Frontline Teams Research Articles

Abstract P-448

Aims & Objectives: Cardiac arrests in PICU are infrequent but can cause significant mortality & morbidity, prolonging stay and increasing healthcare expenses. Between July 2015 and 2016, 7.2% of admissions to our unit had a cardiac arrest, which is much higher in comparison with multi-centre studies (2–3%). We designed a QI project aiming to reduce the number of cardiac arrests on LCH PICU by 50%, with a multi-dimensional approach. Methods We involved front line teams, reviewed recent cases of cardiac arrests and conducted a safety climate survey to identify areas for improvement. ReCAP initiative uses quality improvement methodology to actively identify high risk patients, address gaps in knowledge, provide clarity in communication and encourage a learning and supportive culture. The five main dimensions are recognition, pre-brief, clear documentation, debrief and simulation aimed to improve situational awareness and human factors related to escalation and early intervention. Pre-brief is the heart of this project, a novel concept adapted from aviation. A senior clinician leads a group discussion about pathology, signs of deterioration, immediate plan and role allocation for possible resuscitation for any child deemed to be at risk of cardiac arrest. Results Since launching on 1st January 2017, we have seen a 46% reduction in cardiac arrests compared to the last 2 years. There has been a tangible improvement in situational awareness and safety culture as evident by regular feedback. Conclusions Innovative strategies like pre-brief and addressing human factors with input from front-line teams can improve quality of care and patient safety.

PARTNERING OF A FRONTLINE HEALTHCARE TEAM WITH A FAMILY ADVISOR TO IMPROVE ACUTE ASTHMA CARE IN A PEDIATRIC EMERGENCY DEPARTMENT: COST SAVINGS ANALYSIS

Abstract BACKGROUND In 2016, a Canadian paediatric emergency department (ED) partnered with families in the co-design of a LEAN-based quality improvement (QI) project with the goal of increasing the proportion of asthmatic children receiving oral corticosteroids within one hour of arrival. LEAN projects aim to eliminate non-value-added process steps and to creatively solve problems as a team. Implemented changes included a process redesign with steroids given at the door and a revised asthma pathway increasing nurse autonomy prior to physician assessment. A sustained improvement (>12 months) was achieved, with asthmatic children consistently (>90%) receiving timely steroids within a mean time of 20 minutes. OBJECTIVES The objective of this study was to determine the cost savings of the improvements achieved by eliminating non-value-added process steps executed by physicians and nurses. The primary outcome measure was the number of documented care acts by physicians and nurses. DESIGN/METHODS Cases were identified by using the diagnostic code for asthma in the electronic medical record. This study included children 1 to 18 with Pediatric Respiratory Assessment Measure (PRAM) score ≥ 4 at triage. Patients who required admission were excluded. We reviewed a random sample of 20 to 30 charts monthly for 12 months, 6 months pre- and post-implementation of the revised asthma pathway. Physicians are remunerated on a fee-for-service basis and we modeled cost-savings of physician remunerations based on publically available physician fees. We assessed the number of documented nursing acts as a proxy for resource allocation in the ED given that the pathway increased nursing autonomy prior to physician assessment. RESULTS A total of 270 patients were included. With a simple process redesign aimed at getting children timely steroids at triage, the number of physician assessments decreased by 18%. In terms of physician billing, the cost savings were $24 per asthmatic patient in the ED. With >3000 asthma ED visits annually, the resulting estimated cost savings were >$72,000 per year. Even though increased nursing autonomy was part of the new process, documented nursing acts decreased by 10%. Moreover, although not included in the cost savings analysis, ED length of stay and admission rates both decreased. CONCLUSION Engaging frontline healthcare teams to co-design improvement initiatives with family partners in the ED is an excellent mechanism for leaders to sponsor. Frontline teams can implement creative and simple solutions that result in improved quality of care while also reducing unnecessary healthcare expenditures.

