High-quality Delivery Research Articles

Practical guide to the diagnosis and management of heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is an immune reaction to heparin associated with thrombocytopenia, thrombotic risk, and a high risk of morbidity and mortality. Given the frequent use of heparin and the common occurrence of thrombocytopenia in hospitalized patients, the diagnosis and management of HIT is a recurrent challenge in everyday inpatient care. This article presents practical guidance and tools to support the individual clinician providing evidence-based care to patients with suspected or confirmed HIT. The optimal diagnostic evaluation requires the stepwise use of risk-stratification tools and laboratory assays. Management requires the selection and use of nonheparin anticoagulation in these complex patients with both increased thrombotic risk and possible concurrent increased bleeding risk due to thrombocytopenia. Each step in the diagnostic and management process has important nuances and complexities, many of which vary based on patient characteristics and institutional resources. Given the many challenges of HIT care, truly practical management is best achieved when tools are implemented to support the delivery of consistent, high quality, and cost-effective care across health systems.

Residential medication management reviews: a call for improved collaboration and systems integration in aged care

Purpose Residential Medication Management Reviews (RMMR) are a key component of safe, high-quality aged care service delivery. The RMMR is an interdisciplinary approach to medication management that relies on collaboration, communication and integration of systems. Acting as an improvement opportunity, the purpose of this paper is to present findings from a regional study, aimed at assessing the impact of RMMR on falls and hospital admissions and identifies barriers to impactful research in this area. Design/methodology/approach A three-year retrospective quantitative longitudinal practice audit was conducted in a regional state-managed high-care residential facility in Queensland, Australia. Data was collected pre-RMMR and six months post-RMMR. Findings The data collected was insufficient to achieve statistical significance or demonstrate the impact of RMMR on health outcomes. Factors impeding the research included limited ability to collect the data due to the lack of integration of information systems and limited stakeholder engagement resulting in poor recruitment. This highlights the need for improvement in RMMR processes and practices, and indeed wider research collaboration in the aged care sector. Research limitations/implications Thís paper acts as a call to action to improve research and interprofessional collaboration in Australian aged care. Originality/value The aged care industry needs high-quality research to drive practice improvement and collaborative care and service delivery. This paper advocates for improvements in the aged care sector with respect to research engagement and communication pathways between service providers. Advancement in systems integration for information sharing, recruitment of participants and stakeholder engagement will support evidence-based practice and process change.

Trauma-Informed Care in Undergraduate Nursing Education: An Integrative Review.

Trauma-informed care (TIC) requires health care providers and organizations to provide care in a way that assumes everyone has a trauma history (Hopper et al.). Although there has been a recent rise to investigate TIC within various nursing specialties, knowledge related to integrating TIC into nursing curricula remains unclear. An integrative review following Whittemore and Knafl procedures synthesized the literature related to TIC in undergraduate nursing education. Five themes surfaced: (1) isolated tic integration in undergraduate courses; (2) TIC for safe learning environments; (3) inconsistent TIC definitions in nursing education; (4) prerequisite nurse educator training; and (5) students recognizing an implementation gap and seeking solutions. This review highlights TIC integration challenges in nursing education, emphasizing the need for ongoing research, training, and collaboration. These efforts are vital to equip future nursing professionals with the skills to provide high-quality trauma-informed care, benefiting students, patients, and health care delivery. [J Nurs Educ. 2024;63(11):737-745.].

Research on machining technology of stepped boring for intersecting holes in aircraft

Abstract During the assembly process of a large-scale aircraft fuselage, critical bearing areas require the drilling of intersecting holes, which are commonly processed using traditional single-edged reamers by most domestic manufacturers. To improve the efficiency and accuracy of the finishing process for these holes, enhance the quality of the assembly, and further shorten the construction cycle for precision processing, improvements need to be made to traditional single-edge reamer machining methods. This paper proposes a new approach that uses stepped reamers to machine intersecting holes. By setting up an experimental platform to simulate actual processing conditions and optimize processing parameters, the study analyzes and compares the quality and efficiency of traditional reaming and stepped reaming modes. The results show that stepped reaming can improve processing efficiency by 50.6% compared to traditional machining while also reducing human intervention and minimizing quality risks. The findings from this research project can be extended to various aircraft fuselages or wings for precise drilling of intersecting holes, providing significant guidance for efficient and high-quality delivery of aircraft.

