Performance Improvement Interventions Research Articles

Advancing Emergency Medical Services’ (EMS) Response Capability for Behavioral Health Emergencies: Los Angeles County’s Performance Improvement Initiative

Introduction Behavioral health emergencies (BHEs) are a common patient encounter for emergency medical services (EMS) clinicians and other first responders, in particular law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices. In 2016, the Los Angeles County EMS Agency’s Commission initiated a comprehensive evaluation of the 9-1-1 response for BHEs and developed a plan for improving the quality of care and safety for patients and first responders. Methods A Behavioral Health Initiative Committee was assembled with broad representation from EMS, LE, health agencies, and the public. Committee objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement. Results The committee generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities’ capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, develop alternate destination for EMS transport. Conclusion This paper describes a comprehensive performance improvement initiative in LAC-EMSA’s 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs.

Challenges in the care of patients with RET-altered thyroid cancer: a multicountry mixed-methods study

BackgroundThe discovery of driver oncogenes for thyroid carcinomas and the identification of genomically targeted therapies to inhibit those oncogenes have altered the treatment algorithm in thyroid cancer (TC), while germline testing for RET mutations has become indicated for patients with a family history of RET gene mutations or hereditary medullary TC (MTC). In the context of an increasing number of selective RET inhibitors approved for use, this paper aims to describe challenges and barriers affecting providers’ ability to deliver optimal care for patients with RET-altered TC across the patient healthcare journey.MethodsA mixed-method educational and behavioral needs assessment was conducted in Germany (GER), Japan (JPN), the United Kingdom (UK), and the United States (US) prior to RET-selective inhibitor approval. Participants included medical oncologists (MO), endocrinologists (EN) and clinical pathologists (CP) caring for patients affected with TC. Data collection tools were implemented in three languages (English, German, Japanese). Qualitative data were coded and thematically analyzed in NVivo. Quantitative data were analyzed via frequency and crosstabulations in SPSS. The findings presented here were part of a broader study that also investigated lung cancer challenges and included pulmonologists.ResultsA total of 44 interviews and 378 surveys were completed. Suboptimal knowledge and skills were self-identified among providers, affecting (1) assessment of genetic risk factors (56%, 159/285 of MOs and ENs), (2) selection of appropriate genetic biomarkers (59%, 53/90 of CPs), (3) treatment plan initiation (65%, 173/275 of MOs and ENs), (4) management of side effects associated with multitargeted tyrosine kinase inhibitors (78%, 116/149 of MOs and ENs), and (5) transfer of patients into palliative care services (58%, 160/274 of MOs and ENs). Interviews underscored the presence of systemic barriers affecting the use of RET molecular tests and selective inhibitors, in addition to suboptimal knowledge and skills necessary to manage the safety and efficacy of targeted therapies.ConclusionThis study describes concrete educational needs for providers involved in the care of patients with RET-altered thyroid carcinomas. Findings can be used to inform the design of evidence-based education and performance improvement interventions in the field and support integration into practice of newly approved RET-selective inhibitors.

The Impact of Performance Improvement Interventions and Phlebotomy Staff Counseling on Blood Culture Contamination Rates: Experience of Security Forces Hospital, Makkah, Saudi Arabia

The Impact of Performance Improvement Interventions and Phlebotomy Staff Counseling on Blood Culture Contamination Rates: Experience of Security Forces Hospital, Makkah, Saudi Arabia

Using a human performance technology and improvement intervention to mitigate human resource business partner skill gaps

Using a human performance technology and improvement intervention to mitigate human resource business partner skill gaps

Practice Gaps and Barriers in Optimal Care Among Healthcare Professionals Treating Patients with CLL and MCL with BTK Inhibitors: Results of a 2-Phase Qualitative/Quantitative Study