Use of a daily rounding checklist on the Clinical Teaching Unit improves interdisciplinary communication around discharge

Abstract BACKGROUND As the care needs of the paediatric inpatient population become increasingly complex, demands for hospitalization and efficient patient flow have resulted in the need for increased attention to discharge processes. Inefficient discharges impact flow throughout the healthcare system, extend length of stay, increase health care costs and decrease patient satisfaction. As a large inpatient service with high staff turnover, our Clinical Teaching Unit (CTU) experiences considerable variability in approach to discharge planning. Prior work at our institution has recognized inconsistent practice and gaps in communication around discharge planning as challenges to efficient patient discharge. OBJECTIVES Using quality improvement (QI) methodology, we aimed to decrease discharge delays on CTU, by implementing a process to identify and document patient specific discharge criteria. By focusing on discharge criteria, we sought to improve communication regarding discharge goals and patient readiness between care members, encouraging early discharge planning. DESIGN/METHODS We implemented a standardized CTU rounding checklist for use during daily inpatient rounds. On this checklist, physicians were instructed to document clear, patient-specific discharge criteria. Use of the checklist was encouraged through multiple avenues, including announcements at educational events, real time feedback on use to the front-line care teams and a monthly competition between resident teams. Through Plan-Do-Study-Act (PDSA) cycles, we collected feedback from the multidisciplinary team, and the checklist underwent multiple iterations to optimize use. CTU inpatient rounds were observed weekly and outcome, process and balance measures were collected. RESULTS With implementation of the checklist, a cultural shift towards explicit, thoughtful discussion of discharge criteria and planning was observed on daily patient rounds. Identification of patient specific discharge criteria increased from less than 30% to over 90% after implementation of the checklist. The purposeful documentation of discharge criteria received positive nursing feedback, and nursing awareness of discharge goals improved from 20–30% to over 70%. Improvements were sustained over a six-month period. CONCLUSION This QI project utilized a daily rounding checklist to engage care teams in purposeful conversations around discharge on rounds. By documenting patient-specific discharge criteria, interdisciplinary communication was improved and bedside nurses felt better informed of discharge goals. Future project directions include the development of diagnosis specific standardized discharge criteria, exploration of specific discharge barriers, and identification of institution-specific resources that may help alleviate these delays to further improve discharge efficiency.

Analysing the role of technology in compliance and regulatory structures

This paper does not set out to be an expert treatise on RegTech or FinTech, or any of the other catchy compound words that have entered our daily lexicon. It simply outlines one organisation’s journey in determining the need for a technological solution for a myriad of compliance obligations. The firm in which the author works has eight (soon to be nine) offices around the world, with two in Australia, and one in the UK, Germany, Switzerland (applying for registration), South Korea, Hong Kong, Japan and the USA. There are some group entities also licenced in Canada and the Cayman Islands. Some regimes require more than one licence (eg, five in Australia alone). The subsequent regulatory burden is significant. Add to that a global insurance programme, a global taxation programme, a global risk management framework, a global governance framework plus the day to day burden of simply running a business — the compliance obligations are huge. Yet, on number of staff alone, the present author’s organisation is nothing like some of the massive financial behemoths around the world, a potential cause of compliance management headaches. This paper is about IFM Investors’ experience in implementing technology into the business to become more effective, and less intrusive on the front line teams when it comes to meeting firm-wide compliance tasks. In doing so, IFM Investors had some learnings along the way from which readers might avoid some of the challenges faced.

A Picture is Not Worth a Thousand Words – Implementation of Offline Volumetric Image Review

