Healthcare Improvement Work Research Articles

Aiming for equity in care provision

Since the introduction of the triple aim for health quality improvement around 2008 the suggested multi-layered approach to quality improvement has gained ground. The idea is that when working for quality improvement in the health and care sector one needs to have several aims in sight at the same time. Originally the three aims singled out were: enhancing patient experience, improving population health, and reducing costs. These were then expanded to include an additional goal of improving the work life of health care providers (the quadruple aim). Now, the last addition to the idea is a new layer; namely equity (the quintuple aim). 
 This presentation addresses the discussion on how to work towards the newly added aim on equity. In Scandinavia and elsewhere in Europe we are moving towards more integrated care, but also more complex care economies consisting of an increasing number of private and public providers that in various ways depend also on domestic agents. Indeed, the ongoing transformations of care work holds in it several potential routes for change when it comes to equity, and it is of vital importance we keep our gaze on these issues to ensure a desired outcome. 
 From gender research it has been pointed out that research addressing inequality and equity in (care) work, often remain on an individual micro level, when instead we need to lift our gaze to culture and social structure to get the whole picture. To meet this challenge the concept of gender regimes can be helpful; it points to the variation in the political and organizational contexts in which care work institutions are founded and embedded. The presentation will explore weather this approach, in combination with a look towards care economy as a societal field going across domestic, public and private spheres, can allow for a conceptual discussion on how we can succeed in increasing awareness of equity and inclusion in health care improvement work.

Cultural health capital and patient partner recruitment into healthcare improvement work

A rising emphasis on patient involvement in clinical research and healthcare improvement has led to the steady incorporation of patients and caregivers into this work. However, interactional factors shaping recruitment processes are not well understood. In this paper, we present a qualitative analysis of interviews with twenty-six patients, family members, engagement staff and healthcare providers who are engaged in healthcare improvement work in the United States. We focus on how stakeholders account for recruitment decisions to participate in healthcare improvement work. We find that expressions of and judgments about patients' and caregivers' cultural health capital shape providers’ decisions to extend invitations to participate in healthcare improvement work. These findings extend current conceptualizations of cultural health capital beyond the clinical encounter to reveal factors shaping patient recruitment into healthcare improvement work. In theorizing how cultural health capital shapes action in this new setting, we found that healthcare providers, engagement staff, and patients/caregivers attended to different aspects of cultural health capital when accounting for why they extended or received a recruitment pitch. We further found that participating in healthcare improvement work led to a boost in cultural health capital for patients and caregivers, which they could use to develop transmissible forms of cultural health capital for less centrally involved patients and caregivers. Finally, we describe how participants in healthcare improvement collaboratives account for a lack of diversity among partners. These findings help us hypothesize the consequences of recruitment processes that rely on displays and judgments of cultural health capital and identify possibilities for change. Using the case of healthcare improvement work in Collaborative Learning Health Systems, our findings advance past work on cultural health capital in medical sociology by theorizing the role of cultural health capital in recruitment processes.

Influencing Discharge Efficiency: Addressing Interdisciplinary Communication, Transportation, and COVID-19 as Barriers.

