Improving health care quality and safety: the role of collective learning

Exploring factors influencing the consistent adoption of a post-stroke upper extremity outcome measure using Normalisation Process Theory

BACKGROUND

Stroke rehabilitation guidelines recommend using outcome measures like the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) to assess post-stroke upper extremity function. However, integrating such outcome measures into routine clinical practice remains challenging, highlighting the need to understand factors affecting their implementation in evolving healthcare models.

OBJECTIVE

Our study aimed to identify the barriers and facilitators to sustain the routine use of the FMA-UE among hospital-based occupational therapists (OTs) using a theory-driven approach.

METHODS

Employing a mixed-method sequential exploratory study design rooted in Normalisation Process Theory (NPT), we gathered quantitative data through a validated survey followed by qualitative insights analysed with directed content analysis from focus group discussions involving occupational therapists from four hospitals.

RESULTS

Survey findings (n = 34) revealed barriers primarily associated with NPT constructs of collective action and coherence. Facilitators were linked to the cognitive participation construct. Key barriers identified in focus groups included insufficient coaching, competing priorities, and perceived limited value of the FMA-UE. Facilitators included legitimation of therapists' role in outcome measurements and an open learning culture.

CONCLUSIONS

Through a theory-based approach, we identified barriers and facilitators to sustain the routine of the FMA-UE. Our findings offer insights for designing implementation strategies to embed the FMA-UE into routine practice, supporting its sustained use in stroke rehabilitation.

Our Unrealized Imperative: Integrating Mental Health Care into Hospice and Palliative Care

The field of Hospice and Palliative Medicine (HPM) has its roots in the principles, promulgated by Dame Cicely Saunders, that patient and family are the unit of care and that comprehensive integration of physical, psychological, social, and spiritual care is necessary to address suffering in all its dimensions. Although we aspire to provide comprehensive care for our patients, most hospice and palliative care (HPM) physicians lack basic competencies for identifying and managing patients with psychological distress and mental health distress and disorders, a growing segment of our clinical population. In this article, I argue that we are not living up to the founding values of our field in how we practice, how we educate our trainees, our research, and in how we pursue our own professional development as faculty. The history of our field, the nature of our clinical workforce, the culture of PC, and our educational programs all contribute to our current practice model, which is not adequate to meet the mental health needs of our patients. I propose strategies to address these challenges focused on enhancing integration between psychiatry/psychology and HPM, changes in fellowship education and faculty development, addressing the stigma against people with mental health diagnoses, and addressing system and cultural challenges that limit our ability to provide the kind of comprehensive, integrative care that our field aspires to.

Organizational learning in surgery in Tanzania's health system: a descriptive cross-sectional study

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.

A blueprint for learning: How NHS England (London) learned during its response to the Covid-19 pandemic

Identification and sharing of lessons is a key aspect of emergency preparedness, resilience and response (EPRR) activity in the national health service (NHS) in England (NHS England, 2022). The overall intent of the lessons identification and implementation process is to improve readiness and response to future major incidents and emergencies, such that, wherever possible, patient harm is minimised and staff well-being is maximised. In this commentary, we draw on international literature to outline some of the major challenges in healthcare organisations to learning from major incidents and emergencies. We describe our experience of identifying lessons and set out the approach used by NHS England (London) to identifying lessons from the NHS response to the Covid-19 pandemic in the capital. We describe the knowledge garnered in our organisation about learning methods during the Covid-19 pandemic. The commentary considers the different approaches to identifying lessons, and the subsequent challenges of learning and implementation. This paper places its focus on the learning processes followed rather than what was learned as a result. It also explores whether the learning process undertaken by NHS England (London) demonstrates the hallmarks of a learning organisation.

The ripple effect of strain in times of change: how manager emotional exhaustion affects team psychological safety and readiness to change

Introduction

Managers assume a pivotal role during periods of organizational change, yet there exists a notable gap in our understanding of how their emotional exhaustion may impact their capacity to generate readiness to change within their teams. Grounded in the conservation of resources theory (COR), this study explores the crossover effect of managers' emotional exhaustion on team readiness to change. We expect this to occur through higher levels of laissez-faire leadership, which impacts the teams' psychological safety.

