Implementation of simulation modelling to improve service planning in specialist orthopaedic and neurosurgical outpatient services

Developing and embedding an advanced practice musculoskeletal physiotherapy service in public specialist outpatient services in Queensland: A health service masterclass

INTRODUCTION

The Musculoskeletal Physiotherapy Screening Clinic and Multi-disciplinary Service (MPSC&MDS) is an advanced practice physiotherapist-led model of care developed initially to address overburdened specialist orthopaedic outpatient public hospital services across Queensland, Australia.

PURPOSE

This Masterclass explores the experiences and success of embedding the MPSC&MDS state-wide across the Queensland public health system and its expansion in scale and reach to other specialist services. Key characteristics and development strategies are described that have collectively underpinned the expansion and sustainability of the service, using relevant stream sections and themes from a recommended musculoskeletal model of care framework.

IMPLICATIONS

The aim of this masterclass is to be informative for readers involved in the future development or refinement of similar models of care.

Barriers and facilitators to implementing geriatric assessment in daily oncology practice in Japan: A qualitative study using an implementation framework

INTRODUCTION

Various guidelines recommend geriatric assessment (GA) for older adults with cancer, but it is not widely implemented in daily practice. This study uses an implementation framework to comprehensively and systematically identify multi-level barriers and facilitators to implementing GA in daily oncology practice.

MATERIALS AND METHODS

We conducted 16 semi-structured interviews with healthcare providers in 10 designated cancer hospitals in Japan, using purposive and convenience sampling. The Consolidated Framework for Implementation Research (CFIR) was used to guide collection and analysis of interview data following a deductive content analysis approach with consensual qualitative research methods. After coding the interview data, ratings were assigned to each CFIR construct for each case, reflecting the valence and strength of each construct relative to implementation success. Then, those constructs that appeared to distinguish between high-implementation hospitals (HI) where GA is routinely performed in daily practice and low-implementation hospitals (LI) where GA is performed only for research purposes or not at all were explored.

RESULTS

Of the 24 CFIR constructs assessed in the interviews, 15 strongly distinguished between HI and LI. In HI, GA was self-administered (Adaptability), or administered via a mobile app with interpretation (Design Quality and Packaging). In HI, healthcare providers were strongly aware of the urgent need to change practice for older adults (Tension for Change) and recognized that GA was compatible with existing workflow as part of their jobs (Compatibility), whereas in LI, they did not realize the need to change practice, and dismissed GA as an extra burden on their heavy workload. In HI, usefulness of GA was widely recognized by healthcare providers (Knowledge & Beliefs about the Intervention), GA had a high priority (Relative Priority) and had strong support from hospital directors, managers, and nursing chiefs (Leadership Engagement), and multiple stakeholders were successfully engaged, including nurses (Key Stakeholders), peer doctors (Opinion Leaders), and those who drive implementation of GA (Champions).

DISCUSSION

These findings suggest that successful implementation of GA should focus on not only individual beliefs about the usefulness of GA and the complexity of GA itself, but also organizational factors related to hospitals and the engagement of multiple stakeholders.

The updated Consolidated Framework for Implementation Research based on user feedback

Background

Many implementation efforts fail, even with highly developed plans for execution, because contextual factors can be powerful forces working against implementation in the real world. The Consolidated Framework for Implementation Research (CFIR) is one of the most commonly used determinant frameworks to assess these contextual factors; however, it has been over 10 years since publication and there is a need for updates. The purpose of this project was to elicit feedback from experienced CFIR users to inform updates to the framework.

Methods

User feedback was obtained from two sources: (1) a literature review with a systematic search; and (2) a survey of authors who used the CFIR in a published study. Data were combined across both sources and reviewed to identify themes; a consensus approach was used to finalize all CFIR updates. The VA Ann Arbor Healthcare System IRB declared this study exempt from the requirements of 38 CFR 16 based on category 2.

Results

The systematic search yielded 376 articles that contained the CFIR in the title and/or abstract and 334 unique authors with contact information; 59 articles included feedback on the CFIR. Forty percent (n = 134/334) of authors completed the survey. The CFIR received positive ratings on most framework sensibility items (e.g., applicability, usability), but respondents also provided recommendations for changes. Overall, updates to the CFIR include revisions to existing domains and constructs as well as the addition, removal, or relocation of constructs. These changes address important critiques of the CFIR, including better centering innovation recipients and adding determinants to equity in implementation.

Conclusion

The updates in the CFIR reflect feedback from a growing community of CFIR users. Although there are many updates, constructs can be mapped back to the original CFIR to ensure longitudinal consistency. We encourage users to continue critiquing the CFIR, facilitating the evolution of the framework as implementation science advances.

