A cluster randomized controlled trial comparing Virtual Learning Collaborative and Technical Assistance strategies to implement an early palliative care program for patients with advanced cancer and their caregivers: a study protocol

Implementation of Agile in healthcare: methodology for a multisite home hospital accelerator

BACKGROUND

The diffusion of innovation in healthcare is sluggish. Evidence-based care models and interventions take years to reach patients. We believe the healthcare community could deliver innovation to the bedside faster if it followed other sectors by employing an organisational framework for efficiently accomplishing work. Home hospital is an example of sluggish diffusion. This model provides hospital-level care in a patient's home instead of in a traditional hospital with equal or better outcomes. Home hospital uptake has steadily grown during the COVID-19 pandemic, yet barriers to launch remain for healthcare organisations, including access to expertise and implementation tools. The Home Hospital Early Adopters Accelerator was created to bring together a network of healthcare organisations to develop tools necessary for programme implementation.

METHODS

The accelerator used the Agile framework known as Scrum to rapidly coordinate work across many different specialised skill sets and blend individuals who had no experience with one another into efficient teams. Its goal was to take 40 weeks to develop 20 'knowledge products',or tools critical to the development of a home hospital programme such as workflows, inclusion criteria and protocols. We conducted a mixed-methods evaluation of the accelerator's implementation, measuring teams' productivity and experience.

RESULTS

18 healthcare organisations participated in the accelerator to produce the expected 20 knowledge products in only 32 working weeks, a 20% reduction in time. Nearly all (97.4%) participants agreed or strongly agreed the Scrum teams worked well together, and 96.8% felt the teams produced a high-quality product. Participants consistently remarked that the Scrum team developed products much faster than their respective organisational teams. The accelerator was not a panacea: it was challenging for some participants to become familiar with the Scrum framework and some participants struggled with balancing participation in the Accelerator with their job duties.

CONCLUSIONS

Implementation of an Agile-based accelerator that joined disparate healthcare organisations into teams equipped to create knowledge products for home hospitals proved both efficient and effective. We demonstrate that implementing an organisational framework to accomplish work is a valuable approach that may be transformative for the sector.

Design and management considerations for control groups in hybrid effectiveness-implementation trials: Narrative review & case studies

Hybrid effectiveness-implementation studies allow researchers to combine study of a clinical intervention's effectiveness with study of its implementation with the aim of accelerating the translation of evidence into practice. However, there currently exists limited guidance on how to design and manage such hybrid studies. This is particularly true for studies that include a comparison/control arm that, by design, receives less implementation support than the intervention arm. Lack of such guidance can present a challenge for researchers both in setting up but also in effectively managing participating sites in such trials. This paper uses a narrative review of the literature (Phase 1 of the research) and comparative case study of three studies (Phase 2 of the research) to identify common themes related to study design and management. Based on these, we comment and reflect on: (1) the balance that needs to be struck between fidelity to the study design and tailoring to emerging requests from participating sites as part of the research process, and (2) the modifications to the implementation strategies being evaluated. Hybrid trial teams should carefully consider the impact of design selection, trial management decisions, and any modifications to implementation processes and/or support on the delivery of a controlled evaluation. The rationale for these choices should be systematically reported to fill the gap in the literature.

Learning Collaboratives: a Strategy for Quality Improvement and Implementation in Behavioral Health

Learning collaboratives are increasingly used in behavioral health. They generally involve bringing together teams from different organizations and using experts to educate and coach the teams in quality improvement, implementing evidence-based practices, and measuring the effects. Although learning collaboratives have demonstrated some effectiveness in general health care, the evidence is less clear in behavioral health and more rigorous studies are needed. Learning collaboratives may contain a range of elements, and which elements are included in any one learning collaborative varies widely; the unique contribution of each element has not been established. This commentary seeks to clarify the concept of a learning collaborative, highlight its common elements, review evidence of its effectiveness, identify its application in behavioral health, and highlight recommendations to guide technical assistance purveyors and behavioral health providers as they employ learning collaboratives to improve behavioral health access and quality.

Feasibility and Application of Cluster Nursing to the Care of Patients with Acute Oncology

Objective

To probe the utility of cluster nursing for the care of acute oncology clients.

Methods

One hundred fourteen cases of acute oncology pioneers undergoing therapy in our clinic from April 2019 to February 2021 were randomly assigned into two consecutive arms, conventional care and cluster care, in accordance with the nursing modality. Complications, satisfaction, quality of survival, and negative emotions were compared across the two parties.

Results

The comorbidity incidence rate of the subject matter in the research cohort was 7.02%, which was below the comorbidity rate of 17.54% in the reaction cohort (P < 0.05); the percentage of satisfaction in the research cohort was 96.49%, which was higher than the satisfaction rate of 78.95% in the reaction cohort (P < 0.05); aftercare, the quality of survival was significantly higher in both groups, and the SAS and SDS scores were significantly lower, with a more pronounced trend of change in the research cohort than in the reaction cohort (P < 0.05).