Methodology

Data was gathered within a Canadian governmental organization undergoing two significant changes-cultural change and digitalization-with a specific focus on leadership as a pivotal factor in preparing teams for change. Employing surveys from 372 team members and 62 managers affected by this change, we conducted path analysis to empirically test the proposed model across 74 teams and their respective managers.

Results

Managers' emotional exhaustion has a negative indirect effect on team readiness to change. The double mediation pathway implies a positive relationship on laissez-faire leadership, which hinders psychological safety. In turn, psychological safety hampers team readiness to change.

Conclusion

Managers must invest significant resources to fulfill their roles and responsibilities during strategic change. Those who feel exhausted during change may look for ways to protect some of their resources by reducing the time and energy they invest leading their team. This self-preserving resource strategy has detrimental consequences on teams' effectiveness during change due to an indirect crossover effect that affects the levels of psychological safety on the team.

Safety: A collective and embedded competency. An ethnographic study of safety practices at an industrial workplace in the Netherlands

INTRODUCTION

Organizations place strong emphasis on the standardized occupational health and safety procedures to reduce work-related illnesses and workplace accidents. However, standardized procedures are not always followed up in daily work practices. Organizations must cope with the differences between standardized procedures and local adaptation by employees.

METHODS

This ethnographic field study at an industrial workplace in the Netherlands provides insights into employees' everyday work practices, how these work practices are shaped, and how they relate to local occupational health and safety procedures. Acknowledging safety as a competency embedded in work practices, as introduced by Gherardi and Nicolini (2002), offers a theoretical point of view for looking beyond the dichotomy of standardization and local adaptations.

RESULTS

The results show that a standardized and noncontextualized occupational health and safety management system that focuses on accident-free days and compliance actually leads to ignorance of practical and tacit competences of workers and no learning and improvement of safety procedures can take place. However, our findings also illustrate how employees in their informal everyday work practices reduce the risks produced by the safety system itself.

CONCLUSION

Overall, the results indicate that social interactions among employees, leaders, and management within the organization play an important role in workplace safety. The analysis highlights the value of vulnerability and trust in relationships at work to be able to learn and develop safety procedures that align with local demands.

PRACTICAL APPLICATIONS

This study emphasizes the need for participatory approaches in creating safer and healthier workplaces. The cocreation of occupational health and safety (OHS) rules and procedures, however, can only function if they are combined with a responsive leadership style.

Lessons Learned About System-Level Improvement in Serious Illness Communication: A Qualitative Study of Serious Illness Care Program Implementation in Five Health Systems

BACKGROUND

Serious illness communication is a key element of high-quality care, but it is difficult to implement in practice. The Serious Illness Care Program (SICP) is a multifaceted intervention that contributes to more, earlier, and better serious illness conversations and improved patient outcomes. This qualitative study examined the organizational and implementation factors that influenced improvement in real-world contexts.

METHODS

The authors performed semistructured interviews of 30 health professionals at five health systems that adopted SICP as quality improvement initiatives to investigate the organizational and implementation factors that appeared to influence improvement.

RESULTS

After SICP implementation across the organizations studied, approximately 4,661 clinicians have been trained in serious illness communication and 56,712 patients had had an electronic health record (EHR)-documented serious illness conversation. Facilitators included (1) visible support from leaders, who financially invested in an implementation team and champions, expressed the importance of serious illness communication as an institutional priority, and created incentives for training and documenting serious illness conversations; (2) EHR and data infrastructure to foster performance improvement and accountability, including an accessible documentation template, a reporting system, and customized data feedback for clinicians; and (3) communication skills training and sustained support for clinicians to problem-solve communication challenges, reflect on communication experiences, and adapt the intervention. Inhibitors included leadership inaction, competing priorities and incentives, variable clinician acceptance of EHR and data tools, and inadequate support for clinicians after training.

CONCLUSION

Successful implementation appeared to rely on multilevel organizational strategies to prioritize, reward, and reinforce serious illness communication. The insights derived from this research may function as an organizational road map to guide implementation of SICP or related quality initiatives.