Study to assess the utility of discrete event simulation software in projection & optimization of resources in the out‐patient department at an apex cancer institute in India

Background and Aims

Methods

Results

Conclusion

Introducing a MAP for adherence care in the paediatric cystic fibrosis clinic: a multiple methods implementation study

BACKGROUND

People with cystic fibrosis are required to adhere to a burdensome daily treatment regimen. Comprehensive adherence protocols can support more consistent use of adherence interventions and improve treatment adherence rates. This study aimed to explore the feasibility, acceptability, and appropriateness of implementing an adherence protocol into the outpatient cystic fibrosis clinic of a tertiary, paediatric hospital.

METHODS

This implementation study employed a pre-post observation design, using multiple methods. Focus groups and semi-structured interviews were conducted pre-implementation to understand clinician and consumer perspectives on adherence care. A multicomponent adherence protocol (including multidisciplinary written treatment plans, digital mental health screening and customised communication tools) was then implemented as standard care for a three-month implementation phase. Quantitative data was collected throughout using purpose-designed audit tools and surveys. The Replicating Effective Practice (REP) Framework guided the implementation process. Analysis was informed by The Consolidated Framework for Implementation Research (CFIR) to identify factors that support or challenge the integration of adherence protocols into standard care.

RESULTS

Thirteen clinicians, eight parents and two adolescents participated in focus groups or interviews that informed development of the tailored multicomponent adherence protocol for implementation. Medical chart audits demonstrated that the protocol was used with 44-57% of eligible consumers three months after introduction. Eighteen clinicians and five consumers participated in post-implementation phase questionnaires. The protocol was considered acceptable and appropriate to clinicians and consumers. Changes in clinicians' practice behaviour were short-lived peaks in response to targeted intervention strategies throughout the implementation phase, such as audit and feedback.

CONCLUSIONS

An adherence protocol is not an "off the shelf" solution to the adherence challenge in a hospital outpatient setting. Despite the tailored adherence protocol being considered appropriate and acceptable to clinicians and consumers, low fidelity indicates limited feasibility in the outpatient clinic setting, where multi-disciplinary members are all considered responsible for adherence care interventions. Key implementation factors and strategies to consider prior to introducing an adherence protocol are described.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619001730190 (Retrospectively registered).

Discharge Planning of Older Persons from Hospital: Comparison of Observed Practice to Recommended Best Practice

Older people are particularly vulnerable to hospital re-presentation following discharge. Ideal discharge planning processes facilitate the transition from hospital to home and prevent subsequent re-presentations to hospital. The objective of this study was to examine discharge planning processes in two Australian hospitals, compare them between sites and to best-practice recommendations. An ethnographic observational study of discharge planning processes was conducted at two general medical inpatient wards at a large tertiary hospital and a smaller regional hospital in Brisbane, Australia. Participants were patients and ward staff involved in discharge planning during a hospital admission. A literature review was conducted to elicit best-practice recommendations for discharge planning. Data for this study (duration: 112 h) were collected directly using field notes by a research assistant embedded in the ward. A directed qualitative content analysis approach was used for data analysis. Results were compared to best-practice recommendations. Findings indicate that both hospitals implemented various best-practice interventions to enhance communication, collaboration, coordination and patient/family engagement for optimal discharge planning. Strategies used were context specific and effective to varying degrees. Clear responsibilities and goals within the multidisciplinary team helped to create cohesive, well-functioning teams. More work is needed to engage patients and families in discharge planning, and to encourage health professionals to consider patients and family as active team members in the discharge planning process.

Agent-Based Modeling for Implementation Research: An Application to Tobacco Smoking Cessation for Persons with Serious Mental Illness

Background

Implementation researchers have sought ways to use simulations to support the core components of implementation, which typically include assessing the need for change, designing implementation strategies, executing the strategies, and evaluating outcomes. The goal of this paper is to explain how agent-based modeling could fulfill this role.

Methods

We describe agent-based modeling with respect to other simulation methods that have been used in implementation science, using non-technical language that is broadly accessible. We then provide a stepwise procedure for developing agent-based models of implementation processes. We use, as a case study to illustrate the procedure, the implementation of evidence-based smoking cessation practices for persons with serious mental illness (SMI) in community mental health clinics.