What matters for sustainable psychosocial interventions and who decides? Critical ethnography of a lay counselling program in Nepal

Lay counselling, or the delivery of talk-based therapeutic support by people without a clinical degree, is gaining popularity as a way of addressing global shortages of mental health professionals. In Nepal, lay counselors have made significant contributions to mental health and psychosocial care over the last two decades, particularly in the aftermath of major emergencies. However, research on the longer-term integration and sustainability of lay counselling interventions remains limited. This ethnographic study explored the meaning and importance of sustainability to different stakeholders in a lay counselling program implemented following Nepal's 2015 earthquake. We conducted participant observation in the everyday lives of five counsellors as well as four focus group discussions and 51 semi-structured interviews with counsellors and other key stakeholders. Our analysis revealed significant discrepancies in perceptions of sustainability; while organizations involved in implementing the program described it as a sustainability success due to continued government financing, counsellors emphasized their own and the government's failure to sustain high-quality service delivery in practice. Program-level barriers included inadequate budget and remuneration, lack of clinical supervision, and poor integration within existing systems. We also identified wider sociopolitical influences on sustainability, including the social positioning of counsellors, low understanding and acceptability of counselling, and a rapidly changing political landscape. These findings reveal the need for a critical approach to sustainability in global mental health, warning against superficial engagement that prioritizes continuity of government financing over quality of care and workers' rights. Advocating for an ecological orientation within sustainability research, we also discuss the importance of looking beyond program design factors to consider how local and national sociopolitical dynamics influence frontline service provision.

Investigating the implementation of a novel approach to alcohol screening and brief intervention in Mexico: a mixed-methods study using pseudo-patients.

Low- and middle-income countries bear disproportionate burdens from excessive alcohol consumption, yet have fewer resources to identify and intervene with risky drinkers. Low-cost screening and brief intervention (SBI) models offer a tool for addressing this health problem and reducing disparities. In this mixed-methods study, trained pseudo-patients visited health clinics in Zacatecas, Mexico, where a novel SBI model was used with trained nonmedical health educators (HEs) conducting SBI in waiting areas. Pseudo-patients, who provided responses to the AUDIT-C screening items designed to trigger a brief intervention (BI), waited for HEs to engage them in an SBI encounter. Data on HEs' behaviors, SBI components provided, and contextual characteristics were coded from audio recordings of the encounters using an SBI checklist and from pseudo-patient interviews. Quantitative analyses examined the consistency in pseudo-patients' targeted AUDIT-C scores and those documented by HEs as well as the frequency of delivery of SBI components. Across 71 interactions, kappas between HEs' scores and the targeted AUDIT-C scores ranged from 0.33 to 0.45 across AUDIT-C items; it was 0.16 for the total AUDIT-C. In 41% of interactions, the HEs recorded total AUDIT-C scores that accurately reflected the targeted scores, 45% were below, and 14% exceeded them. Analyses of checklist items and transcripts showed that HEs demonstrated desired interpersonal skills (attentive, empathetic, professional) and provided general information regarding risks and recommendations about reducing consumption. In contrast, personalized BI components (exploring pseudo-patients' personal challenges and concerns about reducing drinking; making a plan) occurred much less frequently. Pseudo-patient interviews revealed contextual factors (noise, lack of privacy) that may have negatively affected SBI interactions. Using trained nonmedical persons to administer SBI holds promise to increase its reach. However, ongoing training and monitoring, prioritizing comprehensive BIs, eliminating contextual barriers, and electronic delivery of screening may help ensure high quality delivery.