Improving serious illness communication: a qualitative study of clinical culture

OBJECTIVE

Communication about patients' values, goals, and prognosis in serious illness (serious illness communication) is a cornerstone of person-centered care yet difficult to implement in practice. As part of Serious Illness Care Program implementation in five health systems, we studied the clinical culture-related factors that supported or impeded improvement in serious illness conversations.

METHODS

Qualitative analysis of semi-structured interviews of clinical leaders, implementation teams, and frontline champions.

RESULTS

We completed 30 interviews across palliative care, oncology, primary care, and hospital medicine. Participants identified four culture-related domains that influenced serious illness communication improvement: (1) clinical paradigms; (2) interprofessional empowerment; (3) perceived conversation impact; (4) practice norms. Changes in clinicians' beliefs, attitudes, and behaviors in these domains supported values and goals conversations, including: shifting paradigms about serious illness communication from 'end-of-life planning' to 'knowing and honoring what matters most to patients;' improvements in psychological safety that empowered advanced practice clinicians, nurses and social workers to take expanded roles; experiencing benefits of earlier values and goals conversations; shifting from avoidant norms to integration norms in which earlier serious illness discussions became part of routine processes. Culture-related inhibitors included: beliefs that conversations are about dying or withdrawing care; attitudes that serious illness communication is the physician's job; discomfort managing emotions; lack of reliable processes.

CONCLUSIONS

Aspects of clinical culture, such as paradigms about serious illness communication and inter-professional empowerment, are linked to successful adoption of serious illness communication. Further research is warranted to identify effective strategies to enhance clinical culture and drive clinician practice change.

Mapping quality improvement education initiatives to Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines

AIMS AND OBJECTIVES

To explore the rigour of nurse-led quality improvement projects involving education, training or continuing professional development, and examine evaluation frameworks contained within.

BACKGROUND

Healthcare organisations invest significantly in quality improvement in the pursuit of cost-effective, safe, evidence-based and person-centred care. Consequently, efforts to examine the success of investment in quality improvement activities are prominent, against a backdrop of rising healthcare expenditure, reforms, consumer expectations and feedback.

DESIGN

A qualitative document analysis of quality improvement projects located in a local health district repository was undertaken.

METHODS

N = 3004 projects were screened against inclusion criteria, with n = 160 projects remaining for analysis. Projects were mapped to an adapted version of the Standards for QUality Improvement Reporting Excellence (SQUIRE), specifically the education extension (SQUIRE-EDU). Additionally, project evaluation frameworks were positioned within Kirkpatrick's four levels of training evaluation model. The SQUIRE checklist was also applied in line with EQUATOR guidelines.

RESULTS

Of n = 60 completed projects assessed against four broad SQUIRE-EDU categories and relevant criteria, n = 36 were assessed not to have met any categories, n = 14 projects met one category, n = 8 projects met two categories, and n = 2 projects met three categories. None of the completed projects met all four SQUIRE-EDU categories. There was insufficient documentation relating to evaluation frameworks in n = 133 projects to position within Kirkpatrick's four levels of training evaluation.

CONCLUSIONS

Scientific rigour should underpin all quality improvement efforts. We recommend that SQUIRE international consensus guidelines (full or abridged) should guide both the design and reporting of all local quality improvement efforts.

RELEVANCE TO CLINICAL PRACTICE

To be of value to the expansion of evidence-based practice, quality improvement platforms should be designed to reflect the structural logic, rigour and reporting recommendations being advocated in consensus reporting guidelines. This may require investment in training and development programs, and identification of governance and support systems. No Patient or Public Contribution, as the study was retrospective in nature and involved a health service repository of quality improvement projects accessible to health service staff only.

