shorter than that of the control group (P<0.05), and the blood loss during the operation was less than that of the control group (P<0.05). The length of postoperative hospital stay was shorter than that of the control group (P<0.05). At 24 h after operation, the amplitude of H-reflex in diseased side soleus muscle was significantly lower than that in healthy side (P<0.05). The preoperative, postoperative and 24 h postoperatively, the latency of H-reflex in diseased side soleus muscle was shorter than that of healthy side (P<0.05). The latency and amplitude of H-reflex latency in soleus muscle were significantly lower (P<0.05), and the height of intervertebral space in observation group was significantly higher than that in control group (P<0.05). The total percentage of postsurgical sensory dysfunction, dyskinesia, post-root canal stenosis, disc herniation and cerebrospinal fluid leakage was lower than that of the control group (P<0.05). Japanese Orthopaedic Association score of the observation group was significantly higher at 1 month, and 1 year after operation lower than the control group (P<0.05). Taken together, soleus muscle H-reflex monitoring can effectively reduce the damage to the nerve roots under percutaneous endoscopic intervertebral endoscopic surgery under general anesthesia, improve the accuracy of surgery, reduce the complications, shorten the operation time and reduce the surgical bleeding, which is more beneficial to patients smooth recovery.
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Affiliation(s)
- Huixue Wang
- Department of Spinal Surgery, People's Hospital of Linyi, Linyi, Shandong 276003, P.R. China
| | - Yingji Gao
- Department of Spinal Surgery, People's Hospital of Linyi, Linyi, Shandong 276003, P.R. China
| | - Lixin Ji
- Department of Spinal Surgery, People's Hospital of Linyi, Linyi, Shandong 276003, P.R. China
| | - Wanshan Bai
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, Jiangsu 210002, P.R. China
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