Background: Multiple BTK inhibitors (BTKis) are approved for treating patients with chronic lymphocytic leukemia (CLL) and mantle cell lymphoma (MCL), with further approvals expected in the near future, increasing the clinical complexity of decision-making in patient care. This study sought to quantify knowledge and practice gaps among oncology healthcare professionals (HCPs) in the use of BTKis to treat patients with CLL and MCL, with the goal of informing the design of evidence-based education interventions aimed at addressing these gaps. Methods: From November 2021 - January 2022, 488 eligible HCPs (including physicians, physician assistants, nurse practitioners, and pharmacists) participated in a 2-phase study focused on knowledge and use of BTKis for CLL and MCL. Participants were required to be active practitioners who treated patients with CLL and/or MCL. In the exploratory qualitative phase of this study, 30 US participants completed a 45-minute telephone interview focusing on factors that influence clinical reasoning in selecting and providing treatment for CLL and MCL. Interviews were transcribed, and thematic analysis was performed. The quantitative phase of this study consisted of an online survey composed of multiple-choice questions and semantic differential rating scales. Respondents' answers to each question in the quantitative survey were compared with optimal answers as identified by treatment guidelines and specialists in CLL and MCL patient care. Results: Of responding HCPs, 59% were physicians, 64% had been in practice >10 years, 73% practiced in a nonacademic setting, and 73% cared for ≤10 patients with CLL and/or MCL per week. A group of 7 core practice gaps were identified through combined analysis of data from the qualitative and quantitative surveys; these included optimal therapy selection in the first- and later-line settings for CLL and MCL, awareness of mechanisms of resistance to approved BTKi therapy, and knowledge of investigational therapies and appropriate clinical trial referral. For example, of 270 responding HCPs, 47% were unable to select preferred first-line therapy (per expert recommendations) for a patient with CLL and high tumor burden and renal insufficiency, with 9% recommending a chemoimmunotherapy regimen. Likewise, a significant percentage of surveyed HCPs lacked confidence in their approach to therapy selection for patients with relapsed/refractory CLL or MCL, with optimal sequencing identified as a primary concern. Many HCPs were unfamiliar with BTKi mechanisms of action. Gaps in knowledge were particularly evident with novel BTKis, including pirtobrutinib, with 46% of online survey respondents uncertain about the noncovalent mechanism of this agent and only 33% aware that pirtobrutinib has shown activity in patients with CLL and disease progression on ibrutinib due to the appearance of a BTK C481 mutation. In total, 60% of respondents would not consider recommending a newly approved agent if they were not familiar with the class or mechanism of action of this agent. Conclusions: Many HCPs lack confidence and knowledge in applying optimal care for patients with CLL and MCL, particularly with regard to the use of BTKis, both in first- and later-line therapy. A lack of familiarity with promising novel BTKis under clinical investigation may lead to missed opportunities to enroll eligible patients on clinical trials and potentially delay integration of these agents into clinical practice as new indications emerge. Results of this study provide evidence to support the design of clinical tools, educational programs, and performance improvement interventions. Detailed findings will be presented, including group-specific analyses and investigation of the causalities of each of the identified practice gaps.

Practice Gaps and Barriers in Optimal Care Among Healthcare Providers Treating Patients with Myelodysplastic Syndrome (MDS) and Acute Myeloid Leukemia (AML): Results of a Two-Phase Qualitative/Quantitative Study