Outsourcing Non-Core Services in Healthcare: A Cost-Benefit Analysis

Outsourcing non-core services in healthcare, such as housekeeping, IT support, catering, and security, has emerged as a popular strategy for healthcare organizations looking to reduce costs and focus on patient care. This paper presents a comprehensive cost-benefit analysis of outsourcing these services, considering both financial and operational implications. Through a combination of quantitative analysis and qualitative insights from healthcare administrators, the study explores how outsourcing affects cost savings, operational efficiency, and overall service quality. The findings indicate that outsourcing non-core services can lead to significant cost reductions—ranging from 7% to 28% depending on the service—while also enhancing operational efficiency. In particular, services such as housekeeping and IT support benefit from outsourcing due to the specialized expertise of third-party providers. Outsourced services not only reduce internal operational burdens but also contribute to a more streamlined allocation of resources toward core healthcare functions, including patient care. However, the analysis also highlights several risks, such as loss of control over service quality and concerns related to data security, particularly when IT services are outsourced. These challenges can potentially affect the reliability of healthcare operations if not properly managed. The study suggests that healthcare organizations must implement strict service-level agreements (SLAs) and performance monitoring mechanisms to mitigate these risks and ensure continuity of high-quality service delivery.

Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis: One Decade Later.

In 2012, the National Academies of Sciences, Engineering, and Medicine convened a committee charged with addressing the quality of cancer care in the United States and providing recommendations to policymakers and the cancer care community on strategies to improve cancer care delivery from the time of diagnosis through end-of-life. The resulting committee report, titled Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis (2013), presented a conceptual framework that included six interconnected components of care with corresponding recommendations. Over the past decade, the delivery of high-quality of cancer care has become more challenging and increasingly demanding on the workforce. In this manuscript, we review the goals and recommendations made in 2013, describe progress to date, and offer insights into future dedicated efforts and/or new strategies needed to achieve high-quality cancer care.

Breaking Barriers and Navigating the Future of Emergency Care: The Role of the Emergency Nurse Practitioner.

Over the past two decades, the emergency nurse practitioner (ENP) role has significantly enhanced emergency care in the United States. With the increasing complexity of emergency care, ENPs have expanded into nontraditional settings, necessitating regulatory updates to maintain patient safety. The Consensus Model for Advanced Practice Registered Nurse Regulation has influenced ENP practice, yet consistent regulatory recognition is still needed due to the marked evolution in ENP practice. Despite collaborative efforts to prepare the ENP workforce and ensure competency through standardized education, certification, and licensure, recent unethical publications and skewed statistics have threatened the specialty's progress. Addressing these challenges is crucial for advancing the ENP role and ensuring high-quality emergency care delivery.

Adverse Event Management Tool for Hospitals: A Game-Changer for Patient Safety

As medical technology continues to advance, concerns about associated risks to both patients and healthcare providers arise. Ensuring high-quality healthcare delivery stands as a paramount objective for every healthcare institution. Among the essential attributes required to meet this goal is the safety of all stakeholders. Nevertheless, numerous instances arise wherein unintended incidents occur involving healthcare personnel during the delivery of patient care. This study utilized a mixed-methods approach incorporating interviews, observations, and statistical analysis to investigate the occurrence of adverse events related to medical equipment in hospitals. The findings reveal that, despite 84% of surveyed nursing personnel indicating no experience with adverse events caused by medical equipment, factors such as inadequate preventive maintenance, lack of training, budget constraints, and staff shortages support the need for the development of patient safety support tools, as all the aforementioned factors increase the likelihood of unintentional errors during patient care. Based on these findings, a tailored reporting tool was developed to streamline the documentation of equipment failures and adverse events within hospitals. Designed based on identified needs and characteristics, this tool aims to facilitate timely notification of critical events, especially those with the potential to impact patient safety.

Care seeking during pregnancy: testing the assumptions behind service delivery redesign for maternal and newborn health in rural Kenya.

