Donabedian Model Of Quality Research Articles

Harnessing delegation and technology to identify and manage malnutrition in a digital hospital: An implementation study

AbstractAimsDelegation of nutrition care activities to Dietetic Assistants in hospitals has been identified as one innovative malnutrition model of care, but there has been limited evaluation of their roles. This study aimed to develop, implement and evaluate a new Malnutrition Model of Care embracing automated delegation and digital systems.MethodsThe Malnutrition Model of Care was created to detect patients at risk of malnutrition (using the Malnutrition Screening Tool) and nutritional decline (via routine intake tracking at all meals and snacks). Digital systems generated automated referrals to dietetics, with protocols to support Dietetic Assistants to action these to direct care escalation to the ward dietitian. Dietetic Assistant training included simulations and clinical task instructions. Implementation evaluation was guided by the Donabedian model of quality and included a review of inpatient dietetics occasions of service, survey of Dietetic Assistant role satisfaction and task confidence, and hospital‐wide cross‐sectional malnutrition audit. Data was descriptively analysed.ResultsDuring the first year of implementation, 60% of Dietetics inpatient occasions of service were completed by Dietetic Assistants, with 26% of Dietetic Assistant inpatient tasks initiated from nursing malnutrition risk screening. Most Dietetic Assistants reported adequate training and confidence in completing delegated tasks. Malnutrition prevalence was 14% with no hospital‐acquired malnutrition identified. No clinical incidents were reported.ConclusionsThe Dietetic Assistant workforce and technology were harnessed to implement an innovative delegated Malnutrition Model of Care that appears to be safe and effective at managing malnutrition from preliminary evaluation. Work continues to formally assess service efficiencies, cost and patient experience.

Biomedical Dogmas Still Influence the Delivery of Exercise Therapy in Chronic Low Back Pain Management: Mixed-Methods Study.

Non-specific, chronic low back pain (NSCLBP) is a leading cause of disability, prompting long-term rehabilitation. Positive patient beliefs and expectations towards lasting exercise engagement play a crucial role for a successful management of this condition. The aim was to investigate beliefs, unmet needs and expectations of NSCLBP patients for exercise-related health behaviour change in the context of rehabilitative care. In a mono-centric mixed-methods study, we conducted semi-structured interviews with NSCLBP patients and care providers. We recruited in a rehabilitation clinic which is specialized in orthopaedics and internal medicine. Interviews were analysed deductively by combining health behaviour change theories with Donabedian's quality model of care. In a patient survey, disability (RMDQ), exercise behaviours, fear avoidance beliefs (FABQ), self-efficacy in chronic disease management (SES6G), process- and outcome-expectations (OEE-2) were queried and analysed descriptively. Twenty-two interviews were conducted and 40 questionnaires completed. Qualitative results revealed that NSCLBP patients had persistent biomedical perspectives on their health condition, marked by strong preferences for biomedical diagnostics and beliefs in the superiority of specific exercise regimes. Based on met expectations and positive movement experiences, patients' motivation was successfully fostered in the motivational phase of health behavior change. In the volitional phase, the postulated desire to receive self-management strategies was largely unmet. Psychosocial aspects of care were not widely accepted. The survey study sample showed a disability score (RMDQ) of M = 6.8 (±4.6). Mean scores of validated scales reflecting on attitudes, beliefs and expectations of chronic NSCLBP management were at FABQ-pa M = 15.4 (±6.0), FABQ-w M = 24.0 (±12.1), SES6G M = 6.4 (±2.3), and OEE-2 M = 2.7 (±0.5). In this sample, patients' understanding of NSCLBP was still dominated by biomedical dogmas and perspectives. Inpatient rehabilitation predominantly addressed expectations towards the motivational phase of exercise-related health behaviour change.

Quality Improvement and Patient Safety Rounds—A New Paradigm in Cardiothoracic Surgery

BackgroundThe delivery of cardiothoracic health care is complex, and despite best efforts, adverse patient outcomes do occur. There is significant heterogeneity in morbidity and mortality rounds within and between institutions as well as undertones of a “blame and shame” culture prohibitive to meaningful quality assessment and improvement of patient care. The Quality Improvement and Patient Safety (QIPS) program was designed to address these issues. MethodsQIPS is built on the Donabedian model of quality and established phase-of-care adverse event analysis. It focuses on cultivating a culture of transparency. Every case review yields important demographic data, event factors, and the case inflection point, creating an institution-specific QIPS database. The QIPS format was presented by The Society of Thoracic Surgeons Workforce on Patient Safety at 2 Society of Thoracic Surgeons webinar series in December 2021 and August 2022. Descriptive data on both presentations were collected. ResultsThe December 2021 webinar had 75 unique viewers from 13 countries, and there were 343 asynchronous playbacks. The August 2022 webinar had 38 unique viewers from 9 countries and 310 asynchronous playbacks. ConclusionsThe standardized QIPS methods allow consistent recording of event factors and the inflection point, which are root causes of case morbidity or mortality. Dedication to the program will build a granular databank and identify recurring individual or system issues to launch quality improvement initiatives that address institution-specific needs. QIPS is simple, effective, and reproducible and seeks to create a culture of patient-centered quality and excellence in cardiothoracic surgery programs.