Background: Rapid advances in the understanding of the biology of MDS and AML have led to novel therapeutic interventions that have increased the clinical complexity of decision making in patient care. This study sought to quantify professional practice gaps and barriers to optimal care among healthcare providers treating patients with MDS and AML at academic medical centers and/or community cancer centers and clinics globally, with the goal of informing the design of evidence-based education interventions aiming at addressing these gaps.Methods: In February-May 2021, 329 physicians (n = 190), physician assistants (n = 16) and advanced practice providers [nurse practitioners (n = 51) and pharmacists (n = 72)] were recruited to participate in a two-phase national educational study focused on MDS and AML. Eligible participants had to be active practitioners who treat patients with MDS and AML (n = 263 US; 66 ex-US). In the exploratory qualitative phase of this study, 30 US participants completed a 45-minute telephone interview focusing on the personal, contextual, and behavioral factors that influence a provider's clinical reasoning process in diagnosis and treatment. These participants completed a brief online case-based survey before the interview. Interviews were transcribed and analyzed through thematic analysis. The quantitative phase of this study consisted of an online survey composed of specific multiple-choice questions, semantic differential rating scales, and case vignettes. Respondents' answers to each of the questions in the quantitative survey were compared with optimal answers as identified by treatment guidelines and faculty experts.Results: A group of 6 core practice gaps were identified through combined analysis of data from the online surveys and in-depth interviews. Of note, just 10% of US and 3% of ex-US participants agreed with expert opinion and would consider patients over 75 years with high-risk MDS or AML as possible candidates for stem cell transplant. For newly diagnosed high-risk MDS, 20% to 35% of participants are incorporating venetoclax/azacitidine into practice off-label, even for patients with TP53 mutations. About half (52%) of participants agreed with expert recommendation of venetoclax + HMA for elderly patients (>75 y) with newly diagnosed AML. A minority of participants' practice (18%) matched expert recommendations of venetoclax + HMA for a 68 yo patient with newly diagnosed AML and ECOG PS 2 with a FLT3 mutation with many participants (33%) recommending intensive chemotherapy with midostaurin. Similarly, for secondary AML progression from MDS with previous HMA therapy, a minority of participants (24%) agreed with the expert recommendation of CPX-351. Finally, a minority of study participants knew the mechanisms of action or targets of promising agents in clinical trials for patients with TP53 mutations, including eprenetapopt/APR-246 (31%) and magrolimab (36%). Detailed results of analysis will be presented, including group-specific analyses and investigation of the causalities of each of the practice gaps identified.Conclusions: Many hematology/oncology professionals are not applying optimal care in patients with MDS and AML. Most notably, study participants may not adequately consider stem cell transplant for older patients with high-risk MDS or AML potentially impacting outcomes. At the same time, the overuse of intensive chemotherapy regimens by healthcare providers could have multiple consequences for older patients with AML including poorer outcomes and reduced quality of life. Finally, a lack of familiarity with promising agents under clinical investigation in MDS and AML with TP53 mutations may lead to missed opportunities to enroll eligible patients on clinical trials and potentially delay integration of emerging data and agents with new indications into clinical practice. Results of this study provide evidence to support the design of clinical tools, educational programs, and performance improvement interventions. DisclosuresDaver: Bristol Myers Squibb: Consultancy, Research Funding; Genentech: Consultancy, Research Funding; Daiichi Sankyo: Consultancy, Research Funding; Glycomimetics: Research Funding; Gilead Sciences, Inc.: Consultancy, Research Funding; Sevier: Consultancy, Research Funding; Abbvie: Consultancy, Research Funding; Novimmune: Research Funding; FATE Therapeutics: Research Funding; Astellas: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Amgen: Consultancy, Research Funding; ImmunoGen: Consultancy, Research Funding; Trillium: Consultancy, Research Funding; Trovagene: Consultancy, Research Funding; Hanmi: Research Funding; Novartis: Consultancy; Jazz Pharmaceuticals: Consultancy, Other: Data Monitoring Committee member; Dava Oncology (Arog): Consultancy; Celgene: Consultancy; Syndax: Consultancy; Shattuck Labs: Consultancy; Agios: Consultancy; Kite Pharmaceuticals: Consultancy; SOBI: Consultancy; STAR Therapeutics: Consultancy; Karyopharm: Research Funding; Newave: Research Funding. Stein: Janssen Pharmaceuticals: Consultancy; Genentech: Consultancy; Astellas: Consultancy; Syndax Pharmaceuticals: Consultancy; Daiichi Sankyo: Consultancy; Syros Pharmaceuticals, Inc.: Consultancy; PinotBio: Consultancy; Celgene: Consultancy; Bristol Myers Squibb: Consultancy; Foghorn Therapeutics: Consultancy; Jazz Pharmaceuticals: Consultancy; Gilead Sciences, Inc.: Consultancy; Blueprint Medicines: Consultancy; Abbvie: Consultancy; Agios Pharmaceuticals, Inc: Consultancy; Novartis: Consultancy.

A Comparison of Mentoring and Coaching: What's the Difference?

The work of educators in urban high schools may at times seem rather daunting. Teachers serving in these settings are often in search of intervention strategies that can assist in their efforts to support students in achieving improved outcomes. Mentoring and coaching are two powerful interventions that organizations can implement when attempting to improve their outcomes in human performance. The focus of either of these two personal development interventions is on enhancing individuals through organizational opportunities and self-initiative. However, many times the specific aspects of these two different approaches may be confused and even be referred to interchangeably. A comparison of the fundamental differences between mentoring and coaching will be described in this article. An analysis of the pros and cons of using formal mentoring and coaching programs, as viable performance improvement interventions within an educational organization, will also be presented. Additionally, a brief research-based plan to develop, implement, and evaluate coaching for secondary Career and Technical Education teachers working in high school settings will also be shared. Specific challenges and barriers to the immediate and long-term success of the coaching intervention and effective ways to overcome them will also be examined.

Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention

BackgroundIn this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure.MethodsWe performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months.ResultsPACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07–1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51–7.57, p < 0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed.ConclusionsThis study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc.Trial registrationnot applicable.