The current institutional practice of communicating Head and Neck patient set-up problems and issues identified during image-guided radiation therapy (IGRT) is through email to the responsible radiation oncologist (RO). The email includes a screen capture of a single cone-beam computed tomography (CBCT) slice with a written description of the problem identified by front-line Radiation Therapists (RTTs). To gain a better understanding of the issue, the RO will often attend patient set-up the next day to review the CBCT with the RTTs on the treatment unit. To eliminate decision-making based on a single screen shot of a volumetric image and to reduce the number of times ROs are required at the treatment unit for online review, the use of Image Review Workspace in the Radiation Therapy Electronic Medical Records (RTEMR) system was piloted. The process for offline CBCT image review in Image Review Workspace within RT EMR was tested for feasibility through collaboration with the Head and Neck site leads (RO, Medical Physics [MP], RTT) and the clinical application specialist team. Workflow for offline review was assessed for feasibility and ease of use; technical issues identified were resolved prior to pilot roll-out. The workflow for offline review in Image Review Workspace initiates with an email alert by front line RTTs to the responsible RO, planner, and MP outlining the issue identified on the daily CBCT, requesting for image review. The RO would then view the volumetric CBCT in RTEMR and provide feedback regarding the set-up issue before the next clinical day. The image in RTEMR would not require approvals as the workspace is used solely as a platform to view the issue volumetrically. To assist with pilot implementation, training documents and teaching sessions were prepared for front-line RTTs and Head and Neck ROs describing the tools available within Image Review Workspace to view the patient CBCTs. Additionally, a standardized email template was created to ensure staff were comprehensive when describing IGRT issues, including a link with the instructions for using Image Review Workspace. The benefit of using the Image Review Workspace in RTEMR is that ROs can view the patient's entire CBCT image in a volume versus a single slice; decision-making is more informed based on three-dimensional data. This process also reduces the number of times ROs are required to attend set-up at the treatment unit to investigate image guidance issues. One identified challenge of Image Review Workspace is the amount of time required to initially load the patient's CBCT image, which can take up to two minutes. The ability to review CBCTs offline in a volumetric environment aids in clinical decision making and communication between the ROs and front-line team. Through the success of this pilot on the Head and Neck site, the process for offline CBCT image review in RTEMR is being implemented by other sites at our institution.

Factors Influencing Team Behaviors in Surgery: A Qualitative Study to Inform Teamwork Interventions

BackgroundSurgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members’ nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations suggests that team behaviors are also contingent on psychosocial, cultural, and organizational factors. This study examined factors influencing surgical team behaviors to inform more contextually sensitive and effective approaches to optimizing surgical teamwork.MethodsThis qualitative study of cardiac surgical teams in a large United States teaching hospital included 34 semistructured interviews. Thematic network analysis was used to examine perceptions of ideal teamwork and factors influencing team behaviors in the operating room.ResultsPerceptions of ideal teamwork were largely shared, but team members held discrepant views of which team and leadership behaviors enhanced or undermined teamwork. Other factors affecting team behaviors were related to the local organizational culture, including management of staff behavior, variable case demands, and team members’ technical competence, and fitness of organizational structures and processes to support teamwork. These factors affected perceptions of what constituted optimal interpersonal and team behaviors in the operating room.ConclusionsTeam behaviors are contextually contingent and organizationally determined, and beliefs about optimal behaviors are not necessarily shared. Interventions to optimize surgical teamwork require establishing consensus regarding best practice, ability to adapt as circumstances require, and organizational commitment to addressing contextual factors that affect teams.

A Grounded Theory Study of Collaboration in Multidisciplinary Teams

ABSTRACTThe multidisciplinary team response to child abuse emerged during the 1980s as increasing numbers of reports brought recognition that one agency alone lacked the expertise and resources to effectively deal with this complex issue. Using constructivist grounded theory, we interviewed a diverse sample of frontline team members about how they perceived collaboration and working with representatives from different agencies responsible for child abuse investigations. The study revealed how team members rely upon relationships built over time through shared experiences to facilitate communication and information sharing. Findings suggest multidisciplinary team members face challenges and collaborative relationships may mitigate these circumstances.

Report From the Night Shift: How Administrative Supervisors Achieve Nurse and Patient Safety.

The administrative supervisor role (the nurse leader on the evening or night shift) has been present in hospitals for more than 100 years, but research is just commencing regarding how this leader achieves nurse and patient safety. This focused ethnographic study was conducted in 2 parts. The first part consisted of focus groups with night-shift staff nurses, held at 7 hospitals in the mid-Atlantic region of the United States, with the objective of obtaining the staff nurses' perception of the supervisors' role. The second part consisted of interviews with 30 administrative supervisors, recruited nationally from 20 different states, to explore the supervisors' perspective on practices used to enhance safety. The focus group and interview transcripts were thematically analyzed, using an iterative, comparative method to identify codes and sort for patterns. The findings reveal that administrative supervisors "make it (whatever needs to be done) work" and achieve nurse and patient safety by building trust with the staff, doing rounds, educating, and providing support to the front line team. These shift leaders foster a culture of safety with their relationship-oriented leadership style. By gaining further understanding about the administrative supervisor role, new workflow processes can be explored; specific continuing education programs can be developed; and additional research can be conducted.

