Collaborative Improvement Efforts Research Articles

The implementation of Geography learning with spatial representation using the discrepancy evaluation model

This study aims to evaluate the learning process of geography with spatial representation in high school using the Discrepancy Evaluation Model (DEM) from Provus. Evaluation goes through five stages: design, installation, process, and product, as well as implementation comparison. Respondents were five teachers and 208 students from SMA 1 Srandakan, MAN 2 Yogyakarta, and SMA 1 Pundong in Yogyakarta. The evaluation was carried out in February-July 2021. The focus of the evaluation includes (1) learning design, (2) learning tools, (3) learning implementation, (4) learning outcomes, geographic critical thinking, and (5) implementing learning comparisons. Data were collected through document studies, observations, tests, and questionnaires. Descriptive analysis was used to measure gaps in each stage and efforts to improve them, while experimental quantitative analysis was used to compare learning. The DEM results describe gap variations in stages 1-4. However, in collaborative improvement efforts at stages 1-3, there is an increase in spatial critical thinking skills. The test results at stage 5, learning geography with spatial representations, are more effective for improving students' spatial critical thinking skills than textbook-oriented learning and media images. Recommendations on the results of the evaluation at all stages for organizing geography learning with spatial representation: (1) strengthening understanding and mentoring of the concept of spatial representation and learning design, (2) monitoring and periodic testing of geography learning with spatial representation to improve critical thinking skills in geography.

Perspectives of acute, post-acute, physician and community support providers on community collaborative efforts to improve transitions of care

BackgroundTransitional care (TC) involves multiple organizations as patients transition from hospitals. Collaboration to reduce readmissions has been encouraged by government initiatives. As part of Project ACHIEVE, a comparative TC study, we sought provider perspectives on TC improvement efforts. MethodsWe aimed to identify perceived problems that drove improvement efforts, influences on interventions implemented, facilitators or barriers to desired outcomes, and sustainability. Investigators interviewed 63 representatives from collaborative improvement efforts across 13 states in 2015. Directed content analysis was performed, with inductive coding as insights emerged. Data was also analyzed for differences in participant perceptions, such as the organization represented, geographic characteristics, and source of funding for interventions. ResultsParticipants in semi-structured interviews included physicians, nurses, care navigators, and administrators from hospitals, nursing facilities, community-based organizations, and medical practices. Participants reported that changing reimbursement practices and readmissions penalties drove TC efforts, and common problems they sought to address included insufficient inter-provider communication, medication management, and challenges related to chronic condition management. Solutions implemented were often adapted according to community and setting characteristics and population factors. Findings also suggest differences in the types of interventions implemented according to funding sources, which also impacted the ability to sustain these interventions. ConclusionsCross-site collaboration, communication, and partnership among stakeholders is essential to effective transitional care. Collaboration led to shared understanding among stakeholders of health care and support services available in the community. Coalition-based work also facilitated trust among partners which led to expansion and sustainment of TC efforts. Unmet social needs of patients are a barrier. ImplicationsOpportunities exist for increased and improved collaboration among clinical providers with community-based and social services organizations. Increased involvement of primary care providers in such collaborations would improve communication with both the patient and involved providers. Communities with external funding were more likely to implement evidence-based interventions, while those relying on institutional support addressed identified problems with more targeted interventions.

The Power of How

Nearly 20 years ago, the International Society for Performance Improvement (ISPI) developed the Certified Performance Technologist evidence-based credential. The ISPI Principles and Systematic Process clearly define what is done to improve the performance of people and organizations. The Institute for Performance Improvement and the Hale Center have researched how performance improvement practitioners facilitate collaborative improvement efforts that engage those who can impact and sustain the right results. Those who guide collaborative improvement, innovation, or implementation can now access comprehensive training and project-based, job-embedded certification through the Institute for Performance Improvement. The Certified Performance Improvement designation is jointly awarded by the Institute and ISPI.

Saving 20,000 Days and Beyond using breakthrough improvements: lessons from an adaption of the Breakthrough Series Collaborative.

ObjectivesTo report on selected findings from an evaluation of two consecutive quality improvement campaigns that adapted the Breakthrough Series Collaborative model to the broad topic of reducing demand for hospital care and reflect on lessons learned from their adaption of the model for subsequent collaborative improvement efforts.MethodsWe conducted a series of semi-structured interviews with Campaign sponsors and Collaborative team leaders as part of the broader realist evaluation of the two Campaigns. In addition, follow-up semi-structured interviews with Campaign sponsors and implementers were undertaken three years after the evaluation concluded (ex post evaluation interviews) to understand which adaptions to the Breakthrough Series Collaborative model had been the most influential.ResultsThe interviews explored two features that differentiated the Campaigns from other Breakthrough Series Collaboratives. Firstly, the Campaigns enabled a diverse range of improvement solutions to be tested which had implications for the collaborative nature of the learning collaboratives. Secondly, two sequential Campaigns were implemented that incorporated common elements and provided the opportunity for the transfer of knowledge from one Campaign to the next.ConclusionsGiven widespread pressure to transform health care into a learning system, this paper provides a practical example of using cumulative insights to encourage the sustainability of collaborative improvement efforts. These insights centre on the gains from spreading improvement methodology throughout the organization and learning how to select and support successful collaborative teams.