Safe Among the Unsafe: Psychological Safety Climate Strength Matters for Team Performance

Team psychological safety, as a shared perception, is persistently found to be important for team performance. However, team members may not necessarily agree on the level of safety within the team. What happens when team members have dispersed perceptions of team psychological safety? Through a survey-based study involving 1,149 members of 160 management teams, we found that, not only is the level of team psychological safety positively related to team performance, but also that sharedness among team members (team psychological safety climate strength) moderates this relationship. The more team members agree on the level of team psychological safety, the stronger the effect of team psychological safety on team performance. Further, having at least one member who perceives the team as psychologically safe may lift team performance in a team of low psychological safety. We discuss theoretical and practical implications of looking beyond average levels of team psychological safety for building high-performing teams.

Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon

INTRODUCTION

Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants' perceptions on leadership, medical errors, and the QI process in Cameroon.

METHODS

Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation.

RESULTS

A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants' perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4.

CONCLUSIONS

These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.

The Incident Feedback Committee (IFC): A Useful Tool to Investigate Errors in Clinical Research

In clinical practice, an objective of safety management is to identify preventable causes of adverse events to avoid the incidents from recurring. Likewise, in the field of clinical research adequate methods to investigate incidents that impair the quality of a clinical trial are needed. Understanding the causes of errors and undesirable incidents can help guarantee participant safety, improve the practices of research coordinators, investigators, and clinical research assistants and help to minimize research costs. Here, we present the main features of our Incident Feedback Committees (IFC) in clinical research, with outcomes over 5 years. Methods: The IFC has adapted the ALARM and ORION post-event methods with investigations focused on ‘the incidents’ occurring during research studies. It sought the root causes contributing to these incidents and proposed corrective actions. Results: Since our IFC was set up in 2015 it has examined 52 incidents from nine studies. The most frequent causes mainly concerned the working environment (54%). Most incidents had two or more causes. Some corrective actions were planned for ongoing or future studies. Conclusion: IFCs provide a useful and much-appreciated method of analysing incidents in the performance of clinical research. A multicentre study is needed to evaluate the effect of IFCs on the quality of an establishment’s clinical research, at the individual level (patient safety) and also at the system level (changes in the organization of tasks).

Empowering or addicting? An analysis of the effects of team members–supervisor relationships on job satisfaction in healthcare

Patient-centredness relies on integrated care, which requires teamwork to be effectively implemented. Positive relationships between team members and supervisors are crucial to enhance health professionals’ satisfaction with their job and, consequently, to increase their commitment to organizational excellence. However, the positive effects of team members–supervisor exchange may dilute when the team is endowed with autonomy at work. The article proposes a moderation analysis aimed at collecting evidence of the implications of team members–supervisor relationships on job satisfaction (JS) with team autonomy (TA) as a moderating variable. Results of the study suggest that positive exchanges between team members and supervisors enhance health professionals’ satisfaction with their job. However, TA acts as a negative and statistically significant moderator. Good exchanges between team members and their supervisor seem to lose their positive effects on JS when health professionals are provided with a greater self-determination to accomplish their organizational activities. Tailored management interventions should be designed to sustain teamwork when increased autonomy at work is assigned to health professionals.

Nursing staff's experience of appearance issues in various nursing situations

Background

Health care professionals frequently interact with unknown patients in a process involving appearance-based judgements and priority-setting, all of which has an effect on health care equality. The healthcare provider–patient interaction is also highly relevant for the awareness and support of patients’ appearance concerns, with an associated possibility for improving patients’ satisfaction with their appearance and health. The aim was therefore to explore nursing staff’s experience of patients’ appearance issues in various nursing situations, with the purpose to facilitate awareness raising and knowledge development.

Method

A qualitative research approach with focus group interviews was chosen due to the exploratory aim of the study. Five semi-structured focus group interviews were conducted with 24 nursing staff in total (19 women and five men). The participants’ ages varied (20 to 45 years) as did their professional nursing experience. The interviews lasted approximately one hour, were digitally recorded, transcribed verbatim and analysed through thematic analysis.

Results

The thematic analysis resulted in the two themes Patient perspective and Professional nursing role, with associated subthemes. The findings showed the importance and impact of appearance issues in nursing situations and how these are linked to the health of the patients. Some groups of patients were identified as more vulnerable than others, which was associated with health care inequalities and health disparities. Value-based strategies along with knowledge, and skills for holistic person-centred care were identified as important resources for the development of appearance-related awareness and support in various nursing situations.