Results

For our case study, we present descriptions of the motivating research questions, specific models used to answer these questions, and a summary of the insights that can be obtained from the models. In the first example, we use a simple form of agent-based modeling to simulate the observed smoking behaviors of persons with SMI in a recently completed trial (IDEAL, Comprehensive Cardiovascular Risk Reduction Trial in Persons with SMI). In the second example, we illustrate how a more complex agent-based approach that includes interactions between patients, providers and site administrators can be used to provide guidance for an implementation intervention that includes training and organizational strategies. This example is based in part on an ongoing project focused on scaling up evidence-based tobacco smoking cessation practices in community mental health clinics in Maryland.

Conclusion

In this paper we explain how agent-based models can be used to address implementation science research questions and provide a procedure for setting up simulation models. Through our examples, we show how what-if scenarios can be examined in the implementation process, which are particularly useful in implementation frameworks with adaptive components.

Disparities in Service and Clinical Outcomes in State-Wide Advanced Practice Physiotherapist-Led Services

This study explored variations in the primary service and clinical outcomes of a state-wide advanced practice physiotherapist-led service embedded in public medical specialist orthopaedic and neurosurgical outpatient services across Queensland, Australia. An audit of the service database over a six-year period was taken from 18 service facilities. The primary service and clinical outcomes were described. Variations in these outcomes between facilities were explored with a regression analysis adjusting for known patient- and service-related characteristics. The findings showed substantial positive impacts of the advanced practice model across all facilities, with 69.4% of patients discharged without a need for medical specialist review (primary service outcome), consistent with 68.9% of patients reporting clinically important improvements in their condition (primary clinical outcome). However, 15 facilities significantly varied from the state average for the primary service outcome (despite only three facilities varying in the primary clinical outcome). While this disparity in the primary service outcomes appears to be influenced by potentially modifiable differences in the service-related processes between facilities, these process differences only explained part of the variation. This study described the subsequent development of a new, more comprehensive set of service evaluation metrics to better inform future service planning.

Implementation and Evaluation of a Standardized Nurse-Administered Assessment of Functional and Psychosocial Issues for Patients in Acute Care

BACKGROUND

Increasingly, adults presenting to healthcare facilities have multiple morbidities that impact medical management and require initial and ongoing assessment. The interRAI Acute Care (AC), one of a suite of instruments used for integrated care, is a nurse-administered standardized assessment of functional and psychosocial domains that contribute to complexity of patients admitted to acute care.

AIM

This study aimed to implement and evaluate the interRAI AC assessment system using a multi-strategy approach based on the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.

METHODS

This nurse-led quality improvement study was piloted in a 200-bed public hospital in Brisbane, Australia, over the period 2017 to 2018. The interRAI AC is a set of clinical observations of functional and psychosocial domains, supported by software to derive diagnostic and risk screeners, scales to measure and monitor severity, and alerts to assist in care planning. Empirical data, surveys, and qualitative feedback were used to measure process and impact outcomes using the RE-AIM evaluation framework (Reach, Efficacy, Adoption, Implementation, and Maintenance).

RESULTS

In comparison to usual practice, the interRAI assessment system and supporting software was able to improve the integrity and compliance of nurse assessments, identifying key risk domains to facilitate management of care. Pre-implementation documentation (630 items in 45 patient admissions) had 39% missing data compared with 1% missing data during the interRAI implementation phase (9,030 items in 645 patient admissions). Qualitative feedback from nurses in relation to staff engagement and behavioral intention to use the new technology was mixed.

LINKING EVIDENCE TO ACTION

Despite challenges to implementing a system-wide change, evaluation results demonstrated considerable efficiency gains in the nursing assessment system. For successful implementation of the interRAI AC, study findings suggest the need for interoperability with other information systems, access to training, and continued leadership support.

Analysis of the Installed Productive Capacity in a Medical Angiography Room through Discrete Event Simulation

The installed productive capacity of a healthcare center’s equipment limits the efficient use of its resources. This paper, therefore, analyzes the installed productive capacity of a hospital angiography room and how to optimize patient demand. For this purpose, a Discrete Event Simulation (DES) model based on historical variables from the current system was created using computer software. The authors analyzed 2044 procedures performed between 2014 and 2015 in a hospital in San José, Costa Rica. The model was statistically validated to determine that it does not significantly differ from the current system, considering the DMAIC stages for continuous process improvement. In the current scenario, resource utilization is 0.99, and the waiting list increases every month. The results showed that the current capacity of the service could be doubled, and that resource utilization could be reduced to 0.64 and waiting times by 94%. An increase in service efficiency could be achieved by shortening maximum waiting times from 6.75 days to 3.70 h. DES simulation, therefore, allows optimizing of the use of healthcare systems’ resources and hospital management.