Citizen feedback in a fragile setting: social accountability interventions in the primary healthcare sector in Sierra Leone.

Fragile and conflict-affected states are frequently characterised by their inability to fulfil three core governance functions: provision of security, effective delivery of basic public goods and services, and managing political participation and accountability. This article explores the utility of social accountability interventions in fragile environments. Successful social accountability interventions can lead to joint examinations of public service standards by service-users and providers, resulting in collaborative improvement efforts. The few available studies of such interventions implemented in fragile or conflict-affected states show reasons for optimism as well as challenges. This article advocates the continued use of social accountability methods in fragile settings and provides examples of social accountability interventions in the health sector in Sierra Leone. The study suggests that social accountability can improve interaction between citizens and public service providers. Successful social accountability interventions can also lead to better quality and more accessible public services, which, in turn, can enhance state legitimacy.

Improving Glycemic Control Safely in Critical Care Patients: A Collaborative Systems Approach in Nine Hospitals

Safely improve glycemic control in the critical care units of nine hospitals. Critical care adult inpatients from nine hospitals with ≥4 point-of-care blood glucose (BG) readings over ≥2 days were targeted by collaborative improvement efforts to reduce hyper- and hypoglycemia. Balanced glucometric goals for each hospital were set targeting improvement from baseline or goals deemed desirable from Society of Hospital Medicine (SHM) benchmarking data. Collaborative interventions included standardized insulin infusion protocols, hypoglycemia prevention bundles, audit and feedback, education, and measure-vention (coupling measurement of patients "off protocol" with concurrent interventions to correct suboptimal care). All sites improved glycemic control. Six reached prespecified levels of improvement of the day-weighted mean BG. The day-weighted mean BG for the cohort decreased by 7.7 mg/dL (95% confidence interval [CI], 7.0 mg/dL to 8.4 mg/dL) to 151.3 mg/dL. Six of nine sites showed improvement in the percent intensive care unit (ICU) days with severe hyperglycemia (any BG >299 mg/dL). ICU severe hyperglycemic days declined from 8.6 to 7.2% for the cohort (relative risk, 0.84; 95% CI, 0.80 to 0.88). Patient days with any BG <70 mg/dL were reduced by 0.4% (95% CI, 0.06% to 0.6%), from 4.5 to 4.1%, for a small but statistically significant reduction in hypoglycemia. Seven of nine sites showed improvement. Multihospital improvements in ICU glycemic control, severe hyperglycemia, and hypoglycemia are feasible. Balanced goals for glycemic control and hypoglycemia in the ICU using SHM benchmarks and metrics enhanced successful improvement efforts with good staff acceptance and sustainability. BG = blood glucose CMI = case-mix index CY = calendar year DKA = diabetic ketoacidosis EMR = electronic medical record GBMF = Gordon and Betty Moore Foundation ICU = intensive care unit IIP = insulin infusion protocol SHM = Society of z Hospital Medicine.

Counting unplanned extubations: marked variation among neonatologists.

To assess if neonatologists detect and count unplanned extubations (UEs) uniformly. An Institutional Review Board-exempted anonymous web-based survey of neonatology attending and fellow members of the AAP Neonatal-Perinatal Medicine section was administered. Respondents were queried on practices concerning UE; they were then presented with different case scenarios and asked if they would count the event as a UE. Of the 509 respondents, 61% track UE rates. Of those who track UE rates, 53% reported rates of 1-3 per 100 ventilator days. The top two factors perceived as causing UEs were endotracheal tube (ETT) dislodgement by patient (65%) and failure of ETT holding system at attachment to the face (56%). In the various scenarios where ETT was urgently removed by staff, only 19 to 62% of respondents counted the event as a UE, including 23% if the ETT was removed by the attending. There was consensus on the scenarios representing self-extubation and elective change of the ETT. There is wide variation in methods for detecting and counting UE events among neonatologists, which precludes comparison of UE rates across institutions. We speculate that a standardized definition and classification of events will enable benchmarking among neonatal intensive care units, which should accelerate collaborative improvement efforts towards reducing UEs in neonates.