At one tertiary, academic medical center, two general medicine units averaged 94% and 97% occupancy causing strain on patient throughput. This project was implemented at these two comparable general medicine units, totaling 64 beds. On each of these units, Pareto analyses on causal factors related to discharge order to exit time (DOTE) were performed. DOTE was defined as the period in minutes from when a provider orders a discharge to when the patient actually exits a room. Prime DOTE reduction opportunities were elicited that highlighted the need to address coordination of hospital discharge transportation; that is, arriving family members averaged 120 and 129 min for the two units, and medicars and ambulances averaged 122 and 156 min, which fell above the established 90-min overall strategic DOTE goal. Coordinating efficient discharges decreases the likelihood of hospital bottlenecking and improves patient satisfaction. The health care team is composed of physician and provider services, nursing, and case management, as well as the patient and family. Team-focused interventions aimed at reducing DOTE included leveraging interdisciplinary communication technology and messaging for efficiency and accuracy within the health care team and proactive scheduling of hospital discharge transportation arrival. Process objectives measured included percentage of the health care team educated and utilization of the discharge suite. Outcome objectives measured included median DOTE times, patient satisfaction, and emergency department boarding volume and times. Significantly, admissions for coronavirus disease-2019 (COVID-19) cases were also rapidly increasing early on during program implementation resulting in one of the two general medicine units to be designated for COVID-19 overflow. Using Lean methodology, the project design was formed based on the Institute for Healthcare Improvement's work on improving hospital-wide patient flow and the Agency for Healthcare Research and Quality's (AHRQ) IDEAL patient discharge framework to better achieve the well-known, triple aim. In response to COVID-19 demands, the Plan-Do-Study-Act process was warranted to be able to manage acute changes, using iterative processing. This program evaluation study assessed whether a communication training program that taught an interdisciplinary team of case managers, nurses, physicians, and related staff how to reduce DOTE was useful. The program had a material impact on the DOTE metric knowing that the hospital's ultimate strategic goal is to reduce DOTE to 90 min or less. A reduction in discharge time was documented when using weekly data from the hospital's discharge dashboard powered by the Maestro database. More specifically, nurses fully trained in the interdisciplinary communications program aimed to reduce DOTE had significantly lower DOTE outcomes on their discharges compared with untrained staff (i.e., average untrained = 127 min, average trained = 93 min). In addition, the fully trained nurses had 14% more of their discharges fall at or below the 90-min goal compared with untrained staff (i.e., untrained = 40%, trained = 54%). Supplemental research also suggested that the content of the communication training program was very relevant (e.g., empowering families to pick up the patients and using scheduling vs. will-call transportation strategies with patients lowered the DOTE metric). Corollary analyses showed that readmissions were also lowered, and patient satisfaction ratings increased. In addition, the interdisciplinary communications training program can benefit from being updated to include content on how COVID-19 issues adversely impact discharge times since significant relationships between various COVID-19 measures and higher discharge exit times were documented.

"Nurses' use of visual management in hospitals-A longitudinal, quantitative study on its implications on systems performance and working conditions".

The aim of this study was to examine potential benefits provided by daily visual management tool use and explore its association with systems performance and working conditions among hospital nurses. Visual management tools used in everyday work and improvement work in health care theoretically contribute to shared understanding of complex work systems and provide certain user benefits. Cognitive load, miscommunication within and between professional groups, and pressure to engage in care process redesign add to nurses' strained working conditions. Quantitative longitudinal. Questionnaires were distributed at T0, (N=948, 66% response rate), T1 (N=900, 70% response rate), and T2 (N=621, 72% response rate) to nurses at five hospitals. Three groups of users (daily users, start users, and non-daily users) were compared by means T1-T2 (significance tested with Wilcoxon signed rank test) and by mixed model repeated measures T0, T1, T2. Daily use associated to better overview of work, collaboration, social capital, and clinical engagement. Job resources were rated higher by daily users. Mental stress increased and development opportunities decreased over time among non-daily users. There were associations between use and perceptions of systems performance, though the differences between groups were small. This study specifically explores visual management tool use in the hospital setting, which contributes to research by broadening the understanding of cognitive, social, and emotional benefits provided by visual management tool use. Daily use was associated to positive working conditions, small but positive differences in systems performance, and indicated a buffering effect on nurses' mental stress.

The impact of a quality improvement skills-building programme on self-efficacy

Background: The Quality and Service Improvement Redesign Practitioner programme is a five-day action-based educational programme for UK healthcare and NHS professionals delivered by the ACT Academy of NHS Improvement. The programme provides a grounding in improvement science for participants undertaking projects in real time. Aims: The aim of the study was to investigate the impact of the programme upon participant's self-efficacy. Methods: The General Self-Efficacy scale was given to participants on the first and last day of the Quality and Service Improvement Redesign Practitioner programme, covering a four-month time frame. In total, 108 healthcare participants from four cohorts of the programme completed the measure. Results: A one-tailed t-test showed that self-reported self-efficacy scores significantly increased from the start to the end of the programme. Conclusions: The results provide positive evidence for the impact of the programme upon self-reported self-efficacy for those actively engaged in quality improvement work in healthcare.

Showing the Unsayable: Participatory Visual Approaches and the Constitution of \u2018Patient Experience\u2019 in Healthcare Quality Improvement

This article considers the strengths and potential contributions of participatory visual methods for healthcare quality improvement research. It argues that such approaches may enable us to expand our understanding of ‘patient experience’ and of its potential for generating new knowledge for health systems. In particular, they may open up dimensions of people’s engagement with services and treatments which exceed both the declarative nature of responses to questionnaires and the narrative sequencing of self reports gathered through qualitative interviewing. I will suggest that working with such methods may necessitate a more reflexive approach to the constitution of evidence in quality improvement work. To this end, the article will first consider the emerging rationale for the use of visual participatory methods in improvement before outlining the implications of two related approaches—photo-elicitation and PhotoVoice—for the constitution of ‘experience’. It will then move to a participatory model for healthcare improvement work, Experience Based Co-Design (EBCD). It will argue that EBCD exemplifies both the strengths and the limitations of adequating visual participatory approaches to quality improvement ends. The article will conclude with a critical reflection on a small photographic study, in which the author participated, and which sought to harness service user perspectives for the design of psychiatric facilities, as a way of considering the potential contribution of visual participatory methods for quality improvement.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and...

