A qualitative study of how clinicians reach agreement in perioperative pathway development: the Consensus Model for Standardising Healthcare.

Healthcare is a complex, multi-layered team environment where effective change often requires reaching consensus among relatively autonomous stakeholders. Although conducting informal consensus discussions is a frequently used implementation strategy in real-world clinical settings, limited information exists about what defines consensus when using these methods. Specifying the criteria for consensus is important, as it can shape the design of consensus-building strategies. This study aimed to identify and define the key domains of consensus used in local consensus discussions to standardise healthcare practices. A qualitative study was conducted in one private hospital in Australia using a modified, grounded theory methodology. Clinical, non-clinical and leadership staff involved in developing standardised perioperative pathways using informal consensus discussions were recruited. Data were collected via semi-structured interviews and naturalistic participant observations between February 2023 and May 2024. Data collection and analysis occurred concurrently until theoretical saturation was achieved. Data were analysed using open coding with constant comparison, focussed and theoretical coding to develop theoretical concepts. Sixteen hours of observations with 31 participants and nine semi-structured interviews were conducted. Analysis identified four distinct consensus criteria: i) unanimous consensus, ii) delegated consensus, iii) assumed consensus and iv) concessional consensus. While unanimity was the preferred outcome, other consensus types emerged as viable alternatives when unanimous agreement was challenging to achieve. Each criterion had differing factors and mechanisms which influenced reaching the consensus criterion, underpinning assumptions, and considerations for practice, which formed four domains of consensus. These domains provide a structured framework for classifying consensus criteria when conducting local consensus discussions in healthcare. The findings broaden our understanding of consensus in local healthcare discussions, moving beyond a singular focus on unanimity. By clearly defining consensus types, organisations can strategically select consensus methods that best support decision-making and intervention implementation.

ABSTRACTAimsTo identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries.DesignSystematic review.Data SourcesFive databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023.MethodsTwo reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions.ResultsThe initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full‐text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions.ConclusionsLocal consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented.Implications for the Profession and/or Patient CareAdvancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals.ImpactThese findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives.Reporting MethodThis review adheres to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines.No patient or public contribution.Trial Registration: CRD42023413817

Globally, the need for medical student training to be undertaken in the private sector is likely to increase. In Australia, it has increased by 250 per cent in the last decade. Effective clinical education is highly dependent on the attitudes and willingness to participate of both patients and medical staff. We aimed to examine these attitudes in both private and public hospitals. Patients and medical staff at a private and a public hospital in Sydney were surveyed during December 2016 and January 2017 to investigate attitudes to medical student training. Attitudes were compared between hospitals. We also compared recent attitudes in the private hospital with those obtained in 2012. Patients at the public hospital were significantly more likely to want a student present at a consultation than those at a private hospital. Public hospital doctors had more positive attitudes towards medical students than their private colleagues. The negative financial impact of teaching was more significant for those in private practice. Since 2012, attitudes of private hospital patients towards medical students became significantly more positive whereas doctors' attitudes became less positive. The expansion of clinical education into the private sector is likely to increase globally DISCUSSION: The willingness of patients to participate in medical student training in both public and private hospitals is encouraging for future expansion into the private sector. The reduced willingness amongst private hospital medical staff over time and, in comparison to public hospital staff, suggests a need to address barriers for staff in the private sector.

