Donabedian's Approach Research Articles

An Infrastructure to Provide Safer, Higher-Quality, and More Equitable Telehealth.

The rapid expansion and prompt widescale adoption of telehealth during the COVID-19 pandemic resulted in telehealth practice variations across health care settings and has implications for patient safety, health equity, and quality of care. Telehealth is part of the public health infrastructure, and health care stakeholders have an opportunity to strategically plan for telehealth expansion and sustainability in organizations as the pandemic wanes. A framework to guide organizational telehealth integration is needed that can support safe, accessible, and high-quality telehealth to patients regardless of social and/or economic status. The purpose of this article is to propose an innovative telehealth model, supported by systems theory, to address the complexity of telehealth implementation in health care organizations. A Donabedian approach is used to address quality. The telehealth model is an organizational infrastructure that outlines how policy and authority requirements, organization factors, provider competencies, and patient determinants of health influence safer, more equitable, higher-quality telehealth. The framework can guide leaders in building, redesigning, and measuring the impact of telehealth programs as health care shifts into a revolutionary technology era to meet the needs of diverse organizations and populations.

Infection prevention and control practices of non-medical individuals in a neonatal intensive care unit: A Donabedian approach

ObjectiveTo describe the infection prevention and control practices of non-medical individuals in a neonatal intensive care unit, using the Donabedian model. DesignWe used an observational descriptive qualitative approach, collecting data over 38 h of non-participant, unstructured observations. An interprofessional observational team recorded their observations. SettingObservations were collected in the neonatal intensive care unit of a regional hospital in Gauteng, South Africa. ParticipantsWe observed non-medical individuals involved in the day-to-day operations related to infection prevention and control in a neonatal intensive care unit, specifically the cleaners and laundry staff, maintenance and technical services, and significant others. Individuals were selectively observed due to their proximity and convenient presence in the neonatal intensive care unit at the time of observation. Measurements and findingsData were deductively analysed and categorised into Donabedian's pre-existing structure- process- outcome framework. Themes that evolved were the absence of policies and procedures, inadequate written information, unsuitable physical layout of the neonatal intensive care unit, non-adherence to hand hygiene, lack of personal protective equipment, poor cleaning practices, poor service delivery and unavailability of documented evidence on cleaning routines, delivery of supplies and infection prevention and control training. Key conclusionsIn the neonatal intensive care unit, non-medical individuals did not adhere to infection prevention and control measures. The absence of standard operating procedures may contribute to cross contamination and an increase in hospital acquired infections. Implications for practiceInfection prevention should be regarded as an interprofessional team effort and requires situational awareness. The infection prevention control practitioner and unit manager should collaborate with support services and significant others to ensure that these individuals have appropriate knowledge about and adhere to infection prevention control practices in a neonatal intensive care unit. The infection prevention control committee should be expanded to include support staff managers. Orientation programmes should be implemented to raise the awareness of non-medical individuals about the important role they play in infection prevention and control.

A quality-improvement approach to effective trauma team activation

Appropriate, timely trauma team activation (TTA) can directly affect outcomes for patients with trauma. A review of quality-performance indicators at our Canadian level 1 trauma centre showed a high level of undertriage, with TTA compliance rates less than 60% for major trauma. A quality-improvement project was undertaken, targeting a sustained goal of at least 90% TTA compliance based on Accreditation Canada guidelines. Quality-improvement action followed a well-defined process. Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis. This was followed by rapid change cycles that focused on structure and processes with ongoing audits to support and sustain change. Trauma team activation compliance improved from 58.8% to more than 90% over 2 years. Quality indicators showed a statistically significant reduction in the time to computed tomography scanner, time in the acute care region of the emergency department and total time in the emergency department, with improved TTA compliance. Compliance with TTA protocols improved to more than 90% over a 2-year period, which shows the benefit of having a clearly outlined qualityimprovement process. This well-defined quality-improvement method provides a framework for use by other institutions that seek to improve their processes of trauma care, including activation rates.

Expanding the primary care patient-centered medical home through new roles for registered nurses

Abstract New models of health care delivery such as the patient-centered medical home have emerged to address the Triple Aim of improving the health and the care of patients with the benefit of reducing the cost of quality primary care. The Donabedian approach of addressing structure and process to produce quality outcomes is used to introduce an innovative model of the patient-centered medical home that includes nurses as part of the interdisciplinary team of care providers. New nursing roles and processes are described that optimally utilize electronic health record technology to improve care coordination and care delivery. Economic outcomes have been realized in the form of incentives to a primary care practice and reimbursement for quality, cost-effective care. Recognition of outstanding quality care in this new model demonstrates how an effective care system is evolving to meet the changing health care needs of the population.