Shared Leadership for Nursing

What is ‘shared leadership’, how does it work and how did five Intermountain Healthcare hospitals use it to help their employees become more engaged and their managers more efficient? Shared leadership — an organisational model that is designed to engage front-line staff in traditional management functions, improve communication and help individuals advance their careers — was implemented in 75 nursing units in 5 of Intermountain Healthcare’s hospitals in January 2014. The model involves three councils in each department: one focused on nursing practice issues, another on leadership issues and a third on patient and employee engagement. The goal of shared leadership is to increase involvement among front-line team members by giving them ownership for responsibilities that traditionally belong to nurse managers, and to give managers more time to lead by spending less time managing. The model also addressed two consistent challenges: The region’s nurse managers faced the constant need to do more with less. Employee surveys in the region showed that more employees wanted more control over their. Falling scores on one survey question — At work, do my opinions seem to count? — were a specific concern. A year after shared leadership was implemented, the model has produced four major benefits: 1. It engages the front-line staff 2. It creates value for the organisation 3. It improves communication 4. It develops individuals

A Formative Assessment of Nurses' Leadership Role in Zambia's Community Health System.

Despite its achievements in decreasing HIV prevalence and under-five mortality, Zambia still faces high maternal and neonatal mortality, particularly in the rural and remote areas where almost 60% of the population resides. After significant investments in developing its community health system, the Zambian Ministry of Health was interested to understand how to leverage the role of nurses to sustain achievements made and further improve the quality of care in rural communities. The Ministry joined research partners in an assessment into the role and leadership capacity of nurses heading rural health facilities. A seven-member research team conducted 30 in-depth interviews and 10 focus group discussions in four provinces with four categories of respondents: national decision-makers, provincial and district managers, rural facility staff and community respondents (neighborhood health committee members and volunteers). An initial scoping visit and literature review informed the development of specific interview guides for each category of respondent. After audio-recording and transcription, research team members identified and reached consensus on key themes, and presented and validated the findings at a national stakeholder workshop. Zambia's front-line health teams are a complex mixture of professional facility staff, community providers, community-based volunteers and neighborhood health committees. Nurses and nurse-midwives head over half the rural facilities in Zambia, where they are expected to lead the delivery of safe, high-quality care with staff and volunteers who often operate beyond their level of training. Nurses and midwives who are assigned to head rural facilities are not adequately prepared or recognized for the leadership responsibilities they are expected to fulfill. This paper highlights opportunities to support rural facility heads in effectively leading front-line health teams to deliver primary healthcare to rural communities. Front-line teams require a leader to coordinate and motivate seamless and sustainable quality services that are accessible to all. Zambia has the potential to support integrated, responsive quality care and advance toward universal health coverage if nurses are adequately prepared and recognized with job descriptions that reflect their responsibilities and opportunities for career advancement.

Leveraging selected operational improvement practices to achieve both efficiency and creativity: A multi-level study in frontline service operations

Compared with the repetitive nature in manufacturing operations, frontline service operations are more dynamic because of the need to deal with many unpredictable customer-related activities. Thus, many service firms strive to achieve not only efficiency in service delivery, but also creativity in decisions or problem-solving with an aim to maintaining competitiveness in today's dynamic environments. However, the discipline of operations management has traditionally focused on improving efficiency in operational activities, while offering very limited insights regarding practices that can improve operational efficiency as well as employee creativity. Grounded in social cognitive theory, we identify three operational improvement practices in this paper, namely continuous improvement, structured methods, and psychological safety, which are pertinent to learning experiences and behaviours (i.e., major elements in developing individuals' creativity), can help service firms achieve both operational efficiency and employee creativity. We also adopt a multi-level analysis to study whether two relevant learning capabilities, namely potential absorptive capacity and ambidexterity, can enhance the effectiveness of the three identified operational improvement practices. We test our hypotheses by using survey data collected from 146 frontline teams in China's banking industry. We contribute to research on service operations management by offering new insights linking operational improvement practices and employee creativity. Service firms that value the importance of both operational efficiency and creative solutions should find our results particularly useful because our results provide precise guidelines on improving both operational performance and employee creativity through the adoption of relevant operational improvement practices and learning capabilities.

Governing Collaborative Healthcare Improvement: Lessons From an Atlantic Canadian Case.