There is a critical need for an updated, more comprehensive, and integrated conceptual model to help health care providers, patients, and consumers, as well as researchers using this theoretical model, to better understand health information, communication, and information seeking of patients and consumers. My colleagues and I have developed such a model, based on an ongoing research agenda and empirical data provided by pilot studies in the area of breast cancer. However, this expanded model is now developed in such a manner that based on deliberations with experts in other clinical disciplines such as arthritis and diabetes, it is likely it can at least be tested with patients diagnosed and consumers at risk for these diseases. A situation recently unfolded in my neighbourhood which vividly illustrates the need for this conceptual model. It also illustrates how the model is useful beyond the area of breast cancer information. A 51-year-old, college-educated, married, mother of seven children sat down to read a popular women's magazine for a few minutes while she waited for her physician husband to come home from work. As she scanned the magazine she came across an article about the warning signs of ovarian cancer. As she read the article, she became engrossed in its details because she recognized the signs and symptoms discussed and realized she had experienced each of them. Her pulse raced as she began to realize that what she had attributed to perhaps the aging process and a hectic lifestyle could in reality be ovarian cancer. When her husband came home they discussed the issue, and the next day she made an appointment with her personal physician. A number of tests were ordered, a large abdominal mass was found, and surgery was ordered. This woman has terminal ovarian cancer. In a span of 10 days, her life and that of her family has changed dramatically based on her reading of a journal that prompted her to seek medical care. This is not a unique experience; such scenarios likely occur with hundreds, if not thousands, of individuals around the globe. However, as a researcher who examines health information use, especially as it relates to health care decision-making, I noted many implications from this experience that can inform health communication research. First, health information is not always intentionally sought, yet it may be used and have profound consequences. This requires consideration of the existence, role, and importance of 'passive' receipt of information vs. 'active' information seeking. My neighbour casually came across important information in a magazine written for the general public. The recent professional emphasis on 'Health Information Seeking Behaviour' must take into account that some individuals, who have no intent of seeking health information, come across such information as they go about their activities of daily living. Second, the information received came from traditional print media, not the 'new media,' such as the world wide web, that are so frequently cited as playing a major role in health information. This underscores the need for a comprehensive view of health information sources that recognizes not only 'high tech' or 'new media' sources, but also those that are traditional and easily accessible. Third, in this case an educated, economically upper class woman received her health information through a medium aimed at women of all educational and socio-economic classes. Given the current emphasis in the health care professions on targeting 'at risk' populations, it is important to recognize that while personal variables such as socio-economic status play a role in information use, contextual issues, such as relaxing with a popular magazine vs. accessing a medical journal or website, are also important influences. In 2001, together with colleagues Patrick and Kruse, I published an article titled 'The natural history of the use of healthcare information by women with breast cancer: a conceptual model.'1 The objective of the paper was to fill a significant knowledge gap, as a review of the literature at that time revealed a paucity of empirical studies using a strong conceptual framework or model that could provide the vital theoretical underpinnings for studies of health information use and communication, especially in understanding patient decision-making, and provide a context in which to analyse and interpret empirical data. More is known today, because of the efforts of many groups including the journal Health Expectations2,3 and in the United States, the National Cancer Institute's 'Health Information Service,'4–6 but far more work is needed. Noting the lack of a strong conceptual model using a broad spectrum of health, we developed the model first described in that 2001 paper. The first conceptual model1 illustrated the theoretical underpinnings of our approach and provides a context in which to analyse and interpret the results. In fact the National Cancer Institute's 'Health Information Service'5 cites this model as one of three viable models of health information seeking behaviour together with those of Johnson.17 Our model depicted the interrelationships among the various personal and situational factors that comprise the patient's information environment and different phases of her use of various types of information to make decisions about her own health care. We were heavily influenced by components of the Health Belief Model (HBM),7,8 the awareness-to-adherence model of physician adoption of clinical guideline information,9 and the patient practice variation theory I published in 1993.10 In an effort to test our model first published in 1991, we collected data from a total of 121 women who had previously been diagnosed with breast cancer and consented to participate in our survey. The pilot study was approved by the University of Missouri Health Sciences Institutional Review Board. The survey was conducted with patients in the Kansas City area, Columbia and mid-Missouri, and the Newark, New Jersey, area. Following the conceptual model initially developed, there was a logical progression of answers one would expect. For example, if a woman said she was not aware of health information related to breast cancer, one would not expect her to later say that health information influenced her decisions about her personal health care. An initial data analysis indicated that the expected logical pattern was not always followed. In fact only 73 of the women surveyed followed the expected pattern, with 48 not following the pattern. In an effort to better understand this potential validity problem, we took a two-step approach. First, we conducted a focus group meeting with the staff involved in patient interviews and those who worked on model development to review and discuss the detailed notes taken during the time of the interviews. We then re-contacted a sample of these women for whom our nurse interviewer had sufficiently detailed notes regarding the women's medical situation and use of health information. What we found was that the initial model had a number of flaws. Perhaps the most notable was the explicit lack of recognition of the role that the 'passive receipt' of information played in the process. For example, like the woman in the vignette above, a number of women did not intentionally seek health information. This finding is consistent with the work of Carlsson11, who reports that 'patients actively sought