Quality indicators for palliative care in intensive care units: a systematic review.

Establishing appropriate quality assessment indicators for palliative care in intensive care units (ICUs) is vital. This systematic review summarizes the existing quality indicators (QIs) for palliative care in ICUs. It assesses the methodological quality of QI development to pave the way for more valid QIs. A literature search was conducted using MEDLINE, PsycINFO, CINAHL, Cochrane databases, and the Ichushi-web database for Japanese literature for all studies published until November 2021. The included QIs were drawn from the National Consensus Project for Quality Palliative Care (NCP) and the Donabedian model of quality. Methodological quality was assessed based on the appraisal of indicators through the research and evaluation tool. Five studies were included, from which 109 indicators were extracted: 78% were process indicators, 5% were outcome indicators, and 17% were structure indicators. The most common indicators addressed the palliative care domain of "ethical and legal aspects of care" (n=38, 30%). Another distinctive feature of some indicators was a focus on supporting ICU staff. Regarding methodological quality, the "scientific evidence" varied (11-89%). Most of the data on QI measures and data sources were obtained from a review of electronic medical records (EMRs). Administrative data also provided a few measurable indicators. Out of all the QIs covered in this review, most were process indicators, and only a few were outcome indicators. Ethical and legal aspects of care and support for the ICU staff emerged as unique to palliative care. Although the existing QIs can be used for palliative care in ICUs, more specific indicators are urgently needed. Continuous quality assessment and improvement, as well as the addition of more palliative care practices in ICUs, would provide further evidence and help develop valid QIs.

Selecting a theoretical framework to guide research on the COVID-19 pandemic impacts on nursing care delivery and the critical care work system (using Reed's Intermodern approach to theory critique)

Understanding the impact of COVID-19 on nursing care delivery in critical care work systems is urgently needed. Theoretical frameworks guide understanding of phenomena in research. In this paper, we critique four theoretical frameworks (Donabedian's Quality Model, the Quality Health Outcomes Model, the Systems Research Organizing Model, and the Systems Engineering (SEIPS) 2.0 Model) using Reed's (2018) Intermodern philosophical perspective of nursing science. Reed's (2018) Intermodern approach to theory critique was selected for its pragmatic perspective and focus on personal and professional health and wellbeing. The SEIPS 2.0 Model was ultimately selected to guide the study of the impact of the COVID-19 Pandemic on nursing care delivery in the critical care work systems.

Doctors experiences on the quality of care for pesticide poisoning patients in hospitals in Kampala, Uganda: a qualitative exploration using donabedian\u2019s model

BackgroundPesticides are responsible for a significant percentage of deaths globally with majority occurring in sub-Saharan Africa. Deaths due to pesticide poisoning can be reduced if poisoning cases are managed optimally. However, the quality of care given to pesticide poisoning patients is still insufficient especially in sub-Saharan Africa. This study was aimed at exploring doctors’ experiences on quality of care for pesticide poisoning cases in hospitals in Kampala, Uganda.MethodsFifteen (15) in-depth interviews were conducted with doctors who were directly involved in management of pesticide poisoning patients in the accident and emergency, Medicine, Pediatrics and Intensive Care Unit wards in 5 hospitals in Kampala, Uganda. All interviews were transcribed and subjected to directed content analysis with the guidance of the Donabedian model of quality of care which emphasizes structure, process and outcome measures as pertinent to ensuring quality of care.ResultsDoctors reported structural, process and outcome facets that support diagnosis and treatment of pesticide poisoning cases that improved the quality of care they provided. Among the structures includes hospital units such as Intensive Care Unit (ICU), pediatrics and internal medicine; equipment and clinical guidelines such as airway, breathing and consciousness (ABC) protocol; and doctors’ knowledge and experiences. Doctors relied on history, and signs and symptoms to establish the cause and severity of pesticide poisoning. However, some patients and caretakers provided inaccurate pesticide poisoning history. Due to its availability in hospitals, doctors largely relied on atropine to manage pesticide poisoning cases whether or not relevant to treat the actual pesticide active ingredient responsible for the poisoning. Although majority of the cases treated recovered, those due to suicide were further referred to the hospital psychiatrist. Sharing experiences of managing pesticide poisoning patients among health workers and engaging in sensitization outreaches against pesticide poisoning were reported as potential activities to improve quality of care for pesticide poisoning patients.ConclusionDoctors reflected on the structure, process and outcome measures of quality of care given to pesticide poisoning patients. The implications of hospital structures and clinical process to the quality of the outcomes of care demonstrates their importance in improving management of pesticide poisoning cases in hospitals in Kampala, Uganda.