The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) Quality Improvement Collaborative (QIC) in Eastern Canada provided an approach to spur system-level reform across multiple health systems for patients and families living with chronic disease. Developed and led by senior executives with a unique governance approach and involving clinical front-line teams, the AHC serves as a practical example of leadership creating and driving momentum for achieving success in collaborative health system improvements.

Using the PRISM Model to Drive Quality Improvement in the Emergency Department

In recent years, there has been a push to improve and standardize the quality of clinical care delivered. This has led to marked efforts across institutions to invest in quality improvement (QI) as a part of daily practice. “Problem-solving, Root cause analysis, Improvement Science, and Monitoring” (PRISM) is a model used to detail a stepwise approach to QI in a way that can be easily followed, sustained, and eventually integrated into an organization’s learning system. This model is being used to improve the efficiency of our emergency department admissions process. The various tools that are a part of PRISM are discussed in detail here. Frontline team members have been educated about PRISM and are now engaged and leading improvement efforts within our organization. In short, PRISM has provided the common QI language for our transformation toward becoming a leader in patient- and family-centered care.

Software como serviço: um estudo de caso

Este artigo analisa o processo de servitização em uma empresa de tecnologia de informação. Inicialmente foi realizada uma revisão de literatura, seguida de um estudo de caso na empresa de software. Observações diretas e entrevistas com os colaboradores envolvidos diretamente no processo foram realizadas, caracterizando motivações, mudanças e desafios. A partir da análise dos resultados, foi desenvolvido um checklist que auxilia as empresas na adoção de tal prática. Algumas ações são importantes na implantação da servitização: a revisão do portfólio de produtos e clientes; a preparação das equipes de linha de frente, envolvimento da gestão e liderança, a gestão de contratos e a gestão de melhorias.

Immunotherapy for High-Risk Neuroblastoma: Management of Side Effects and Complications.

Despite more intensive therapy, high-risk neuroblastoma continues to be a challenging disease to treat. Postconsolidation immunotherapy has been studied for many years and has proven to be effective in clinical trials. Immunotherapy has become the standard of care for patients with high-risk disease, and many institutions across the country are providing this therapy. The care of these patients is complex and often associated with many side effects. The purpose of this article is to review the most common side effects seen in clinical practice and examine their management. Furthermore, this article will discuss the need for a consistent and educated multidisciplinary front-line team to care for these patients, with advanced practitioners playing a lead role to provide the care and attention needed for this patient population.

The Effects of the Transforming Care at the Bedside Program on Perceived Team Effectiveness and Patient Outcomes.

The objective of the study was to document the impact of Transforming Care at the Bedside (TCAB) program on health care team's effectiveness, patient safety, and patient experience. A pretest and posttest (team effectiveness) and a time-series study design (patient experience and safety) were used. The intervention (the TCAB program) was implemented in 8 units in a multihospital academic health science center in Montreal, Quebec, Canada. The impact of TCAB interventions was measured using the Team Effectiveness (TCAB teams, n = 50), and Clostridium difficile-associated diarrhea and vancomycin-resistant Enterobacter rates (patient safety) and Hospital Consumer Assessment of Healthcare Providers and Systems (patient experience; n = 551 patients). The intervention was composed of 4 learning modules, each lasting 12 to 15 weeks of workshops held at the start of each module, combined with hands-on learning 1 day per week. Transforming Care at the Bedside teams also selected 1 key safety indicator to improve throughout the initiative. Pretest and posttest differences indicate improvement on the 5 team effectiveness subscales. Improvement in vancomycin-resistant Enterococcus rate was also detected. No significant improvement was detected for patient experience. These findings call to attention the need to support ongoing quality improvement competency development among frontline teams.