information to a limited degree, but the majority of patients take an interest when cancer issues are presented in newspapers and magazines, or on radio and television. A more passive information seeking strategy was common in her study of Swedish cancer patients, especially among those with lower educational levels.11 Many women in our study also came across information while they read the newspaper, read magazines, listened to radio shows, watched television, or simply spoke with others about their cancer diagnosis and treatment. So these women initially answered that they were not aware of such information, but ultimately health information became available and was in many cases very useful. In other cases, subjects may have thought only about media as sources as health information, but did not view direct communication with their physician or nurse as a source of information. Finally, there were inconsistencies introduced by the lack of a specific time frame to recall the cancer experience; this was especially true for long-term survivors. These further investigations clarified the need for more explicit wording in the survey instrument and the related conceptual model, as well as further development of the model to take into account both active and passive receipt of health information. This is now detailed in the expanded conceptual model depicted on page 4. As a further test, we conducted yet another survey using the model's revised instrument with 14 patients; consistently the logical patterns one would expect were found in all cases. Finally, consistent with the approaches taken by Cowin12 and Ouitmet et al.,13 we convened a focus group of experts in health communications, health services research, biostatistics, and nursing who in reviewing the data along with the supporting documentation determined that the revised model has both face and internal validity. Our experience shows the necessity of further work in the development, dissemination, and testing of conceptual models that assist in the understanding of this important development in the history and evolution of the role of patients in their own care. Additionally, we also need to better understand the nature, type, source, and use of health information by healthy consumers, including those with a known risk for various diseases, given our advances in knowledge of genetics and the role of family history in disease. Thus, I propose that we include but differentiate 'patients' and 'consumers' in any such models (Fig. 1). Expanded conceptual model of health information seeking behaviors and the use of information for health care decisions. Johnson14 cites Summers et al.,15 who in reporting about the critical nature of cancer-related information seeking, describe information seeking as 'the result of a complex set of interactions among multiple variables each with different capabilities to predict information use'15 and propose the need for good theory that promotes deeper understanding of the issues involved.14 Bower and Bilbody16 write that 'models are abstract representations of complex areas' and cite the original work of Siegler and Osmond,17 who describe models as 'inventions of the human mind to place facts, events and theories in an orderly manner. As such, they help place empirical data, research evidence, and systematic reviews in a broad perspective and 'can assist in the interpretation of evidence in a policy context … which may provide a more solid bridge between evidence and the policy context.'16 However, they also add that conceptual models must be continually evaluated; consequently, the proposed revised model is presented in this paper. A number of cautions are in order to fully understand this model. The model is indeed derived from the experience and reports of patients themselves. As such, it is consistent with a 'patient-centred' view of care, and may be useful in placing research findings in a broad patient perspective. However, when applied in an individual patient clinical setting, caution must be taken consistent with Barnett et al.,18 who write that a 'patient-centred approach must involve tailoring information to individual patient requirement' as 'it is difficult to predict how much information patients feel they need.' While it is widely recognized that appropriate information can increase knowledge, reduce anxiety and distress, reduce decisional conflict, and increase adherence to various regimens,15,16,19,20 many patients do not want any health information other than that provided by their personal physician. Friis et al.21 report this is more likely in the elderly, but it may also occur with other types of patients. For example, most studies focus on outpatients and little is known about the information needs of severely ill cancer patients treated in hospital.21 Therefore, the revised model takes these situations into account as some patients/consumers may decide not to access information. While the traditional medical perspective may not recognize such a view, a 'patient-centred' model must recognize patient needs and wants even when they are contrary to what the professional may view as necessary or helpful. Despite that fact that 'being informed and seeking information are discussed as society's expectations of today's cancer patient,'21 it may be in the best interests of a given patient to not seek information, 'as a strategy to maintain hope.' This also was identified in our study by at least one participant. The next step is more vigorous testing of the proposed model in various populations and cultures. This will provide not only important data for the model's enhancement, but also help us to better understand the current status of the use of health information by both patients and consumers, and clarify some of the confusion found in the current literature. For example, some articles point to the tremendous growth in health information and especially internet-based information,22 while others report that at least in the United States, as of 2001, only one-half of adults 'place a high priority on seeking health information.'23 Finally, Tu and Hargraves24 report that 'contrary to [the] popular belief that Americans avidly seek health information – especially on the internet – a majority of Americans in 2001 sought no information about health concerns, according to a Center for Health System Change study.' Interestingly, this study found that, like the woman in the above vignette, 'instead of surfing the internet, the 38% of Americans who did obtain health information relied more often on traditional sources such as books or magazines.' However, they report that level of education was shown to explain a large difference in health seeking information. While popular opinion and the reality of health information use are not yet consistent, it is anticipated that over time this situation will change as information increases, health awareness is heightened, literacy improves, education levels rise, and the consumer movement continues to evolve and mature. More rigorous studies using a model such as the one proposed here are needed as we attempt, as health professionals, to better understand patient and consumer desires for health information, how they will change over time, and how we must modify and develop new and more appropriate types of information that patients will use and find helpful as they face an illness, or simply wish to remain proactive in maintaining health.