Nurse Led, Nurse Driven Service Lines: How Nurse Leaders Are Navigating Change

In 2012, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) published the ground-breaking report: Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health. 1 One of the recommendations from the IOM report was to expand opportunities for nurses to lead and diffuse collaborative improvement efforts; and to include and encourage nurses to lead, manage, and collaborate efforts with physicians and other members of the health care team.

Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic Medical Center

Incomplete medication reconciliation has been identified as a source of adverse drug events and a threat to patient safety. How best to measure and improve rates of medication reconciliation in ambulatory care remains unknown. An institutional collaborative improvement effort to develop and implement medication reconciliation processes was designed and facilitated across all 148 Brigham and Women's Hospital (Boston) ambulatory specialty practices: 63 underwent a more rigorous approach, a modified approach was undertaken in another 71 specialty practices, and a less intensive approach took place in the 14 primary care practices. The level of intervention varied on the basis of preexisting improvement infrastructure and practice prescription rates. Two electronically measured metrics were created to evaluate ambulatory visits to a provider in which there was a medication change: (1) Measure 1: the percentage of active medications prescribed by that provider that were reconciled; and (2) Measure 2: how often all the medications prescribed by that provider were reconciled. After the collaborative was completed, performance data were routinely shared with frontline staff and hospital leadership, and medication reconciliation rates became part of an institutional financial incentive program. For Measure 1, specialty practices improved from 71% to 90% (September 2012-August 2014; 24-month period). Primary care practice performance improved from 62% to 91% (December 2012-August 2014; 20-month period). For Measure 2, overall performance across all ambulatory practices increased from 81% to 90% during the first 12 months of the financial incentive program (October 2013- September 2014). A collaborative model of process improvement paired with financial incentives can successfully increase rates of ambulatory medication reconciliation.

Connected Care Quotient (CCQ) and the Future of Nursing.

It is nearly five years since the Institute of Medicine released its seminal report, Future of Nursing: Leading Change, Advancing Health. report made several far-reaching recommendations for nursing as follows:* Remove scope-of-practice barriers.* Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.* Implement nurse residency programs.* Increase the proportion of nurses with baccalaureate degrees to 80 percent by 2020.* Double the number of nurses with doctorates by 2020.* Ensure that nurses engage in lifelong learning.* Prepare and enable nurses to lead change to advance health.* Build an infrastructure for the collection and analysis of interprofessional health care workforce data.To evaluate progress, resolve issues outlined in the report, and assess the impact of the AARP and Robert Wood Johnson Foundation's (RWJF) Future of Nursing: Campaign for Action, the Committee for the Evaluation of the Impact of the Institute of Medicine Report held a series of meetings this spring and summer. According to the project description (www8.nationalacademies.org/cp/projectview.aspx- ?key=49704), The workshops...invite[d] stakeholders representing nursing, medicine, health systems, consumer groups, business and policy makers at the state and national levels to provide testimony...on the following broad topics: practice, education, and leadership; with diversity, interprofessional collaboration, and needed data as cross-cutting issues. (See the Figure for the names of committee members.)Dr. Marsha Howell Adams, president of the NLN, participated in the first workshop on May 28. This workshop had two sessions. first focused on assessing data and information about the progress of the Campaign for Action. second involved three stakeholder groups (Education and Training, Delivery of Care - Policy and Regulatory, and Delivery of Care - Health Care Organizations and Providers). goal was to gain insight into the efforts, successes, and barriers to implementing the recommendations. (Recordings and slides for these presentations are available online at http://iom.nationalacademies.org/ Activities/Workforce/FutureofNursingImpact/2015-MAY-28.aspx.)The second workshop, held July 27-28, included a variety of sessions: Day 1, Toward a More Highly Educated Nursing Workforce, Models of Academic Progression, Nursing Education and Workforce Data, Toward Establishing Nurse Residency Programs, and Recruiting and Retaining a Diverse Nursing Workforce; Day 2, Impact of Health Care System Changes on the Culture of Care Delivery and Roundtable on Culture Change in the Health Professions and Health Care Delivery. (The agenda, recordings, and slides are online at http://iom.nationalacademies. org/Activities/Workforce/FutureofNursingImpact/2015- JUL-27.aspx.)I had the privilege of speaking on the second day in a panel discussion on the culture of care delivery moderated by Richard A. Berman, a professor at the Institute for Advanced Discovery & Innovation, University of South Florida, our taskmaster in terms of timing. (See the Figure for all panel participants.) When I received the letter with the invitation to participate, I had heart palpitations: OMG, they want me to speak!Our 75-minute session began with a brief introduction by Berman, followed by individual remarks by each of the panelists (six minutes, slides optional), and then 40 minutes of Q&A with the IOM committee. Berman asked us to focus on the changes we have seen in the health care delivery system and in the skills or roles of nurses in health care delivery. committee sent specific questions on a number of topics - how technology has affected the nursing profession in terms of patient care and team-based care, leadership in team-based care, the impact of value-based payment on primary care and the health system, and cultural and organizational conflicts that need monitoring and management - and we could anticipate questions on topics including interprofessional practice and leadership in the health arena. …