Conclusion

Strategies for improvement can be realised through the educational system for nursing staff, but mainly by using collective reflective learning forums in different workplaces. An empowerment approach is considered a useful framework for the implementation of holistic person-centred care, functioning as a resource for appearance-related awareness and support in various nursing situations. However, more research is needed on the complex and challenging phenomenon of appearance issues in nursing situations. Knowledge development related to successful person-centred strategies for appearance-related awareness and support is important, especially strategies with a salutogenic perspective.

Common Problematic Scholarly Activity Project Planning Expectations of Project Novices

INTRODUCTION

Scholarly Activity (SA) projects, whether using methods more traditionally associated with research and or "quality improvement" projects, have been shown to confer value to resident physicians and other project novices in multiple ways. The inclusion of community and university-based residents and faculty in spearheading SA projects has led to improved understanding of medical literature and enhanced clinical practices, arguably producing more "well-rounded" physicians.

PURPOSE OF PAPER

The primary purpose of this paper is to provide a summary of problematic expectations frequently assumed by project novices when developing and conducting SA projects.

RESULTS

The authors will discuss a total of 26 problematic project-related novice expectations during five typical project phase categories.

CONCLUSIONS

Learning to navigate the complexities of training to become a practicing physician, while also planning high quality SA project designs has been and will continue to be a complex challenge. The authors hope that this article can be used by supervising faculty and other graduate medical education mentors to assist the SA project novice (SAPN) plan SA projects. By establishing realistic expectations during project planning phases, the SAPN can avoid potential missteps that typically impede SA project completion.

Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others?

BACKGROUND

Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings.

METHODS

We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers.

RESULTS

Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum.

CONCLUSION

Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

Baseline Patient Safety Culture in Cameroon: Setting a Foundation for Trauma Quality Improvement

BACKGROUND

Trauma quality improvement (QI) has resulted in decreased trauma mortality and morbidity in high-income countries and has the potential to do the same in low- and middle-income countries. Effective implementation of QI programs relies on a foundational culture of patient safety; however, studies on trauma-related patient safety culture in Sub-Saharan Africa remain scarce. This study assesses baseline patient safety culture in Cameroon to best identify opportunities for improvement.

MATERIALS AND METHODS

Over a 3-week period, the Hospital Survey on Patient Safety Culture was administered in three hospitals in the Littoral region of Cameroon. Percentages of positive responses (PPRs) were calculated across 42 items in 12 survey dimensions. A mixed-effects logistic regression model was used to summarize dimension-level percentages and confidence intervals.

RESULTS

A total of 179 trauma-related hospital personnel were surveyed with an overall response rate of 76.8%. High PPRs indicate favorable patient safety culture. Of the 12 dimensions evaluated by the Hospital Survey on Patient Safety Culture, nine had a PPR below 50%. Dimensions particularly pertinent in the context of QI include Nonpunitive Response to Errors with a PPR of 25.8% and Organization Learning-Continuous Improvement with a PPR of 64.7%.

CONCLUSIONS

The present study elucidates an opportunity for the development of trauma patient safety culture in Cameroon. Low PPR for Nonpunitive Response to Errors indicates a need to shift cultural paradigms from ascribing individual blame to addressing systemic shortcomings of patient care. Moving forward, data from this study will inform interventions to cultivate patient safety culture in partnering Cameroonian hospitals.

Coach Mindset: Preparing Leaders to Create a Climate of Trust and Value

Health care, like other industries, is faced with increased competition from both traditional and nontraditional players. A top challenge facing organizations is the ability to effectively develop leaders to lead in an increasingly volatile, uncertain, complex, and ambiguous environment. Organizations with effective leaders have been shown to outperform their peers. Transforming leadership to include the adoption of a coach mindset that creates a climate of trust, enables improved engagement and performance of nurses (employees) and teams, while also accelerating the creation of value and outcome improvements for patients, is a pursuit worthy of leadership attention. The purpose of this article is to describe a conceptual framework, define a coach mindset, and describe the mediating antecedents and consequences that result when leaders adopt a coach mindset as a leadership competency. This work can be applied as a part of leadership development implementation and adoption-related activities and used in future research.