Is There a Starling Curve for Intensive Care?

Peer Reviewed

BackgroundManagement of chronic incurable diseases such as chronic obstructive pulmonary disease (COPD) and asthma is difficult. Incorporation of patient preferences is widely encouraged.PurposeTo summarize original research articles determining patient preference in moderate-to-severe disease.MethodsAcceptable articles consisted of original research determining preferences for any aspect of care in patients with COPD/asthma. The target population included those with severe disease; however, articles were accepted if they separated outcomes by severity or if the majority had at least moderate-to-severe disease. We also accepted simulation research based on scenarios describing situations involving moderate-to-severe disease that elicited preferences. Two reviewers searched Medline and Embase for articles published from the date of inception of the databases until the end of November 2014, with differences resolved through consensus discussion. Data were tabulated and analyzed descriptively.ResultsAbout 478 articles identified, 448 were rejected and 30 analyzed. There were 25 on COPD and five on asthma. Themes identified as most important in COPD were symptom relief (dyspnea/breathlessness), a positive patient–physician relationship, quality-of-life impairments, and information availability. Patients strongly preferred sponsors’ inhalers. At end-of-life, 69% preferred receiving CPR, 70% wanted noninvasive, and 58% invasive mechanical intervention. While patients with asthma preferred treatments that increased symptom-free days, they were willing to trade days without symptoms for a reduction in adverse events and greater convenience. Asthma patients were willing to pay for waking up once and not needing their inhaler over waking up once overnight and needing their inhaler.ConclusionFew studies have examined patient preference in these diseases. More research is needed to fill in knowledge gaps.

to achieve the degree of saturation in study that applied the grounded theory. qualitative research, carried out in four Family Health Units, between June 2018 and May 2019. The data from the interviews with 30 health professionals and non-participant observation were coded in the stages: open, axial and integration. the degree of saturation was achieved by two conceptual models - theoretical saturation and inductive thematic. Theoretical saturation was considered: the development of conceptual codes and observation, in the collection and analysis of data, when they generated new categories/subcategories or only indicated increasing instances. For thematic inductive saturation, the use of new codes based on each interview stood out. the visual layout for the number of codes, the theoretical scope of the concepts and the delimitation of the sample groups guided the identification of the degree of saturation for the development of the conceptual body that supported the substantive theory.