Change Management in Quality Improvement: The Softer Skills

Quality improvement work in healthcare requires an understanding of not only the methodology and science of improvement but also a mastery of the concepts of change management. These “softer skills” include leadership, team building, culture, context, and patient and family engagement. Capable leaders and teams facilitate improvement by fostering a culture of improvement. By engaging patients and families, interventions and innovations can be appropriately tailored to suit individual contexts. Without the incorporation of these change management concepts, successful, sustainable quality improvement cannot be achieved.

How to build up the actionable knowledge base: the role of ‘best fit’ framework synthesis for studies of improvement in healthcare

Increasing recognition of the role and value of theory in improvement work in healthcare offers the prospect of capitalising upon, and consolidating, actionable lessons from synthesis of improvement projects and...

The SQUIRE Guidelines: an evaluation from the field, 5 years post release

BackgroundThe Standards for Quality Improvement Reporting Excellence (SQUIRE) Guidelines were published in 2008 to increase the completeness, precision and accuracy of published reports of systematic efforts to improve the quality,...

An improvement project within urological care.

The purpose of this paper is to describe staff experiences in an on-going improvement project regarding patients with ureteral stones. A qualitative descriptive study based on eight group interviews and 48 narratives, was performed. Data were analysed using qualitative content analysis. Trustworthiness was ensured by using a well-documented improvement process method during six months. The results formed three categories: an absent comprehensive view; complexity; and vulnerability within the organisation. A holistic perspective regarding urological care at the micro-, meso- and macro-levels is needed to improve planning and caring processes. This study includes one team (six members, different health professionals) within the same urology department. Results show that staff need information, such as guidelines and support throughout the improvement work to deliver high-quality care. Moreover, there is a need for evidence-based guidelines at national level to support improvement work. Healthcare staff need to pay attention to all team member needs to improve urological care. Organisational and managerial aspect are needed to support clear and common goals regarding healthcare improvement work. Urological improvement projects, generally, are lacking, which is why this study is important to improve nephrolithiasis patient care.

Demystifying theory and its use in improvement

The role and value of theory in improvement work in healthcare has been seriously underrecognised. We join others in proposing that more informed use of theory can strengthen improvement programmes...

Applying different quality and safety models in healthcare improvement work: Boundary objects and system thinking

A number of theoretical models can be applied to help guide quality improvement and patient safety interventions in hospitals. However there are often significant differences between such models and, therefore, their potential contribution when applied in diverse contexts. The aim of this paper is to explore how two such models have been applied by hospitals to improve quality and safety. We describe and compare the models: (1) The Organizing for Quality (OQ) model, and (2) the Design for Integrated Safety Culture (DISC) model. We analyze the theoretical foundations of the models, and show, by using a retrospective comparative case study approach from two European hospitals, how these models have been applied to improve quality and safety. The analysis shows that differences appear in the theoretical foundations, practical approaches and applications of the models. Nevertheless, the case studies indicate that the choice between the OQ and DISC models is of less importance for guiding the practice of quality and safety improvement work, as they are both systemic and share some important characteristics. The main contribution of the models lay in their role as boundary objects directing attention towards organizational and systems thinking, culture, and collaboration.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies...

Analysis of Means Used to Compare Providers' Referral Patterns

The objective of this study was to demonstrate through a case study how an analysis of means (ANOM) chart can be used to compare groups and to advocate the usefulness of this method in improvement work. The ANOM technique was used to compare referral rates among providers at the Dartmouth-Hitchcock Medical Center's Spine Center. The purpose was to see whether there were any differences across providers in referral rates to Behavioral Medicine services for patients who scored low on their mental health score and whether referral rates were any different among the patient characteristics. ANOM charts were also used to determine whether patient characteristics were different among the providers. Six of the 17 providers had significantly different referral rates compared to the overall referral rate of 38%. Seven patients' characteristics had a significantly different referral rate compared to the system's rate. The additional ANOM charts used to compare providers relative to specific patient characteristics demonstrated several special causes and revealed characteristic referral patterns for some of the providers analyzed. The ANOM chart may be underutilized in health care improvement work. The ANOM procedure of analyzing patient characteristics to determine differences among providers could be explored in other patient populations and settings.