The performance measurement conundrum: Construct validity of the Individual Work Performance Questionnaire in South Africa

Background: Performance remains high on the agenda of both researchers and practitioners, and rigorous measurement is central to evidence-based investigations. Several instruments have been developed to measure performance, of which one – the Individual Work Performance Questionnaire (IWPQ) – seems to be a scientifically rigorous instrument. Despite the growth in IWPQ validation studies, little is known about its psychometric properties in South Africa. Aim: The current study seeks to address the construct validity of the IWPQ. The objective was to evaluate the construct (i.e. convergent, discriminant and nomological) validity of the instrument. Setting: Information technology professionals were targeted in the current study, and the final sample consisted of 296 employees. Method: Latent variable modelling was performed, using both independent cluster and exploratory structural equation model frameworks, with the mean- and variance-adjusted weighted least squares estimator. The analysis was complemented with the heterotrait-monotrait method. Results: The results supported the construct validity of the instrument. Specifically, individual work performance was found to be a three-dimensional construct with acceptable convergent and discriminant validity. Job resources were also related to the three performance dimensions. Conclusion: The factor structure of the IWPQ mirrors the factor structure found in the literature. Researchers and practitioners can use this instrument in South Africa to identify determinants and consequence of individual work performance, as well as to evaluate the effectiveness of performance improvement interventions.

Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice.

Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention. Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model. Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff. Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.

Trends and Implications of Models, Frameworks, and Approaches Used by Instructional Designers in Workplace Learning and Performance Improvement

We undertook a three-step process to develop, test, and implement a survey research study to identify the models, frameworks, taxonomies, and approaches, most often used by instructional designers to support workplace learning and performance improvement initiatives in a variety of organizational contexts today. A total of 199 professionals working on instructional design, e-learning, and performance improvement projects responded to the survey. They shared the models they use to inform instructional and non-instructional learning interventions, and performance improvement interventions, project work. Our results show the most widely used ID and HPI-related models include: ADDIE, performance gap analysis, Kirkpatrick's evaluation model, Agile development model, rapid ID prototyping model, Merrill's first principles, the behavioral engineering model (BEM), the cognitive load overlay model, ISPI's human performance technology (HPT) process model, and CADDIE. We present implications for program design, course design, and the ensuing choices of study for emerging practitioners working in different contexts.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Lumbar Drains After Cardiac Surgery: Evidence-Based Solutions for Safe Management.

Evaluation of a Health Care Performance Improvement Initiative to Facilitate Optimal Clinical Outcomes in Patients Receiving Ventricular Assist Device Support

Ventricular assist device (VAD) patients are at high risk for morbidities and mortality. One potentially beneficial component of the Joint Commission VAD Certification process is the requirement that individual VAD programs select 4 performance measures to improve and optimize patients' clinical outcomes. Review of patient data after our program's first certification visit in 2008 showed that, compared to national recommendations and published reports, our patients had suboptimal outcomes in 4 areas after device implantation: length of hospital stay, receipt of early (<48 hours) postsurgical physical therapy, driveline infection incidence, and adequacy of nutritional status (prealbumin ≥18 mg/dL). Plan-Do-Study-Act processes were implemented to shorten length of stay, increase patient receipt of early physical therapy, decrease driveline infection incidence, and improve nutritional status. With 2008 as our baseline, we deployed interventions for each outcome area across 2009 to 2017. Performance improvement activities included staff, patient, and family didactic, one-on-one, and hands-on education; procedural changes; and outcomes monitoring with feedback to staff on progress. Descriptive and inferential statistics were examined to document change in the outcomes. Across the performance improvement period, length of stay decreased from 40 to 23 days; physical therapy consults increased from 87% to 100% of patients; 1-year driveline infection incidence went from 38% to 23.5%; and the percentage of patients with prealbumin within the normal range increased from 84% to 90%. Performance improvement interventions may enhance ventricular assist device patient outcomes. Interventions' sustainability should be evaluated to ensure that gains are not lost over time.

Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections.

Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections. This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period. Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates. Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.

Reducing Blood Culture Contamination Rates: Experiences of Four Hospital Systems.

IntroductionBlood cultures (BCs) frequently become contaminated during the pre-analytic phase of collection leading to downstream ramifications. We present a summary of performance improvement (PI) interventions provided by four hospital systems and common factors that contributed to decreased blood culture contamination (BCC) rates.MethodsEach hospital independently formed a multidisciplinary team and action plan for implementation of their intervention, focusing on the use of educational and training tools. Their goal was to significantly decrease their BCC rates. Pre- and post-intervention data were compared during the sustainment period to determine their success.ResultsAll hospitals met their goals of post-intervention BCC rates and with most achieving and sustaining BCC rates ≤ 1.0–2.0%.ConclusionOur report highlights how four hospitals independently achieved their objective to decrease their BCC rate with the support of a multidisciplinary team. We propose a benchmark for BCC rates of 1.5 to < 2.0% as achievable and sustainable.