Quantitative Measurement of Blood Loss During Delivery

Objective To facilitate a change in behavior from visual estimation of blood loss to objective quantification of blood loss during delivery. Secondly, to examine the effect of quantification of blood loss on identification of hemorrhage during birth. Design Prospective cohort to examine two methods to measure blood loss, visual and gravimetric, used by physicians and nurses. Sample A convenience sample of 52 birth cases was evaluated. Methods After approval from the Institutional Review Board, a prospective cohort, evidence‐based project at a suburban hospital in the southern United States was implemented from January 1, 2014 to March 30, 2014. All women who were scheduled for delivery, older than age 18, and spoke English were included in the project. After patient consent, the physician was notified of inclusion. Postpartum blood loss was visually estimated by the physicians and nurses. The research team quantified the blood loss by gravimetrically weighing blood lost, subtracting the dry weight, and adding the fluid in drapes and containers. The amniotic fluid was collected separately and not included. The visual and quantified estimates were compared. Implementation Strategies Donabedian's quality model provided a structured, organized way to improve the process of estimating blood loss for the obstetric patient. Additionally, Lewin's change model was used to change practice. Change occurred during implementation as physicians and nurses learned quantification methods and gained satisfaction in knowing that measurements were objective. The final stage or freezing happened when the data were presented and policy was changed. Ongoing data regarding response to maternal hemorrhage are based on objective quantification of blood loss. Results Physicians and registered nurses underestimated (p = .0001) the amount of blood loss at delivery by 21% to 28%. Registered nurses were inconsistent in underestimating blood loss (p = .441). There were no linear correlations or significance differences between hematocrit and hemoglobin postdelivery. Through a paired t test, a significant difference (p = .0001) between visual and gravimetric estimation of blood loss was found. Conclusion/Implications for Nursing Practice Accurate assessment and recognition of postpartum hemorrhage is an essential skill. Researchers indicate that quantitative measurement of blood loss is an accurate method and visual assessment should be eliminated from practice. Knowing the accurate, objective amount of blood lost will enable the health care team to recognize and respond faster to an obstetric hemorrhage. To facilitate a change in behavior from visual estimation of blood loss to objective quantification of blood loss during delivery. Secondly, to examine the effect of quantification of blood loss on identification of hemorrhage during birth. Prospective cohort to examine two methods to measure blood loss, visual and gravimetric, used by physicians and nurses. A convenience sample of 52 birth cases was evaluated. After approval from the Institutional Review Board, a prospective cohort, evidence‐based project at a suburban hospital in the southern United States was implemented from January 1, 2014 to March 30, 2014. All women who were scheduled for delivery, older than age 18, and spoke English were included in the project. After patient consent, the physician was notified of inclusion. Postpartum blood loss was visually estimated by the physicians and nurses. The research team quantified the blood loss by gravimetrically weighing blood lost, subtracting the dry weight, and adding the fluid in drapes and containers. The amniotic fluid was collected separately and not included. The visual and quantified estimates were compared. Donabedian's quality model provided a structured, organized way to improve the process of estimating blood loss for the obstetric patient. Additionally, Lewin's change model was used to change practice. Change occurred during implementation as physicians and nurses learned quantification methods and gained satisfaction in knowing that measurements were objective. The final stage or freezing happened when the data were presented and policy was changed. Ongoing data regarding response to maternal hemorrhage are based on objective quantification of blood loss. Physicians and registered nurses underestimated (p = .0001) the amount of blood loss at delivery by 21% to 28%. Registered nurses were inconsistent in underestimating blood loss (p = .441). There were no linear correlations or significance differences between hematocrit and hemoglobin postdelivery. Through a paired t test, a significant difference (p = .0001) between visual and gravimetric estimation of blood loss was found. Accurate assessment and recognition of postpartum hemorrhage is an essential skill. Researchers indicate that quantitative measurement of blood loss is an accurate method and visual assessment should be eliminated from practice. Knowing the accurate, objective amount of blood lost will enable the health care team to recognize and respond faster to an obstetric hemorrhage.

Listening to patients: improving the outpatient service

This paper assesses the patients' healthcare information needs and expectations when they attend a rheumatology outpatient clinic. It proposes that obtaining the patients' perspectives about the services they use is an essential service-development tool. The aim of this paper is to expand the current domains used to evaluate these perspectives. This paper is an exploratory study, looking at quality assessment and improvement based on Donabedian's quality model in a rheumatology outpatient setting. A structured interview schedule addressing care pathways was used and 70 consecutive patients were recruited. The article provides insights about how relevant change can be brought about when service development is contemplated. It suggests that patients are important stakeholders in the ongoing service development process. Because rheumatological conditions tend to be chronic and require long-term follow-up, the results may lack generalisability. Therefore, researchers are encouraged to test propositions in different clinical settings. The article highlights healthcare delivery areas that are not meeting patient expectations. Some recommendations (such as informing waiting patients regularly about any delays) require minimal additional resources for successful implementation. Service providers need to obtain the patients' healthcare perspectives to ensure that services are built around their needs. This article fulfils an identified need to study how patients perceive service quality.