What makes a good clinical app? Introducing the RCP Health Informatics Unit checklist

Doctors increasingly rely on medical apps running on smart phones or tablet computers to support their work. However, these apps vary hugely in the quality of their data input screens, internal data processing, the methods used to handle sensitive patient data and how they communicate their output to the user. Inspired by Donabedian's approach to assessing quality and the principles of good user interface design, the Royal College of Physicians' Health Informatics Unit has developed and piloted an 18-item checklist to help clinicians assess the structure, functions and impact of medical apps. Use of this checklist should help clinicians to feel more confident about using medical apps themselves, about recommending them to their staff or prescribing them for patients.

Patient perception of nursing service quality; an applied model of Donabedian’s structure‐process‐outcome approach theory

Nursing is a labour-intensive field, and an extensive amount of latent information exists to aid in evaluating the quality of nursing service, with patients' experiences, the primary focus of such evaluations. To effect further improvement in nursing as well as medical care, Donabedian's structure-process-outcome approach has been applied. To classify and confirm patients' specific experiences with regard to nursing service based on Donabedian's structure-process-outcomes model for improving the quality of nursing care. Items were compiled from existing scales and assigned to structure, process or outcomes in Donabedian's model through discussion among expert nurses and pilot data collection. With regard to comfort, surroundings were classified as structure (e.g. accessibility to nurses, disturbance); with regard to patient-practitioner interaction, patient participation was classified as a process (e.g. expertise and skill, patient decision-making); and with regard to changes in patients, satisfaction was classified as an outcome (e.g. information support, overall satisfaction). Patient inquiry was carried out using the finalized questionnaire at general wards in Japanese hospitals in 2005-2006. Reliability and validity were tested using psychometric methods. Data from 1,810 patients (mean age: 59.7 years; mean length of stay: 23.7 days) were analysed. Internal consistency reliability was supported (α = 0.69-0.96), with factor analysis items of structure aggregated to one factor and overall satisfaction under outcome aggregated to one. The remaining items of outcome and process were distributed together in two factors. Inter-scale correlation (r = 0.442-0.807) supported the construct validity of each structure-process-outcome approach. All structure items were represented as negative-worded examples, as they dealt with basic conditions under Japanese universal health care system, and were regarded as representative related to concepts of dissatisfaction and no dissatisfaction. Patients' experiences with nursing service were confirmed using Donabedian's approach and can therefore be applied to improve quality of nursing practice by practitioners, managers and policy makers.

Commentary

<h3>Background:</h3> Appropriate, timely trauma team activation (TTA) can directly affect outcomes for patients with trauma. A review of quality-performance indicators at our Canadian level 1 trauma centre showed a high level of undertriage, with TTA compliance rates less than 60% for major trauma. A quality-improvement project was undertaken, targeting a sustained goal of at least 90% TTA compliance based on Accreditation Canada guidelines. <h3>Methods:</h3> Quality-improvement action followed a well-defined process. Baseline data collection was performed, and, in keeping with the Donabedian approach, we brought together stakeholders to collectively review and understand the reasons behind poor TTA compliance; and root-cause analysis. This was followed by rapid change cycles that focused on structure and processes with ongoing audits to support and sustain change. <h3>Results:</h3> Trauma team activation compliance improved from 58.8% to more than 90% over 2 years. Quality indicators showed a statistically significant reduction in the time to computed tomography scanner, time in the acute care region of the emergency department and total time in the emergency department, with improved TTA compliance. <h3>Conclusion:</h3> Compliance with TTA protocols improved to more than 90% over a 2-year period, which shows the benefit of having a clearly outlined quality-improvement process. This well-defined quality-improvement method provides a framework for use by other institutions that seek to improve their processes of trauma care, including activation rates.

Strategy for Teaching Evaluation Research in Psychiatric/Mental Health Nursing

The evaluation research course presented in this paper is one strategy for introducing needed evaluation research content at the graduate level in nursing. The course was developed for students who were in their final semester of completing requirements for an MSN degree with a major in psychiatric/mental health nursing. To provide for active involvement in the evaluation research process, students evaluated a psychotherapy group in which they were therapists. The theoretical framework for both class content and the evaluation research project was based on Bloch's extension of Donabedian's approach to evaluation. Using the theoretical framework as a guide, students investigated both process and outcome as well as the relationship between process and outcome. Students reported that the knowledge and skills gained were valuable to their clinical practice. On the other hand, students found the course to be very demanding and difficult to complete in a 15 week period. One unexpected benefit, however, was that the course helped students to understand group process better.