Multi-level analysis of the learning health system: Integrating contributions from research on organizations and implementation

Introduction

Organizations and systems that deliver health care may better adapt to rapid change in their environments by acting as learning organizations and learning health systems (LHSs). Despite widespread recognition that multilevel forces shape capacity for learning within care delivery organizations, there is no agreed-on, comprehensive, multilevel framework to inform LHS research and practice.

Methods

We develop such a framework, which can enhance both research on LHSs and practical steps toward their development. We draw on existing frameworks and research within organization and implementation science and synthesize contributions from three influential frameworks: the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework. These frameworks come, respectively, from the fields of implementation science, public health, and organization science.

Results

Our proposed integrative framework includes both intraorganizational levels (individual, team, mid-management, organization) and the operating and general environments in which delivery organizations operate. We stress the importance of examining interactions among influential factors both within and across system levels and focus on the effects of leadership, incentives, and culture. Additionally, we indicate that organizational learning depends substantially on internal and cross-level alignment of these factors. We illustrate the contribution of our multilevel perspective by applying it to the analysis of three diverse implementation initiatives that aimed at specific care improvements and enduring system learning.

Conclusions

The framework and perspective developed here can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors. The framework can also be used as a planning tool by managers and practitioners.

Arabic Version of Learning Organization Survey Short-Form: Hospital Pharmacy Settings

Objective: The objective of this study was to assess the psychometric properties of a translated Arabic version of the Learning Organization Survey (LOS-27) and to use this to evaluate staff perceptions about the organizational learning process in Kuwaiti hospital pharmacies. Setting: This study adopted a cross-sectional survey of the pharmacy employees in 6 hospital pharmacies in Kuwait. Results: The results indicated that the internal consistency of all composites was more than 0.7, except for one. All item loadings for the construct measurements were above 0.7. The standardized root mean square residual (SRMR) score showed a good fit with a value of 0.08. The intercorrelation among composites ranged from 0.34 to 0.68. Conclusions: The results indicate that the Arabic translation of the LOS-27 questionnaire has adequate levels of reliability and validity in comparison with the original US survey results. The overall average positive rate of composites was 64%. Therefore, the findings suggest that the hospital pharmacy staff surveyed in Kuwait were moderately positive in their perceptions about organizational learning in their organizations.

Is research on professional identity formation biased? Early insights from a scoping review and metasynthesis

OBJECTIVE

Despite a recent surge in literature identifying professional identity formation (PIF) as a key process in physician development, the empiric study of PIF in medicine remains in its infancy. To gain insight about PIF, the authors examined the medical literature and that of two other helping professions.

METHODS

The authors conducted a scoping review and qualitative metasynthesis of PIF in medicine, nursing and counselling/psychology. For the scoping review, four databases were searched using a combination of keywords to identify empiric studies on PIF in trainees. After a two-step screening process, thematic analysis was used to conduct the metasynthesis on screened articles.

RESULTS

A total of 7451 titles and abstracts were screened; 92 studies were included in the scoping review. Saturation was reached in the qualitative metasynthesis after reviewing 29 articles.

CONCLUSION

The metasynthesis revealed three inter-related PIF themes across the helping professions: the importance of clinical experience, the role of trainees' expectations of what a helping professional is or should be, and the impact of broader professional culture and systems on PIF. Upon reflection, most striking was that only 10 of the 92 articles examined trainee's sociocultural data, such as race, ethnicity, gender, sexual orientation, age and socio-economic status, in a robust way and included them in their analysis and interpretation. This raises the question of whether conceptions of PIF suffer from sociocultural bias, thereby disadvantaging trainees from diverse populations and preserving the status quo of an historically white, male medical culture.

