Using 'appreciative inquiry' in India to improve infection control practices in maternity care: a qualitative study

Leveraging learning systems to improve quality and patient safety in allergen immunotherapy

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Measuring the effectiveness of an integrated intervention package to improve the level of infection prevention and control: a multi-centre study in Bangladesh

BACKGROUND

Infection prevention and control (IPC) is a critical component of delivering safe, effective and high-quality healthcare services, and eliminating avoidable healthcare-associated infections (HAIs) in health facilities, predominantly in population-dense settings such as Bangladesh.

AIM

Our study aimed to assess the effect of an integrated intervention package in improving the IPC level of the health facilities in Bangladesh.

METHODS

We conducted a pre-post intervention study in six district hospitals (DHs) and 13 Upazila Health Complexes (UHCs) in the six districts of Bangladesh. Baseline and endline assessments were conducted between March and December 2021 using the adapted World Health Organization Infection Prevention and Control Assessment Framework (WHO-IPCAF) tool. The IPCAF score, ranging from 0-800, was calculated by adding the scores of eight components, and the IPC promotion and practice level was categorized as Inadequate (0-200), Basic (201-400), Intermediate (401-600) and Advanced (601-800). The integrated intervention package including IPC committee formation, healthcare provider training, logistics provision, necessary guidelines distribution, triage/flu corners establishment, and infrastructure development was implemented in all facilities.

RESULTS

The average IPCAF score across all the facilities showed a significant increase from 16% (95% CI: 11.5-20.65%) to 54% (95% CI: 51.4-57.1%). Overall, the IPCAF score increased by 34 percentage points (P<0.001) in DHs and 40 percentage points (P<0.001) in UHCs. Following the intervention, 12 (three DHs, nine UHCs) of 19 facilities progressed from inadequate to intermediate, and another three DHs upgraded from basic to intermediate in terms of IPC level.

CONCLUSION

The integrated intervention package improved IPCAF score in all facilities.

Evaluating infection prevention and control structure of Indonesian COVID-19 referral hospitals

Due to the emergence of COVID-19, hospitals are required to increase vigilance in providing care. However, their readiness for infection prevention and control (IPC) as a referral hospital in providing COVID-19 services has not been determined. This study aims to evaluate the IPC structure of 30 private non-profit Indonesian referral hospitals for COVID-19 based on the World Health Organization Infection Prevention and Control Assessment Framework (WHO IPCAF). A descriptive cross-sectional quantitative study was used, where 30 hospitals as the COVID-19 referral hospital were selected. The data collection was conducted by an online survey using the IPCAF questionnaire created by the WHO and was analysed with descriptive analysis. The majority of the hospitals' IPC level is at an advanced level (73.3%). All type B hospitals have an advanced IPC level, while only 64.7% of type C and 71.4% of type D have an advanced level. The highest average IPC score is on the IPC guidelines component (94.0), while the lowest value of 71.9 is on the Surveillance of HAIs component. In the minimum scores, there were hospitals with the lowest scores in HAI Surveillance and Multimodal strategies, namely 20.0 and 25.0, respectively. Preparing human resource capacities, establishing functional programmes, developing and implementing IPC guidelines, and providing adequate supplies are needed to improve hospital IPC structures.

Contribution

This study demonstrates the necessity to improve hospital IPC structures to increase the resilience of health services to natural hazards and public health emergencies.

Systematic review and narrative synthesis of the impact of Appreciative Inquiry in healthcare

BACKGROUND

Appreciative Inquiry is a motivational, organisational change intervention, which can be used to improve the quality and safety of healthcare. It encourages organisations to focus on the positive and investigate the best of 'what is' before thinking of 'what might be', deciding 'what should be' and experiencing 'what can be'. Its effects in healthcare are poorly understood. This review seeks to evaluate whether Appreciative Inquiry can improve healthcare.

METHODS

Major electronic databases and grey literature were searched. Two authors identified reports of Appreciative Inquiry in clinical settings by screening study titles, abstracts and full texts. Data extraction, in duplicate, grouped outcomes into an adapted Kirkpatrick model: participant reaction, attitudes, knowledge/skills, behaviour change, organisational change and patient outcomes.

RESULTS

We included 33 studies. One randomised controlled trial, 9 controlled observational studies, 4 qualitative studies and 19 non-controlled observational reports. Study quality was generally poor, with most having significant risk of bias. Studies report that Appreciative Inquiry impacts outcomes at all Kirkpatrick levels. Participant reaction was positive in the 16 studies reporting it. Attitudes changed in the seventeen studies that reported them. Knowledge/skills changed in the 14 studies that reported it, although in one it was not universal. Behaviour change occurred in 12 of the 13 studies reporting it. Organisational change occurred in all 23 studies that reported it. Patient outcomes were reported in eight studies, six of which reported positive changes and two of which showed no change.

CONCLUSION

There is minimal empirical evidence to support the effectiveness of Appreciative Inquiry in improving healthcare. However, the qualitative and observational evidence suggests that Appreciative Inquiry may have a positive impact on clinical care, leading to improved patient and organisational outcomes. It is, therefore, worthy of consideration when trying to deliver improvements in care. However, high-quality studies are needed to prove its effects.

PROSPERO REGISTRATION NUMBER

CRD42015014485.

Outcomes, mechanisms and contextual factors of positive psychology interventions for health workers: a systematic review of global evidence

BACKGROUND

Interventions using positive psychology (PP), which build on positive qualities of healthcare personnel and institutions, could potentially enhance organisational performance in healthcare. The aim of this systematic review was to identify if PP interventions have an impact on organisational performance of healthcare personnel, and if so, how this impact can be achieved. We developed a logic model to explain the impact of PP interventions on organisational performance.

