Care Delivery System Research Articles

Measuring Nurses’ Impact on Health Care Quality

Quality measurement is central in efforts to improve health care delivery and financing. The Interdisciplinary Nursing Quality Research Initiative supported interdisciplinary research teams to address gaps in measuring the contributions of nursing to quality care. To summarize the research of 4 interdisciplinary teams funded by The Interdisciplinary Nursing Quality Research Initiative and reflect on challenges and future directions to improving quality measurement. Each team summarized their work including the targeted gap in measurement, the methods used, key results, and next steps. The authors discussed key challenges and recommended future directions. These exemplar projects addressed cross-cutting issues related to quality; developed measures of patient experience; tested new ways to model the important relationships between structure, process, and outcome; measured care across the continuum; focused on positive aspects of care; examined the relationship of nursing care with outcomes; and measured both nursing and interdisciplinary care. Challenges include: measuring care delivery from multiple perspectives; determining the dose of care delivered; and measuring the entire care process. Meaningful measures that are simple, feasible, affordable, and integrated into the care delivery system and electronic health record are needed. Advances in health information systems create opportunities to advance quality measurement in innovative ways. These findings and products add to the robust set of measures needed to measure nurses' contributions to the care of hospitalized patients. The implementation of these projects has been rich with lessons about the ongoing challenges related to quality measurement.

Implementation of a registry for quality improvement

Presentation Crohns’ Disease and ulcerative colitis, or Inflammatory Bowel Disease (IBD), are rare in the pediatric population. Thus, conducting research centered on improving the quality of pediatric IBD care can be challenging for individual pediatric gastroenterology centers. By pooling data and sharing results across 35 care centers nationally, the ImproveCareNow network provides the opportunity for conducting quality improvement (QI) research aimed at improving care and outcomes for pediatric patients with IBD and their families [1]. The network serves as a platform for innovation and the establishment of evidencebased practices for IBD care. ImproveCareNow includes a registry database for clinical care, QI and research; a program to teach QI to each site’s QI team; and tools for QI interventions. The presentation at the Academy for Healthcare Improvement Methods meeting demonstrated how a registry can be a vital part of QI and QI research. The ImproveCareNow network uses the Model for Improvement to provide more reliable, pro-active care to pediatric patients with IBD [2]. Continuous improvement activities include examining registry data through detailed reports and acting appropriately based on these data. The centers receive monthly performance reports on 15 key clinical measures, a data quality report, and two population management reports. Control charts, benchmarking data, and care stratification data allow clinicians to identify high-risk patients and drill down to the patient level of analysis. The network also provides QI education and support, including monthly webinars, twice-yearly in-person learning sessions, and tools for effective system redesign. Network staff includes the network, scientific, and project directors, project manager, project coordinators, and QI consultants. Each center has its own QI team (physician leader, nurse leader, and improvement coordinator) that enrolls patients, enters data collected for each visit into a web-based database, and carries out QI activities to improve the site’s care delivery system. The network has demonstrated significant improvements in IBD remission rates, with approximately 75% of patients in remission in 2011 compared to 50% of patients in remission in 2007. The network recently received funding from the Agency for Healthcare Research and Quality (AHRQ) to enhance its capacity. Funding will facilitate the roll-out of innovative informatics techniques to automate data transfer from the electronic health record directly to the registry, which will eliminate the need for manual data entry. Automation will also improve data collection for QI activities, population management procedures, pre-visit planning, patientreported outcomes, comparative effectiveness research, and research focused on effectiveness of new biological agents to treat IBD. These informatics enhancements may reduce the time and personnel costs for the new centers anticipated to join a planned, larger sustainable network across 170 centers nationwide with over 50,000 patients. ImproveCareNow also received additional funding to create a Chronic Care Collaborative Network or C3N. The overall aim is to bring together stakeholders with the shared goal of improving patient self-management, clinical practice, and disease outcomes through innovative use of information technology and social media. Studying the value of the network, or how well it achieves better outcomes at lower costs, and conducting comparative effectiveness research are major priorities as the network moves toward becoming a C3N.

Use of systems change and health information technology to integrate comprehensive tobacco cessation services in a statewide system for delivery of healthcare

Despite the availability of effective treatments and recommendations for systems change, full application of the USPublic Health Service clinical practice guideline for the treatment of tobacco use is seldom achieved. The present report describes a comprehensive, structured approach used to implement the guideline and to integrate evidence-based cessation services into a system for delivery of health care. The PRECEDE-PROCEDE model and systems strategies were employed to design and implement the Tobacco Control Initiative (TCI), which provides evidence-based cessation services for the patients of a statewide public hospital system. For the TCI, multi-level assessments, pilot programs, electronic data collection, and performance feedback were needed to produce system-wide changes in workflow and in the quality of care for tobacco users. Although there are advances in health information technology (HIT), systems approaches are required for responding effectively to the Health Information Technology for Economic and Clinical Health (HI-TECH) Act and to standards governing use of electronic data related to treatment of tobacco use and dependence.