A health systems reform known as Service Delivery Redesign (SDR) for maternal and newborn health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega County, we examine several key assumptions that underpin the SDR policy's theory of change. We analyse data on place of delivery, travel time and distance, out-of-pocket spending, and self-reported quality of care for 19 127 women prospectively enrolled during antenatal care (ANC) and surveyed two times after their delivery. We analyze changes in womens' delivery location preferences in recent years in Kakamega, and over the course of their most recent pregnancy. We also evaluate travel time, out-of-pocket expenditures and patient satisfaction for women who deliver in public hospitals vs primary health centres. We find substantial changes in delivery location at the population level over time and for individual women over the course of pregnancy. Facility delivery has increased from 50.4% in 2010 to 89.5% in 2019; 70% of respondents deliver at a different facility than their reported intention at ANC. Out-of-pocket delivery expenditures are on average 1351 Kenyan shillings (Ksh) in hospitals compared to 964 Ksh in PHC (primary health care)s (P < 0.01). Transport expenditures are 337 Ksh for PHC level deliveries vs 422 Ksh for hospitals (P < 0.01). Self-reported average travel time is 51 min (PHC delivery) vs 47 min (hospital delivery) (P = 0.78). The average distance to a delivery location is 15.1 km for PHC deliveries vs 15.2 km for hospitals (P = 0.99). There were no differences in overall patient-reported quality scores, while some subcomponents of quality favoured hospitals. These findings support several key assumptions of the SDR theory of change in Kakamega County, while also highlighting important challenges that should be addressed to increase the likelihood of successful implementation.

Quality of care for community-dwelling older adults living with dementia in BC: an interrupted time-series analysis to examine the effect of the COVID-19 pandemic

ObjectiveQuality care for older adults living with dementia (OALwD) is a priority in Canada, nationally, and British Columbia (BC), provincially. The COVID-19 pandemic likely changed care quality, but this has not been assessed. We are examining the effect of pandemic-related policy changes on quality of care for community-dwelling OALwD in BC. ApproachThis population-based retrospective cohort study uses linked administrative data to examine trends in population-level indicators of quality care from 2016-2023. We will compare effects among community-dwelling BC residents aged 65+ with dementia and those without dementia. Indicators including hospitalization rate and medication use were selected, based on the Institute of Medicine’s six dimensions of quality (e.g., effectiveness, safety). Interrupted time series (ITS) analysis will examine changes between “pre-pandemic” and “in-pandemic” periods. Equity will be assessed through stratification by sociodemographic variables. Anticipated ResultsPercent change in the level and slope of each indicator’s trend will be reported. Single ITS will identify the effect of the pandemic on each outcome in the dementia group only. Controlled ITS will identify whether changes differ from those observed in older adults without dementia. Together, observed changes in the indicators and differences across equity factors will inform an interpretation of the overall effect of the pandemic on quality of care for community-dwelling OALwD in BC. ImplicationsWe will determine whether quality of care changed for older adults because of the pandemic and whether changes differed for OALwD. This knowledge will inform practice and policy for delivery of high quality, proactive dementia care.

The Data Linkage Hub: a Community of Practice

Objective and ApproachThis paper discusses the Data Linkage Hub (DLH) which is a centre for data linkage excellence and aims to produce and support the delivery of high quality, linked data assets for researchers in the UK. Here, we will give an overview of the DLH’s activity as a Community of Practice for Data Linkage. ResultsWe will discuss the different project types conducted in the DLH; the methods used ranging from bespoke linkage development to the adoption of generalised methodologies; and the customers of the DLH. We will also discuss the tools the DLH have developed, and make available to others, to standardise, streamline and improve quality assessment of linkage. This will include clerical matching tools known as CROW and the CMS, BAT, a bias analysis tool, and a package of PySpark code specifically developed for data linkage. In addition, we will explore the data linkage training materials we offer for different audiences and our involvement in a Data Linkage Champions Network, both increasing the awareness of data linkage and promoting best practise. Conclusion and ImplicationsThe impact of the DLH’s work is far reaching, underpinning statistical outputs, research and public policy. This success is down to the creation of a community of practice bringing together experts to regularly update and discuss linkage.