Developing Integrated Care Teams Across the North West London System

Developing Integrated Care Teams Across the North West London System

Introduction of an Area Deprivation Index Measuring Patient Socio-economic Status in an Integrated Health System: Implications for Population Health

Introduction:Intermountain Healthcare is a fully integrated delivery system based in Salt Lake City, Utah. As a learning healthcare system with a mission of performance excellence, it became apparent that population health management and our efforts to move towards shared accountability would require additional patient-centric metrics in order to provide the right care to the right patients at the right time. Several European countries have adopted social deprivation indices in measuring the impact that social determinants can have on health. Such indices provide a geographic, area-based measure of how socioeconomically deprived residents of that area are on average. Intermountain’s approach was to identify a proxy measure that did not require front-line data collection and could be standardized for our patient population, leading us to the area deprivation index or ADI. This paper describes the specifications and calculation of an ADI for the state of Utah. Results are presented along with introduction of three use cases demonstrating the potential for application of an ADI in quality improvement in a learning healthcare system.Case Description:The Utah ADI shows promise in providing a proxy for patient-reported measures reflecting key socio-economic indicators useful for tailoring patient interventions to improve health care delivery and patient outcomes. Strengths of this approach include a consistent standardized measurement of social determinants, use of more granular block group level measures and a limited data capture burden for front-line teams. While the methodology is generalizable to other communities, results of this index are limited to block groups within the state of Utah and will differ from national calculations or calculations for other states. The use of composite measures to evaluate individual characteristics must also be approached with care. Other limitations with the use of U.S. Census data include use of estimates and missing data.Conclusion:Initial applications in three meaningfully different areas of an integrated health system provide initial evidence of its broad applicability in addressing the impact of social determinants on health. The variation in socio-economic status by quintile also has potential for clinical significance, though more research is needed to link variation in ADI with variation in health outcomes overall and by disease type.

Putting people at the centre: facilitating Making Safeguarding Personal approaches in the context of the Care Act 2014

Purpose – The purpose of this paper is to describe and discuss the pilot Making Safeguarding Personal (MSP) project that ran in three London boroughs in England in 2014-2015. The project aimed to help local authority social work practitioners better engage with adults at risk at the beginning, middle and end of safeguarding work and to develop a more outcomes focused approach to safeguarding. Design/methodology/approach – Three adult social care teams volunteered to take part in the MSP pilot for four months, November 2014-February 2015. They were closely supported through telephone conferencing, bespoke training and individual mentoring. Evaluative data were collected from the participating teams about their work and the MSP change processes to assist in further implementation. Findings – The findings suggested that staff felt that the open discussions with adults at risk that were encouraged by the MSP initiative enabled safeguarding to be more effective and provided a better basis of support for adults at risk. The support from the project team was appreciated. Staff reported their own increased confidence as a result of involving adults at risk in decisions about their situations and risks of harm. They also reported their increased awareness of cross-cutting subjects related to adult safeguarding, such as domestic abuse and working with coercive and controlling behaviours. Permission to exercise greater professional discretion to make responses more considered, rather than the need to adhere to time-limited imperatives, was received positively. Staff felt that this enhanced discussions about resolution and recovery with adults at risk although it required greater expertise, more extensive managerial support, and more time. These were available in the pilot. Research limitations/implications – The MSP pilot was confined to three teams and took place over four months. The numerical data reported in this paper are provided for illustrative purposes and are not statistically significant. As with other evaluations of implementation, the data provided need to be set in the local contexts of population profiles, care settings and the reporting source. The pilot also took place during the early implementation of the Care Act 2014 which affected the context of practice and training. The views of adults at risk were not collected. There is a risk of bias in that participants may have wished to convey positive views of MSP to their colleagues. Practical implications – The paper indicates a need for the roll out of MSP philosophy and MSP approaches to be communicated with other agencies supporting adults at risk and for project support of some form to continue. It will be important to see if the overall enthusiasm, support and motivation reported by the pilot teams when taking a MSP approach in practice extend beyond a pilot period during which the staff received substantial support from a dedicated Professional Standards Safeguarding Team. Many of those staff participating in the pilot perceived the MSP approach as a return to core social work principles and welcomed putting these into practice. Originality/value – The paper provides details of one pilot in which the feasibility of the MSP approach was tested by supporting three frontline teams working in different contexts. The pilot suggests that the level and type of support offered to the pilot teams were effective in a variety of practice settings. It draws attention to the need for the MSP concept and approach to be shared with other agencies and for implementation support to continue beyond initial pilot period.

Huddle up for safer healthcare: how frontline teams can work together to improve patient safety.

This project aimed to: Using quality improvement methodology, safety huddles were tested with four front-line teams in one large acute hospital trust. The wards focused on a harm area to improve; this was determined by the teams and was initially …