Quality improvement by promoting relationships in care environments: the PRiCE model

Person centred services are becoming the norm across developed countries with the concomitant ageing of the generation known as the baby boomers. Older people associated with this generation are more consumer-oriented and have higher expectations of services as they age. Service provision is being developed in many countries, including Singapore, to reflect a person centred approach. Although there are a number of frameworks for person centred care (PCC), there is limited guidance on how to implement such frameworks or how they might be aligned to quality criteria. This study was based in the long term care (LTC) sector in the UK where the main objective was to explore relationships from the perspective of all stakeholders. Using a constructivist methodology, data were collected from three LTC organisations using participant observation, interviews and focus groups with staff, older people and families. The results demonstrated that staff adopted three approaches to care, which influenced relationships and had different outcomes for older people. Subsequent work has developed a framework for the implementation of relationship based approaches to care, including PCC. This included aligning the findings to the Donabedian model of quality (Structure, Process, Outcome). Structural factors included leadership, staff motivation continuity of staff and teamwork. The Process was defined as the different approaches to care that staff adopted and outcomes were defined as the consequences for the older person when staff adopted these approaches to care. The outcome that best described PCC from the perspectives of all stakeholders was: 'Care that matters to me'. This phrase describes how older people, families and staff in the LTC sector defined quality of care. The PRiCE model of quality improvement will be used to offer practical strategies to implement PCC in the ILTC sector, aligning these outcomes to current quality criteria.

Primary Stroke Center Education for Nurses

Primary Stroke Center designation by the Joint Commission distinguishes those healthcare organizations with exemplary stroke prevention and management. However, meeting the Joint Commission's high-level excellence standards is challenging. This article provides nurse leaders with a stroke education template, based on Donabedian's quality model, which meets Primary Stroke Center nurse education requirements. The authors describe the structure, process, and outcomes of a stroke education program for nurses, recognized as Best-in-Practice in Connecticut, successfully implemented in a community hospital.

Implementing a hospital-based animal therapy program for children with cancer: A descriptive study

Children living with cancer must cope with the disease, frequent hospitalizations, aggressive treatments and numerous treatment side effects. Combined, these stressors can lead to adverse biopsychosocial effects. An animal therapy program called "A Magical Dream" was instituted for children hospitalized in pediatric oncology to promote their well-being during hospitalization and facilitate their adaptation to the therapeutic process. The main goal of this preliminary study was to complete a descriptive assessment of the program implementation using Donabedian's quality model. This study aims more specifically at documenting the observed connection between participating in the program, quality of care and satisfaction of participating parents and nurses. A total of 16 parents of children and 12 nurses took part in the implementation study and composed the sample. Data were collected through two self-administered questionnaires intended for parents and one questionnaire for nurses. Evaluating the quality of the animal therapy program includes issues related to user profiles, animal therapy intervention process, organizational structure and client outcomes. It appears that dog-assisted therapy may contribute to alleviate psychological distress in children and parents, facilitate their adaptation to the therapeutic process, and promote their well-being while hospitalized. The goal of a second phase to the project will be to verify the effectiveness of the animal therapy intervention by targeting more specifically children hospitalized with solid tumours. Stemming from a nursing initiative started in 1999, this project aims to promote the well-being of children living with cancer during their hospitalization, reduce their emotional distress and facilitate their adaptation to the therapeutic (psychological, physical and social) process by promoting the emergence of special bonds between children and animals. The animal therapy program at CHUQ allows children accompanied by a parent to spend a whole day with a dog while being hospitalized in a room that is safe, warm and family friendly (Landry et al., 2000). In addition to facilitating the child's adaptation, this initiative may contribute to improving the quality of care, especially by offering a service for which client outcomes have already been noted (refreshing rest, better nourishment, physical exercise, socialization, participation in recreational activities, verbalization of fears and concerns, feeling less anxious, happier, etc.). Animal therapy is defined as a clinical method aiming to promote the natural and healing bonds that exist between humans and animals, both for preventive and therapeutic reasons (Daoust, 1987). The rationale behind this practice is that animals naturally stimulate an attraction and involvement response in humans (Brodie & Biley, 1999), which is then reflected in the person's well-being. As well-being is inconsistent with the state of emotional distress, animal-assisted therapy may be a beneficial intervention to alleviate distress in the child, his family and caregivers.