METHODS

We searched Web of Science, Medline, Psychinfo, Embase, Scopus and CINAHL (from inception until March 2019) and references of included articles to identify studies that evaluated the impact of a PP intervention for health personnel. Study quality was assessed using the SQUIRE checklist for quality improvement studies. Data were extracted about study details, setting, participants, intervention, method of evaluation and results. Outcomes, mechanisms and contexts were coded in nVivo. Data synthesis was guided by Lewis' theory of the impact of PP interventions on organisational performance and Kneale et al.'s method for logic model development. Collected data were integrated into a logic model explaining initial inputs, processes, and intermediate outcomes of PP interventions that lead to improved organisational performance in healthcare settings.

RESULTS

We retrieved 4638 articles and identified five through references of included articles of which 29 studies (31 articles) met our inclusion criteria. Most articles were of low quality (n = 19) and outcome measures varied widely. We identified 54 different outcomes of PP interventions, including 'improved well-being' and 'improved interaction and support'. Forty-nine mechanisms were identified including 'recognising and reframing negative interpretations'. Twenty four contextual factors were identified of which seven acted as barriers. 'Managerial support' was a facilitator mentioned in eight studies. All identified outcomes, mechanisms and contextual factors were integrated into a logic model explaining how interventions using PP can impact organisational performance in healthcare.

CONCLUSION

Few identified outcomes were statistically significant, however, trends in both quantitative and qualitative outcomes show that PP interventions can increase well-being and interaction and support and thus improve organisational performance in healthcare. The developed logic model can be used in the implementation and evaluation of interventions using PP for health personnel.

Pilot Test of an Appreciative Inquiry Intervention in Hypertension Self-management

We implemented an Appreciative Inquiry (AI) intervention to assist people with hypertension improve diet, physical activity, and blood pressure. In a two-group randomized controlled trial conducted over 12 weeks, 50 participants were recruited at an urban outpatient health care clinic. The intervention used participants' high peak positive experiences to promote behavior change, during two face-to-face individual sessions and three coaching telephone calls. Data were analyzed using test of differences between groups and analysis of covariance controlling for confounding variables. The intervention group had significantly higher levels of ideal self, positive emotions, and self-efficacy for chronic disease management than the control group. No significant group differences in physical activity, diet, or blood pressure. Findings provide empirical evidence about the underlying processes by which AI may promote health behavior change. Future research should examine the effectiveness of this AI intervention in a larger sample of patients and over a longer intervention period.

Contextual factors that influence quality improvement implementation in primary care: The role of organizations, teams, and individuals

BACKGROUND

Recent emphasis on value-based health care has highlighted the importance of quality improvement (QI) in primary care settings. QI efforts, which require providers and staff to work in cross-functional teams, may be implemented with varying levels of success, with implementation being affected by factors at the organizational, teamwork, and individual levels.

PURPOSE

The purpose of our study was to (a) identify contextual factors (organizational, teamwork, and individual) that affect implementation effectiveness of QI interventions in primary care settings and (b) compare perspectives about these factors across roles (health care administrators, physician and nonphysician clinicians, and administrative staff).

METHODS/APPROACH

We conducted semistructured interviews with 24 health care administrators, physician and nonphysician primary care providers, and administrative staff representing 10 primary care practices affiliated with one integrated delivery system.

RESULTS

Participants across all roles identified similar organizational- and team-level factors that influence QI implementation including organizational capacity to take on new initiatives (e.g., time availability of physicians), technical capability for QI (e.g., data analysis skills), and team climate (e.g., how well staff work together). There was greater variation in terms of individual-level factors, particularly perceived meaning and purpose of QI. Perceptions about value of QI ranged from positive impacts on patient care and practice competitiveness to decreased efficiency and distractions from patient care, but differences did not appear attributable to role.

CONCLUSIONS

Successful QI implementation requires effective collaboration within cross-functional teams. Additional research is needed to assess how best to employ implementation strategies that promote cross-understanding of QI among team members and, ultimately, effective implementation of QI programs.

PRACTICE IMPLICATIONS

Health care managers in primary care settings should strive to create a strong teamwork climate, reinforced by opportunities for staff in various roles to discuss QI as a collective.

Barriers and facilitators to infection control at a hospital in northern India: a qualitative study

Background

Hospital acquired infections occur at higher rates in low- and middle-income countries, like India, than in high-income countries. Effective implementation of infection control practices is crucial to reducing the transmission of hospital acquired infections at hospitals worldwide. Yet, no comprehensive assessments of the barriers to sustained, successful implementation of hospital interventions have been performed in Indian healthcare settings to date. The Systems Engineering Initiative for Patient Safety (SEIPS) model examines problems through the lens of interactions between people and systems. It is a natural fit for investigating the behavioral and systematic components of infection control practices.

Methods

We conducted a qualitative study to assess the facilitators and barriers to infection control practices at a 1250 bed tertiary care hospital in Haryana, northern India. Twenty semi-structured interviews of nurses and physicians, selected by convenience sampling, were conducted in English using an interview guide based on the SEIPS model. All interview data was subsequently transcribed and coded for themes.

Results

Person, task, and organizational level factors were the primary barriers and facilitators to infection control at this hospital. Major barriers included a high rate of nursing staff turnover, time spent training new staff, limitations in language competency, and heavy clinical workloads. A well developed infection control team and an institutional climate that prioritizes infection control were major facilitators.

Conclusions

Institutional support is critical to the effective implementation of infection control practices. Prioritizing resources to recruit and retain trained, experienced nursing staff is also essential.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-017-0189-9) contains supplementary material, which is available to authorized users.