Building capacity for change: evaluation of an organisation-wide leadership development program

Objective This study evaluated Leading 4 Change, a change leadership development program designed to support healthcare middle managers through a period of significant organisational change and enhance workplace resilience. Methods A mixed methods evaluation was conducted within the program’s framework of a quality improvement activity. Quantitative measures were participant responses (n=160) to online questionnaires, which were compared before and after the program, using an uncontrolled pre-post study design. Four questionnaires were used: Resilience @ Work, General Self-Efficacy, the 11-item Learning Organization Survey and organisational climate. Differences between the pre- and post-program periods were compared using linear mixed-effects models, incorporating repeated measures between ‘pre’ and ‘post’ periods. Qualitative data were obtained by interviewing four participants on three occasions during the program, and through text responses provided by participants during a presentation session after the program finished. Both interview data and textual data were subjected to thematic analysis. Results Integration of data from quantitative and qualitative analyses generated three main findings: (1) participants were satisfied and engaged with the program, which met their learning objectives; (2) the program led to increased workplace resilience, in particular the ability to manage stress and self-efficacy for individuals; and (3) organisational learning perceptions were unchanged. Conclusion Although conducted during a period of intense internal and external pressure, Leading 4 Change led to demonstrable effects. It effectively engaged middle managers across a health system. However, there was no evidence that the effect of the program extended beyond individual participants to their perceptions of their work environment as a learning organisation. What is known about the topic? Although much has been written about change management and change leadership within healthcare, the failure to manage the ‘people’ element and engage employees hampers the success of that change. However, how to engage employees and enhance their resilience and self-efficacy (self-belief to proactively manage) during change has been little explored. Further, the concept of a learning organisation has been developed in private, non-healthcare fields and there is little known about it in other areas, such as healthcare, particularly during change. What does this paper add? The paper describes the evaluation of a 16-week change leadership development program (Leading 4 Change) for middle managers of a public health system undergoing significant reform. It assesses how the program engaged employees, and how and to what extent their workplace resilience, self-efficacy and perceptions of their workplace as a learning organisation changed after the program. Based on the present study, individual development of staff does not necessarily translate directly to better staff perceptions of organisational outcomes. What are the implications for practitioners? Despite being clearly engaged with Leading 4 Change, quantitative and qualitative measures suggested mixed effects of the program on participants. Participants’ self-rated workplace resilience, ability to manage stress and self-efficacy increased after the program. However, there was no evidence that the effect of the program improved staff perceptions of their work as a learning organisation. For complex public sector healthcare organisations to become learning organisations, other organisational factors, in addition to staff development and training, require consideration.

Patient Safety Climate in Healthcare Organizations: tradução e adaptação para a cultura brasileira

Resumo OBJETIVO Traduzir e adaptar o instrumento Patient Safety Climate in Healthcare Organizations - PSCHO para a cultura brasileira. MÉTODOS Estudo metodológico, o qual seguiu as etapas de tradução; síntese; retrotradução; avaliação por um comitê de juízes, composto por uma médica e seis enfermeiras; e pré-teste com 40 sujeitos, entre eles enfermeiros, técnicos de enfermagem, fisioterapeutas e médicos. RESULTADOS As etapas de tradução e retrotradução foram apropriadas. Na síntese, consultou-se a autora do instrumento para ajustar a equivalência de alguns termos. A análise do comitê de juízes demonstrou um índice de validade de conteúdo acima de 80% para a maioria dos itens quanto às equivalências semântica, idiomática, cultural e conceitual. No pré-teste, observou-se adequada validade de conteúdo, facilidade de compreensão dos itens, com um tempo médio de preenchimento de 15 minutos. CONCLUSÃO A tradução e adaptação cultural do instrumento PSCHO foram consideradas satisfatórias, resultando em uma ferramenta de fácil compreensão.

Learning from implementation setbacks: Identifying and responding to contextual challenges

Introduction

We address organizational learning about implementation context during setbacks to primary care redesign in an ambulatory system. The redesign expanded care teams and added a medical assistant assigned administrative and coordination tasks. The redesign was expected to improve care efficiency, prevention, and continuity. In response to setbacks, redesign and system leaders used understanding of context to plan system-wide changes, as well as program adjustments. Doing so enhanced the redesign's prospects and contributed to system learning.