Evidence, theory and variability in osteopathic practice

BACKGROUND:Employer branding (EB) is a collection of ideas and beliefs that influence the perspectives of current and prospective employees regarding an organization and their employment experiences, serving as a strategic tool in the competition to attract talent. Positive EB can help retain current employees and attract new talents, making it an important issue in human resource management. This study aimed to identify and prioritize the factors affecting the EB of private hospitals in Tehran.MATERIALS AND METHODS:The study is applied in purpose and descriptive and analytical in terms of data analysis. Eleven hospitals were selected from 55 private hospitals in Tehran using non-probability and theoretical sampling methods. An expert from each hospital was purposively selected and interviewed. The experts held doctoral degrees in medical specialties and hospital administration experience. In-depth, unstructured interviews with experts constituted the primary method of data collection. Theoretical saturation was reached following the interview with the 11th expert. The entire research process lasted one year, from 2021 to 2022. The method of pairwise comparison matrix with triangular fuzzy numbers was utilized to rank factors contributing to hospital EB.RESULTS:By using a fuzzy method of identification and prioritization, it was found that the most significant factors influencing the EB of private hospitals in Tehran were the level of industry competitiveness, an empowering work environment based on a coaching approach, cooperation with strong suppliers of drugs and hospital and surgery consumables, a generation-based focus on value, and a competitive advantage in EB.CONCLUSIONS:This study provides valuable insights into the factors that contribute to EB in private hospitals in Tehran, which can be used to inform health policy making. The identified factors, such as industry competitiveness, an empowering work environment, and cooperation with strong suppliers, can help private hospitals attract and retain talented employees, ultimately improving the quality of healthcare services provided in the region.

Shared decision making for high-risk surgery

BackgroundActive participation of patients in managing their medical treatment is a major component of the patient empowerment process and may contribute to better clinical outcomes. Patient perceptions and preferences affect the patient–physician encounter in a variety of dimensions, such as patient autonomy, freedom of choice and trust in the healthcare system. The Israeli healthcare system is mostly publicly funded, with additional private healthcare services for surgery and other medical treatments. The aim of this study was to compare the perceptions and preferences of patients in the public and private hospitals in Israel.MethodsA cross‐sectional study among 545 individuals who had surgical procedures at two hospitals in Israel (one public and one private). A structured questionnaire comprising 23 items was used to collect perceptions via personal telephone interviews. The responses were categorized into five clusters and compared by type of health services provider (public vs. private) and sociodemographic characteristics (gender, age and education level).ResultsA hierarchical cluster analysis methodology identified five conceptual groups: trust, concern towards medical errors, dialogue between medical staff and the patient/patient's family, confidentiality and staff bias towards more informed patients, or those with supportive families. Four main themes that highlight patients' preferences were found: physical conditions, personal empowerment and perceived autonomy, patient experience and patient–provider encounter communication. Significant differences between the private and the public healthcare systems were found in four clusters: trust and patient care, patient's concerns, the extent of explanation and medical staff's commitment. Differences secondary to sociodemographic parameters were noticed: patients treated at the private hospital scored significantly higher items of trust, medical staff caring and the importance of choosing their treating surgeon, while patients treated at the public hospital scored higher staff commitment to the patient than those treated at the private hospital.ConclusionsThe study revealed the perceptions underlying the decisions of patients to undergo surgical procedures in public or private hospitals. Mutual learning could pave the way to better patient–physician encounters.Patient or Public ContributionPatients from the two hospitals were involved in this study by responding to the questionnaire. The data presented is based on the patient's responses.