Analysis of Medical Record Evaluation Based on KARS Standards at RS TK II Moh. Ridwan Meuraksa Jakarta

This study focuses on evaluating the medical records at RS TK II Moh. Ridwan Meuraksa, Jakarta, in line with the standards set by the Komite Akreditasi Rumah Sakit (KARS). The evaluation aims to measure the quality of the hospital's medical record system, a critical aspect of hospital operations that impacts patient care and administrative efficiency. The research employs both qualitative and quantitative methods to assess the medical records against KARS standards. Key findings indicate that while the hospital meets basic compliance requirements, there are significant areas for improvement, particularly in the completeness and accuracy of records. Recommendations include the implementation of enhanced training programs for staff, regular audits, and the adoption of advanced electronic medical record systems. The study highlights the importance of adhering to established standards to ensure high-quality healthcare delivery and suggests that continuous improvement in medical record management is essential for achieving accreditation and improving overall patient outcomes.

Text-first virtual care: The key to virtual care sustainability

Virtual care is, and will continue to be, a ubiquitous front door to care as it evolves as a modality to better match the demands and lifestyles of consumers. As with any technology, success comes from learning, iterating, and evolving, and this is certainly true of virtual care as it comes of age. It’s been a complex journey as the modality gained acceptance, moving through the early adopter stage into its adolescent growth spurt propelled by COVID. Virtual care’s growth has been a mix of progress and pitfalls, manifested in policy changes, market shifts, sustainability issues, and the trials of big-name players. However, these challenges have also presented new opportunities for learning, partnering, and a runway for refined models to take hold. The legacy issues surrounding virtual care are now being resolved with the data-rich approach of on-demand, text-first virtual care. Fueled by artificial intelligence (AI) and poised to drive needed change, text-first virtual care is quality-oriented, data-based, and people-first, improving patient engagement and empowering clinicians. Helen Schnase, MD, MBA, shares her experience with on-demand, text-first virtual care and gives insight on how virtual care can continue to thrive and be the ubiquitous front door to care we all want it to be. She lays out why it must be an experience that people want to use and support the tenets of: high-quality comprehensive care delivery; improved access to care; increased engagement and affordability; as well as scalability and the ability to accommodate future innovation.

Ensuring excellence: A deep dive into the quality monitoring of Ayushman Bharat health and wellness Centre

This review evaluates the quality monitoring mechanisms of Ayushman Bharat Health and Wellness Centres, integral to India's pursuit of Universal Health Coverage. AB-HWCs are designed to deliver comprehensive primary healthcare, particularly targeting undeserved communities. Despite the significant expansion and progress in healthcare access, the review identifies persistent service quality and infrastructure disparities. The study underscores the necessity of a robust quality monitoring framework, incorporating standardized checklists to ensure consistent and high-quality service delivery. These checklists play a crucial role in systematically assessing the availability of medical supplies, infrastructure adequacy and others, facilitating timely interventions and modification. Additionally, the integration of cultural competence into healthcare delivery is emphasized to enhance the acceptance and effectiveness of services among diverse populations. The review also highlights the critical roles of Community Health Officers and mid-level healthcare providers in the successful operation of HWCs. While acknowledging the commendable progress made by the AB-HWCs initiative, the study concludes that achieving sustainable and equitable health outcomes necessitates ongoing quality monitoring, strategic resource allocation, and adaptive policy measures. The consistent application of checklists in quality assurance processes is essential for maintaining high care standards and advancement of India towards its UHC objectives.

The Unintended Consequences of Telehealth in Australia: Critical Interpretive Synthesis.

Despite more than 2 decades of telehealth use in Australia and the rapid uptake during the COVID-19 pandemic, little is known about its unintended consequences beyond its planned and intended outcomes. The aim of this review was to synthesize evidence on the unintended consequences of telehealth use in Australia to clarify its impact beyond its planned and intended outcomes. We conducted a search of 4 electronic databases: Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and Scopus. A critical interpretive synthesis approach was adopted for its flexibility and interpretive nature. We extracted data about study characteristics and the types and models of telehealth services. The extracted unintended consequences were coded and mapped into the domains and dimensions of the Australian Health Performance Framework. Of the 4241 records identified by the search, 94 (2.22%) studies were eligible for data extraction and analysis. Of these 94 studies, 23 (24%) reported largely positive unintended consequences of telehealth associated with health status, while 6 (6%) noted a potential negative impact of telehealth on socioeconomic status. The findings of 4 (4%) of the 94 studies highlighted societal and financial consequences of telehealth beyond the health system. Almost all studies (93/94, 99%) reported unintended consequences under the 5 dimensions of the Australian Health Performance Framework. Our synthesis offers a framework for understanding the unintended consequences of the use of telehealth as an alternative to in-person care in Australia. While we have documented many unintended benefits of telehealth use, our findings also shed light on many challenges of delivering care via telehealth across different domains and dimensions. These findings hold significant practice and policy-making implications for ensuring safe and high-quality care delivery via telehealth.