Methods

We conducted a 33-month, mixed-methods study. Qualitative data included quarterly calls with the redesign leaders and 63 activity log entries. There were three site visits; 73 interviews with practice leaders, providers, and medical assistants. Data analysis used categories from an implementation research framework; these were refined and then expanded inductively using log reports, debriefings with change leaders, and documents. Quantitative analysis used system operational data on chronic care, prevention, efficiency, productivity, and patient access.

Results

Redesigned teams were not implemented as widely or rapidly as anticipated and did not deliver hoped-for gains in operational metrics. Interviews reported that team redesign was leading to improvements in chronic care and prevention and eased provider burden. Besides making small adjustments to cope with setbacks, redesign and system leaders engaged in more thorough organizational learning. They examined contextual challenges underlying setbacks and posing risks to the delivery system as a whole. Their responses to challenges helped strengthen the redesign's prospects, improved the delivery system's position in its labor market, and helped the system prepare to meet emerging requirements for value-based care and population health.

Conclusions

This case points to benefits for both health care researchers and change practitioners of paying closer attention to how context affects implementation of organizational change, and to opportunities and conditions for learning from setbacks during change.

Team dynamics within quality improvement teams: a scoping review

PURPOSE

This scoping review examines what is known about the processes of quality improvement (QI) teams, particularly related to how teams impact outcomes. The aim is to provide research-informed guidance for QI leaders and to inform future research questions.

DATA SOURCES

Databases searched included: MedLINE, EMBASE, CINAHL, Web of Science and SCOPUS.

STUDY SELECTION

Eligible publications were written in English, published between 1999 and 2016. Articles were included in the review if they examined processes of the QI team, were related to healthcare QI and were primary research studies. Studies were excluded if they had insufficient detail regarding QI team processes.

DATA EXTRACTION

Descriptive detail extracted included: authors, geographical region and health sector. The Integrated (Health Care) Team Effectiveness Model was used to synthesize findings of studies along domains of team effectiveness: task design, team process, psychosocial traits and organizational context.

RESULTS OF DATA SYNTHESIS

Over two stages of searching, 4813 citations were reviewed. Of those, 48 full-text articles are included in the synthesis. This review demonstrates that QI teams are not immune from dysfunction. Further, a dysfunctional QI team is not likely to influence practice. However, a functional QI team alone is unlikely to create change. A positive QI team dynamic may be a necessary but insufficient condition for implementing QI strategies.

CONCLUSIONS

Areas for further research include: interactions between QI teams and clinical microsystems, understanding the role of interprofessional representation on QI teams and exploring interactions between QI team task, composition and process.

Advances in medical education and practice: role of massive open online courses

Massive open online courses (MOOCs) are increasingly available in the area of health and medicine. These MOOCs are offered through various commercial and noncommercial online platforms. When offered through reputable institutions, they can provide valuable access to reliable information without the constraints of time, geographical location, or level of education. Most current courses appear introductory in nature. In its drive for quality health care, the National Academy of Medicine has prioritized a focus on known chronic care conditions. Many of these conditions are shared internationally. Among its initiatives, the academy encourages consumer and professional groups, patients, clinicians, health care organizations, and universities to work together to identify evidence-based care processes consistent with best practices, organize major prevention programs to target key associated health risk behaviors, and develop systems to measure and evaluate improvements in the provision of patient- and family-centered health care. Carefully designed and collaboratively developed MOOCs would appear a valuable resource to contribute to these initiatives. Such MOOCs can, 1) increase the health literacy of the public with regard to the prevention and treatment of known chronic care conditions, 2) provide ready access to continuing professional, and interprofessional, education, and 3) explore innovative teaching models for student learning focused on patient- and family-centered care. MOOCs would also appear helpful to facilitate effective communication among international communities of patients and clinicians, including student clinicians, with shared interests. Further, the accumulation of MOOC data through large-scale measurement and analysis, obtained nationally and internationally, has the potential to assist in greater understanding of the risk for diseases and their prevention, with this translating into medical education, and authentic, patient- and family-centered methods for student learning. This paper explores these issues.