The experiences of registered intellectual disability nurses caring for the older person with intellectual disability

To explore the experiences of registered intellectual disability nurses caring for the older person with intellectual disability. Increased longevity for the older person with intellectual disability is relatively a new phenomenon with social and medical factors having significantly increased the lifespan. The ageing population of people with intellectual disability is growing in Ireland, and they are outliving or expected to outlive their family carers. A qualitative Heideggerigan phenomenological approach allowed the researcher become immersed in the essence of meaning and analyse how registered intellectual disability nurses working with the older person perceive, experience and express their experience of caring. After ethical approval was granted, data were collected through semi-structured interviews from seven participants and were transcribed and analysed thematically using Burnard's framework for data analysis. Three key themes were identified: 'care delivery', 'inclusiveness' and 'client-focused care'. The study highlights the need for effective planning, an integrated approach to services and that the registered intellectual disability nurse needs to be integrated into the care delivery system within the health service to support client and family carers in the home environment. Overall, the study shows the importance of teamwork, proactive planning, inclusion, attitudes, individualised care, knowing the person and best practice in providing care for older people with intellectual disability. This paper reports on the findings of a study which explored the experiences of caring for the older person with intellectual disability. Teamwork, proactive planning, client-centred approach and supporting clients living at home are important as ageing is inevitable.

Commentary

The crisis of the rising cost of health care in the United States is stimulating major changes in the way care is being delivered. New models such as patient-centered medical homes and accountable care organizations are being developed with the expectation that health care professionals will address and improve the health of populations. Electronic health records and interprofessional teams will be critical to achieving the goal of better health. It is now time to bring together educators and clinicians at academic health centers, public health educators and practitioners, along with researchers, representatives from the health care delivery and financing systems, and community partners to reengineer health professions education to prepare health professions students for the health care system of the future.

HIV INFECTION AND HIV-ASSOCIATED TUBERCULOSIS IN CHILDREN IN UKRAINE

The article presents data on the epidemiology of HIV infection and co-infection with HIV/TB in children in Ukraine. Along with the increasing number of HIV-infected women of reproductive age and their children, it is mentioned the growth of tuberculosis among HIV-infected children. The problems of adequate monitoring and management of these patients, in particular with regard to the prevention of tuberculosis among them are described. There are made conclusions about the need to improve the delivery system of TB care for children born by HIV-infected mothers.

Putting professionalism and delivery of value‐added healthcare at the heart of physician training and continuing professional development

Putting professionalism and delivery of value‐added healthcare at the heart of physician training and continuing professional development

Reengineering acute episodic and chronic care delivery: the Geisinger Health System experience

Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques.

Continuous Quality Improvement and Health Educators

Quality improvement is increasingly at the forefront of health care, creating a growing demand in clinical settings for health professionals adept at understanding and optimizing systems of health care delivery. Compared with clinicians, administrators, and health services researchers, health educators have to date played less of a role in quality improvement. However, as this article argues, the potential for health educators to contribute to such efforts is great because health education and quality improvement are more similar in their goals and approaches than is commonly recognized. Health educators bring important skills to quality improvement practice in areas such as needs assessment, participatory planning, and evaluation. To illustrate the mutual benefits that arise when these two practices intersect, the implementation of an electronic patient scheduling system led by quality improvement professionals in a large home care agency is described.

APN Plan Improves Outcome for Pregnant Patient With Congenital Heart Disease

Advanced practice nurses work in many roles to support delivery of safe patient care. Eighty-five percent of children born with congenital heart disease (CHD) live to adulthood. The pregnant adult with CHD presents challenges for nursing across many care-delivery systems. Progression of care delivery across these systems requires innovative planning and organization. This article describes the plan developed by advanced practice nurses in a CHD clinic and in inpatient coronary care and obstetric units to support a pregnant patient with CHD. The plan focused on collaboration and communication among interdisciplinary teams. The goal was to address multidisciplinary communication, leadership, and staff education. The result was a successful high-risk delivery with organized education and patient care across systems.

APN Plan Improves Outcome for Pregnant Patient With Congenital Heart Disease

Advanced practice nurses work in many roles to support delivery of safe patient care. Eighty-five percent of children born with congenital heart disease (CHD) live to adulthood. The pregnant adult with CHD presents challenges for nursing across many care-delivery systems. Progression of care delivery across these systems requires innovative planning and organization. This article describes the plan developed by advanced practice nurses in a CHD clinic and in inpatient coronary care and obstetric units to support a pregnant patient with CHD. The plan focused on collaboration and communication among interdisciplinary teams. The goal was to address multidisciplinary communication, leadership, and staff education. The result was a successful high-risk delivery with organized education and patient care across systems.