Public health nutrition workforce development is a capacity building strategy identified as a priority in the Australian National Public Health Nutrition Strategy (Eat Well Australia). Systematic and scholarly approaches to workforce development that enhance the capacity of the health system and the broader community to effectively address public health nutrition issues, are limited in Australia. The associated lack of intelligence and a range of methodological difficulties similar to those encountered in broader public health workforce research, provide the need for, and motivation for, this study. The specific objectives of this study relate to the development of workforce development intelligence that: Fills gaps in the knowledge base to inform effective workforce development ; Provides baseline data (benchmarks) for ongoing workforce development planning, evaluation, monitoring and surveillance ; and, Contributes to international scholarship regarding public health nutrition workforce development ; and, Enables the development of a strategic framework for workforce development planning in the national context. The case study research strategy used in this study involved an emergent, multi-method design involving methodological triangulation of data and consensus development. The focus of inquiry was based on a problem-based conceptual framework developed to identify intelligence needs for workforce development strategy planning. Quantitative and qualitative data were collected using five different methods including literature review, interviews with advanced-level public health nutritionists in Australia, a national public health nutrition workforce survey, an analysis of position descriptions and consensus assessment and development via a Delphi survey of an international expert panel. The collection, analysis and interpretation of data in this study focused on developing an intelligence base on six main issues pertinent to public health nutrition workforce development, including: Definitions of public health nutrition; Workforce size and composition; Workforce practices; Core workforce functions needed; Competencies required for effective public health nutrition practice; and, Continuing competency development needs. Data from these multiple methods were used to describe and interpret the determinants of workforce capacity, assisted by triangular analysis. This analysis identified a range of determinants limiting the capacity of the Australian public health nutrition workforce including; A small designated specialist public health nutrition workforce; Workforce instability associated with unsecured funding and staff turnover; Limited collaboration and partnership building practices by the existing workforce; Disorganisation of the workforce in terms of location, accountability, service mandates and support; Workforce practices are not consistent with the required work; Limited access to, and use of, public health nutrition intelligence; A workforce practice culture that does not promote research and dissemination; A lack of practice improvement and learning systems; Limited access to public health nutrition mentors; Limited incentives for practice excellence; An absence of consensus about the required work and competencies required for effective public health nutrition practice; Barriers to continuing competency development; and, Inadequate workforce preparation. This interpretive analysis provided the basis for developing a strategic framework that addresses workforce quantity, quality and performance concerns, based on workforce development strategy categories including: Building human resource infrastructure (quantity); Organisational systems and policy (performance); Intelligence support (performance); Learning systems (quality) and; Workforce preparation. This research has also provided data that can for the basis of tools such as definitions, core function statements, position descriptions and competency standards to assist public health nutrition workforce development in Australia and internationally.

Rates of cesarean birth (CBs) are steadily increasing and account for 36.7% of all births in New South Wales (NSW), with primary cesareans driving the increase. NSW Health guidelines recommend women attempt a vaginal birth after a previous CB (VBAC); however, rates of VBAC are decreasing, particularly within the private hospital setting. This study aimed to determine the rates of adverse outcomes for women who planned a VBAC (pVBAC) compared with women who planned an elective repeat CB (pERCB) at one private hospital in Sydney, Australia. This retrospective data review evaluated patient records over a 10-year period (2010-2019). Records (n = 2039) were divided into four groups: pVBAC, pVBAC + EMCB, labor + ERCB (lab + ERCB), and pERCB. The incidence of adverse maternal and neonatal outcomes is reported as counts and percentages. Regression and chi-squared tests were used to compare groups. Significance was determined at a p-value of <0.05. Overall, very low rates (N = 148, 7.3%) of women had a VBAC compared with a repeat CB at this private hospital over the 10-year period. The incidence of adverse outcomes was low regardless of study group. Outcomes differed significantly between groups for postpartum hemorrhage (pERCB seven times less likely than VBAC group) and special care nursery admission (pVBAC + EMCB is 4.6 times more likely than in the VBAC group). Overall, it is safe to attempt a VBAC at this private hospital, and labor after a cesarean should be recommended, yet very few women had a VBAC at the study site. The incidence of adverse outcomes was low compared with other published research.

Prevention of venous thromboembolism in hospitalized patients: Analysis of reduced cost and improved clinical outcomes