Validation of the Bangla version of the Communication Skills Attitude Scale with the medical students of Bangladesh.

Effective communication skill of physicians is an important component of high-quality healthcare delivery and safe patient care. Communication is embedded in the social and cultural contexts where it takes place. An understanding of medical students' attitudes and learning communication skills would help to design and deliver culturally appropriate medical education. The Communication Skills Attitude Scale (CSAS) is a widely used and validated tool to measure the attitude of medical students toward learning communication skills in different populations, settings, and countries. However, there is no culturally adapted and validated scale in Bangla in the Bangladesh context. This study aims to culturally adapt the CSAS into Bangla, and validate it in a cohort of medical students in Bangladesh. This study used a cross-sectional survey design to collect data from purposively selected 566 undergraduate medical students from the Rajshahi division. The survey was conducted from January to December 2023. Descriptive statistics like frequency distribution and measures of central tendency were used to measure perception regarding communication skills. The sample adequacy was measured through the Kaiser-Meyer-Olkin test. The internal consistency of the items was identified using Cronbach's alpha (α) coefficients. The results of the study show that the Bangla version of the scale is feasible, valid, and internally consistent in the context of a developing country, Bangladesh. The overall internal consistency of the Bangla version is good since the value of Cronbach's alpha (α) is 0.882. For PAS, the internal consistency is 0.933. While, for NAS, the value is 0.719. The item-wise average scores in the PAS indicate that female medical students are more willing to learn communication skills compared with male students (α = 0.933). While, the scores in the NAS indicate that the male students tend to have more negative attitude toward learning communication skills compared with female students (α = 0.719). The CSAS-Bangla is a valid and reliable tool for assessing communication skill attitudes among Bangla speaking medical students. This scale can be used in future studies to measure the attitude of students, designing and evaluating communication skills training programs in medical colleges.

Top Ten Tips Palliative Care Clinicians Should Know About Interpreting a Clinical Trial.

Evidence-based practice is foundational to high-quality palliative care delivery. However, the clinical trials that compose the evidence base are often methodologically imperfect. Applying their conclusions without critical application to the clinical practice context can harm patients. The tips provided can help clinicians infer judiciously from clinical trial results and avoid credulously accepting findings without critique. We suggest that statistical and mathematical expertise is unnecessary, but rather a keen curiosity about investigators' rationale for certain design choices and how these choices can affect results is key. For a more comprehensive understanding of clinical trials, this article can be used with the authors' corresponding ten tips article that focuses on designing a clinical trial.

Patient Safety Culture in the Context of Critical Care: An Observational Study.

A robust safety culture is essential for ensuring high-quality healthcare delivery. From a nursing perspective, especially among critical patients, it fosters ongoing improvement by highlighting areas that need attention. This study aimed to evaluate the perception of patient safety culture among nurses within the critical care environment. An observational study was conducted at a central hospital in Portugal employing the Hospital Survey on Patient Safety Culture (HSPSC) questionnaire. The study encompassed 57, nurses predominantly female (73.7%), aged 25-64. Most participants were general nurses (77.2%), with a significant proportion (61.4%) working in the emergency department and possessing an average tenure of 13 years at the facility. The perception of critical patient safety culture (CPSC) was predominantly positive (40.6%), varying by department, with intensive care nurses reporting the highest positivity rates. Teamwork was identified as a strong point, receiving 80.7% positivity, highlighting it as a well-established domain in the CPSC, whereas other domains were recognised as requiring enhancements. The study pinpointed both strengths and weaknesses within the CPSC, offering a foundation for developing targeted strategies to bolster patient safety culture in critical care settings.