PREVENTING FRAILTY IN OBESE OLDER ADULTS

PREVENTING FRAILTY IN OBESE OLDER ADULTS

Abstract P295: Performance Management and Improvement: One Way to “ImPact” Outcomes

Background: Continuous quality improvement (CQI) in health care systems necessitates an approach to review care delivery processes, systems, group and individual performances, incidents and outcomes. A robust process should 1) be multidisciplinary, 2) occur in “real-time”, 3) provide detailed review and discussion of care processes, performance and outcomes and 4) generate actionable rapid cycle improvement opportunities. Aim: To craft a sustainable management process for CQI for all clinical operational units of the Vanderbilt Heart and Vascular Institute (VHVI). Methods: We convened a standing multidisciplinary biweekly managerial forum (termed ImPact - “Improving Patient Care Together”) of quality medical directors, key clinical physicians and nurses, nursing unit managers, hospital administrators, and quality consultants. ImPact follows a standing structured agenda: 1) all mortalities since last meeting, 2) morbidity including “major misses” and major adverse events, 3) rapid response team calls, 4) out of ICU “codes”, 5) events reported by staff in our hospital's anonymous reporting system, 6) events brought forward by any clinician or unit manager, 7) interval progress on ongoing rapid cycle improvement projects. Results: The topics for rapid cycle improvement that have surfaced to date are listed in the Table . In addition to facilitating and prioritizing rapid cycle quality improvement and patient safety efforts, ImPact provides a link to our regular morbidity and mortality (M&M) conferences in cardiology and cardiac surgery. We have been able to identify common issues that extend beyond individual clinical care areas, allowing better understanding of vulnerabilities in systems of care Conclusions: A multidisciplinary, structured, regularly scheduled meeting of physician and nursing clinical and quality leaders, unit managers and administrators is a critical component of performance management and improvement. Quality Topics Identified Topics Contribution, n Percent Handoff and communication 9 27 Equipment 7 21 Medication administration 5 15 Education to staff (M&M) 4 12 Patient transport 3 9 Blood product administration 2 6 Risk management 2 6 Vascular service integration 1 3

Tenth Annual Herbert Lourie Memorial Symposium on Health Policy - The Evolving Practice of Medicine: A View from the Front Line

The health care system in the United States has been experiencing rapid change for decades. Beginning after World War II, the health care system grew and expanded. Change was driven by advances in technology, shifting demographics, and increases in the supply of physicians and hospitals, all fueled by supportive public policy and governmental funding. While change continues today, new dynamics drive the direction of change. These new dynamics generally share a common theme of cost containment. The purchasing power of buyers, both industry and government, has overshadowed the historical power of providers. Managed care financing mechanisms have changed provider behavior by introduction of utilization management mechanisms and shifted incentives through assumption of insurance risk by providers. The role of patients has also changed as the consumer has become more knowledgeable and empowered. There are large and growing numbers of uninsured Americans. There is growing discontent around the quality of care being provided by the health care system. All these factors, and more, drive today's changes in the organization, delivery, and financing of health care in the United States. However, the change we see in each community varies in terms of its pace and in how the parts of the health care delivery and financing system have organized and reorganized. There appears to be no clearly articulated public policy that is shaping the structure and function of the health care system of the future. This symposium explores the issues behind the variability of the change observed in the health care system from community to community, and particularly to place Syracuse, New York, in the context of these changes.

Care requirements of patients with advanced cancer within a specialist centre – moving to person-centered approaches

Despite the prolonged survival of many patients with advanced cancer and the increasing conceptualization of cancer as a chronic illness, care delivery systems within the Australian context continue to manage advanced cancer as an acute illness. Patients living with advanced cancer are managed alongside those with curable cancers in ambulatory models of care that centre on diagnosis, treatment decision-making or post treatment surveillance. Conversely, the needs of people with advanced disease are often complex, requiring high levels of collaboration between providers across acute, palliative and primary care settings in order to move forwards to a more person-centered approach to care. Aims: This paper addresses three specific aims: 1. to identify the care requirements and concerns of patients and their carers; 2. to examine the role of out-reach telephone calls as a component of care; 3. to identify the nurse’s role in care coordination for patients with advanced cancer. Method: Two nurse clinician researchers (CR) managed a cohort of patients with advanced breast (n=12) and gastrointestinal cancers (n=16) over six and nine months respectively. Data were recorded on every interaction between the CRs and the patients, carers and other health professionals. The CRs were interviewed by an independent nurse researcher. Results: The symptoms and issues causing concern to patients and/or carers included pain, weakness, gastrointestinal symptoms, managing appointments and dealing with anxiety. The CR played a major role in coordinating care to address these concerns and found out-reach telephone calls facilitated the process. Conclusions: Patients with advanced cancer have complex needs and care coordination requirements not routinely met in an acute care setting. Input from a nurse working at an advanced level and the use of out-reach telephone calls can assist in meeting these care needs.