Conclusion

Bundled care for casualty oncology is of major value, with a marked reduction in the incidence of postoperative complications, high quality of survival, an excellent prognosis and negative mood, high patient morale and satisfaction and compliance with curative treatment, and good support for subsequent care.

Development of a national health policy logic model to accelerate the integration of oncology and palliative care: a nationwide Delphi survey in Japan

BACKGROUND

Despite recommendations to deliver palliative care to cancer patients and their caregivers, their distress has not been alleviated satisfactorily. National health policies play a pivotal role in achieving a comprehensive range of quality palliative care delivery for the public. However, there is no standardised logic model to appraise the efficacy of these policies. This study aimed to develop a logic model of a national health policy to deliver cancer palliative care and to reach consensus towards specific policy proposals.

METHODS

A draft version of the logic model and specific policy proposals were formulated by the research team and the internal expert panel, and the independent external expert panel evaluated the policy proposals based on the Delphi survey to reach consensus.

RESULTS

The logic model was divided into three major conceptual categories: 'care-delivery at cancer hospitals', 'community care coordination', and 'social awareness of palliative care'. There were 18 and 45 major and minor policy proposals, which were categorised into four groups: requirement of government-designated cancer hospitals; financial support; Basic Plan to Promote Cancer Control Programs; and others. These policy proposals were independently evaluated by 64 external experts and the first to third Delphi round response rates were 96.9-98.4%. Finally, 47 policy proposals reached consensus. The priority of each proposal was evaluated within the four policy groups.

CONCLUSIONS

A national health policy logic model was developed to accelerate the provision of cancer palliative care. Further research is warranted to verify the study design to investigate the efficacy of the logic model.

Optimizing the implementation of a multisite feasibility trial of a mind-body program in acute orthopedic trauma

The Toolkit for Optimal Recovery (TOR) is a mind-body program for patients with acute orthopedic injuries who are at risk for persistent pain/disability. In preparation for a multisite feasibility trial of TOR at three orthopedic trauma centers, we aim to qualitatively identify barriers and facilitators to study implementation and strategies to mitigate the implementation barriers and leverage facilitators.We conducted 18 live video focus groups among providers and three one-on-one interviews with department chiefs at Level 1 trauma centers in three geographically diverse sites (N = 79 participants). Using a content analysis approach, we detected the site-specific barriers and facilitators of implementation of TOR clinical trial. We organized the data according to 26 constructs of the Consolidated Framework for Implementation Research (CFIR), mapped to three Proctor implementation outcomes relevant to the desired study outcomes (acceptability, appropriateness, and feasibility). Across the three sites, we mapped six of the CFIR constructs to acceptability, eight to appropriateness, and three to feasibility. Prominent perceived barriers across all three sites were related to providers' lack of knowledge/comfort addressing psychosocial factors, and organizational cultures of prioritizing workflow efficiency over patients' psychosocial needs (acceptability), poor fit between TOR clinical trial and the fast-paced clinic structure as well as basic needs of some patients (appropriateness), and limited resources (feasibility). Suggestions to maximize the implementation of the TOR trial included provision of knowledge/tools to improve providers' confidence, streamlining study recruitment procedures, creating a learning collaborative, tailoring the study protocol based on local needs assessments, exercising flexibility in conducting research, dedicating research staff, and identifying/promoting champions and using novel incentive structures with regular check-ins, while keeping study procedures as nonobtrusive and language as de-stigmatizing as possible. These data could serve as a blueprint for implementation of clinical research and innovations in orthopedic and other medical settings.

Adapting ENABLE for patients with advanced cancer and their family caregivers in Singapore: a qualitative formative evaluation

BACKGROUND

ENABLE (Educate, Nurture, Advise, Before Life Ends) is a nurse coach-led, early palliative care model for patients with advanced cancer and their family caregivers. Content covered includes problem-solving, advance care planning, symptom management and self-care. The aim was to evaluate the cultural acceptability of ENABLE among patients with advanced cancer and their caregivers in Singapore and identify modifications for an adapted ENABLE-SG model.

METHODS

Qualitative formative evaluation with a thematic analysis approach in two hospitals in Singapore, involving patients (n = 10), family caregivers (n = 11) and healthcare professionals (n = 10) who care for patients with advanced cancer. Semi-structured interviews were conducted to explore (i) the main needs and challenges facing individuals with advanced cancer and their family caregivers; (ii) patient involvement in healthcare decision making; and (iii) content and delivery of ENABLE.

RESULTS

While physical needs were largely well met, participants expressed that psychosocial care was delivered too late in the illness trajectory. Healthcare decision making approaches varied from a patient-centred shared decision-making model to a family-centred model where patients may not know their cancer diagnosis and prognosis. The content was considered to be relevant, comprehensive and practical; financial assistance, adjustment to body image, and evaluation of complementary therapy were also recommended. Face-to-face rather than telephone sessions were preferred to facilitate rapport building.

CONCLUSIONS

ENABLE was broadly acceptable with some modifications, including adjusting the content to ensure it can be delivered even if the patient is not fully aware of cancer diagnosis and delivering the first session face-to-face with flexibility for subsequent sessions.