Pediatric Collaborative Improvement Networks: Background and Overview

Multiple gaps exist in health care quality and outcomes for children, who receive <50% of recommended care. The American Board of Pediatrics has worked to develop an improvement network model for pediatric subspecialties as the optimal means to improve child health outcomes and to allow subspecialists to meet the performance in practice component of Maintenance of Certification requirements. By using successful subspecialty initiatives as exemplars, and features of the Institute for Healthcare Improvement's Breakthrough Series model, currently 9 of 14 pediatric subspecialties have implemented collaborative network improvement efforts. Key components include a common aim to improve care; national multicenter prospective collaborative improvement efforts; reducing unnecessary variation by identifying, adopting, and testing best practices; use of shared, valid, high-quality real-time data; infrastructure support to apply improvement science; and public sharing of outcomes. As a key distinguisher from time-limited collaboratives, ongoing pediatric collaborative improvement networks begin with a plan to persist until aims are achieved and improvement is sustained. Additional evidence from within and external to health care has accrued to support the model since its proposal in 2002, including the Institute of Medicine's vision for a Learning Healthcare System. Required network infrastructure systems and capabilities have been delineated and can be used to accelerate the spread of the model. Pediatric collaborative improvement networks can serve to close the quality gap, engage patients and caregivers in shared learning, and act as laboratories for accelerated translation of research into practice and new knowledge discovery, resulting in improved care and outcomes for children.

Expanding Horizons: RTNP Calls for Newer Forms of Scholarly Work

As implied by the journal's title, Research and Theory for Nursing Practice (RTNP), our mission is to publish articles with direct relevance to nursing practice. Traditionally, this has included both classical research and theory articles within the domain of nursing. However, in recent years, several movements affecting health care and science are also impacting publication in health care broadly and in nursing specifically. These movements include the growing emphasis on quality, safety, and evidencebased practice as well as the emerging sciences of improvement and translation. Of particular application to nursing also is the rapid expansion of Doctor of Nursing Practice (DNP) programs that aim to produce advanced practice nurses with the knowledge and skills both to lead and participate in these movements. In fact, in the recent report, The Future of Nursing: Leading Change, Advancing Health, the Institute of Medicine in its second recommendation specifically calls for a broad range of constituencies to expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, health care organizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices. (IOM, 2008, p. 2) Consequently, in its role as a venue for the diffusion of information that can inform and enable nurses to make and disseminate practice improvements, editors and reviewers at RTNP are clarifying, reframing, and expanding the nature of articles we solicit and select for publication. Herein, I invite submissions for several types of articles that are of great importance to advancing the mission of RTNP. LITERATURE REVIEWS Systematic reviews that seek to examine evidence pertaining to interventions are of great interest. Reviews should specify goals or questions guiding the review; parameters such as setting, population, or other factors focusing the review; and methods used to surface and include or exclude evidence in the review. Both quantitative (i.e., metaanalyses) and qualitative approaches to summarizing evidence are appropriate. A synthesis of information across studies should reveal new information of value to those seeking to use, apply, or further test the focal intervention(s). EVIDENCE-BASED PROTOCOLS Intervention protocols derived from systematic reviews of the literature are also of high importance. …

A framework for collaborative improvement: lessons from the Institute for Healthcare Improvement's Breakthrough Series.

The article describes the Breakthrough Series, a collaborative improvement model developed by the Institute for Healthcare Improvement. The model adapts and applies existing knowledge to multiple, similar sites to accomplish common aims. It has been used to address several of the most pressing issues in health care today. The article outlines key elements of the Breakthrough Series to provide a framework for future collaborative improvement efforts.

Collaborating across organizational boundaries to improve the quality of care

The paradigm of modern quality management is in wide use in health care. Although much of the initial effort in health care has focused on improving service, administrative, and support processes, many organizations are also using these concepts to improve clinical care. The analysis of data on clinical outcomes has undoubtedly led to many local improvements, but such analysis is inevitably limited by three issues: small samples, lack of detailed knowledge of what others are doing, and paradigm paralysis. These issues can be partially overcome when multiple health care organizations work together on focused clinical quality improvement efforts. Through the use of multiorganizational collaborative groups, literature reviews, expert panels, best-practice conferences, multiorganizational databases, and benchmarking groups, organizations can effectively pool data and learn from the many natural experiments constantly underway in the health care community. This article outlines the key concepts behind such collaborative improvement efforts and describes pioneering work in the application of these techniques in health care. A better understanding and wider use of collaborative improvement efforts may lead to dramatic breakthroughs in clinical outcomes in the coming years.