Correlation between clinincal and autopsy diagnoses in 150 cases seen in university of Port Harcourt teaching hospital, Port Harcourt

Background : Autopsy is a veritable tool for auditing the accuracy of clinincal diagnosis. This study determined the accuracy of clinical diagnosis of diseases using autopsy result. The present report was informed by the unusual presentation of this case and the intent of increasing the index of diagnostic suspicion. A brief appraisal is provided of the clinical parameters, management strategies and challenges. Method : A twelve year consecutive clinico-autopsy study. (1st Jan 1995 – 31st Dec, 2006) at University of Port Harcourt Teaching Hospital (UPTH), was carried out. A total of 150 patients who were previously diagnosed of various diseases and treated for variable period of time, and later died were thoroughly autopsied on request to ascertain the cause of death. Of the 2848 autopsies performed during the study period, 150 were hospital autopsies representing 5.3% of the total autopsies. The 2698 (94.7%) medicolegal autopsies were excluded from the study. Result : The autopsies were performed on patient of both sexes of different ages. Ninety (60%) autopsies were males and 60 (40%) female, giving a male to female ratio of 1.5:1. Out of 150 clinincally diagnosed cases, autopsy accurately confirmed 127 (84.6%) (84.6% concordance rate) and varied in 23 (15.4% discordant rate). Conclusion : Autopsy pathology is beneficial to the clinician, the surviving relatives and constitutes a vital tool for medical education. It should be incorporated in the patient care and management delivery system in the country.

Health Care and Insurance Schemes and Health Outcomes: A Global Comparative Analysis

One of the largest and most urgent problems facing countries today - especially the United States - is health care. With an aging population and seemingly hard limits on resources such as doctors, organs, and medicine, each nation must attempt to distribute the available resources in a fair and efficient way without breaking the bank and, ideally, without selling out the health of its population. Nations’ attempts at creating workable health care systems result in regulatory and insurance schemes that vary widely across the globe, as countries form policies based on national values, institutions, and interests. Differing health outcomes among nations suggest that all health care delivery and insurance mechanisms are not equal. Some nations rely almost exclusively on the private sector for insurance and health care services, while others place health care and insurance squarely under government control, with wildly divergent results. This paper looks at the health systems in twenty-four countries, groups them according to common attributes in their health insurance and health care delivery regimes, and quantitatively compares the health outcomes achieved by those systems in order to answer the question: which health care delivery and insurance systems work best?

Implementing Health Reform at the State Level: Access and Care for Vulnerable Populations

The Affordable Care Act1 (ACA) promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs requires thoughtful regulatory coordination between public and private health systems.

Public's View of Mental Health Services for the Elderly: Responses to Dear Abby

Public's View of Mental Health Services for the Elderly: Responses to Dear Abby

Abstract B10: Nueva Vida: A support network for Latinas with cancer model and system of care delivery with an eye to community participatory research

Abstract Nueva Vida's (NV) goal is to help translate research into practice in the Latino community to shape evidence based practices and influence health policy while communicating the real needs of Latina breast cancer survivors to the scientific community. NV was founded in 1996 by Latina breast cancer survivors and health professionals to address the lack of culturally sensitive cancer support services for Latinas in the Washington, DC area. The mission of NV is to inform, support, and empower Latinas whose lives are affected by cancer, and to advocate for and facilitate the timely access to state of the art cancer care, including screening, diagnosis, and treatment for all Latinas. Since NV's inception, research participation, development, and implementation are integral to the system of care developed and provided in the community to Latina's with breast cancer. Specifically, NV's involvement in community participatory research enables the organization to influence the research agenda about breast cancer in the Latina community, particularly in the fields of psycho-oncology and access to care. NV's prioritization of research in its service delivery model provides an increased opportunity for the enrollment of Latinas in meaningful research on breast cancer with the goal of increasing not only access but awareness of the unique needs of this population. NV's pioneering programs and expertise serving uninsured/underserved Latinas with breast cancer places the agency in the role as a reliable source and key partner to work with the scientific community in the planning, designing, and development of relevant research. Nueva Vida's collaboration with respected research institutions has led to the publication of research portraying critical demographic, clinical, and psychosocial information about minority survivor's behavior. NV has acquired an important presence in the consumer cancer advocacy movement at the national level, bringing the voice of Latinas with cancer to influential tables where research and health policy are shaped. NV's research model not only sets a precedent for community research, but also establishes a better understanding of a historically misrepresented and misunderstood minority population in cancer research in the United States. NV's model of community participatory research documents best practice of service delivery which can be disseminated to other Latino communities and minorities across the United States. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B10.