HR Practices and Employee Retention. Leader -Member Exchange (LMX) as a mediator

The present research aims at investigating the impact of human resource (HR) practices on employee retention with the mediator effect of Leader-Member exchange (LMX) among IT employees in Malaysia. The present research attempts to narrow the research gaps by hypothesizing that HR practices (job security, work-life balance and training opportunities) significantly influence employee retention. The research employs a quantitative research approach whereby data were collected from 109 ICT professionals from MSC status companies in Malaysia. For analyzing the hypothesis, the SEM analysis is conducted. The research found that HR practices significantly influence employee retention among ICT professionals in Malaysia. It was also found that LMX mediates the relationship between HR practices and employee retention. Several implications from this research were discussed. In particular, HR managers, corporate leaders as well as government leaders and officials may use the findings of this research to justify the efforts in designing performance improvement interventions so that employee retention will be monitored and further enhanced among ICT professionals in Malaysia. Several other implications were further discussed.

Effects of a peer-mediated performance improvement intervention on recording of child well-body checks by educational care-providers.

We report the effects of peer-mediated training as a performance improvement intervention on recording of well-body checks by classroom instructors at a specialized school for children and youth. The instructors were trained as peer mediators and then assumed performance monitoring responsibilities in the classroom. Compared to baseline phases in a withdrawal design, peer-mediation increased recording of well-body checks to near-100% among the instructors. Results of the study document positive training effects on a critical health and wellness objective, support and expand the limited research base concerning the effects of peer-mediated training, suggest further application of such training in human services settings.

Clinical Transformation Through Change Management Case Study: Chest Pain in the Emergency Department

Introduction/BackgroundAdults with chest pain presenting to an emergency department are high-risk and high-volume. A methodology which gathers practicing physicians together to review evidence and share practice experience to formulate a written algorithm with key decision points and measures is discussed with implementation, based on change management principles, and results. MethodsA methodology was followed to “establish the standard-of-care”. Literature and data were reviewed, a written consensus algorithm was designed with ability to track adherence and deviations. We performed a before and after analysis of a performance improvement intervention in adult patients with undifferentiated chest pain in our nine-campus hospital system in Florida between January 1st, 2014 and December 31st, 2018. ResultsA total of 200,691 patients were identified as adults with chest pain and the algorithm was used. A dramatic change in the disposition decision rate was noted. When the ‘Baseline-Year’ was compared with the ‘Performance-Year’, chest pain patients discharged from the ED increased by 99%, those going to the ‘Observation’ status decreased by 20%, and inpatient admissions decreased by 63% (p < 0.0001) All patients were tracked for 30-days for major adverse cardiac event (MACE) or return to the ED within the same system. If the s emergency physicians had not changed their practice/behavior and the Baseline-Year decision rate during the entire Performance-Year was unchanged, then 4563 more patients would have gone to Observation and 7986 patients to Inpatient. The opportunity costs avoided would be approximately $31million (US$. ConclusionsFor successful clinical transformation through change management, we learned: select strategic topics, get active physicians together, write a consensus algorithm with freedom to deviate, identify and remove barriers, communicate vision, pilot with feedback, implement, sustain by “hard wiring” into the electronic medical record and measure outputs.

Leveraging existing program data for routine efficiency measurement in Zambia.

Rationale: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level. But program managers lack routine information on unit expenditures at points of care, and higher-level planners are unable to assess resource use in the health system. Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Phased Implementation of REMS: FHI 360 developed the Routine Efficiency Monitoring System (REMS)-a relational database leveraging existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service. Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces. REMS allocation algorithms were developed through facility assessments, and key informant interviews with MoH staff. Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures. Trained users access REMS output through user-friendly dashboards delivered through a web-based application. REMS as a Solution: District health managers use REMS to identify "outlier" facilities to test performance improvement interventions. Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need. REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling. Conclusions and Next Steps: REMS gives managers and planners substantially-improved data on how programs transform resources into services. The GRZ is seeking funding to expand REMS nationally, covering all major disease areas. Improved technical efficiency supports the goal of a sustainable HIV/AIDS response.

Improving Classroom Appearance and Organization Through a Supervisory Performance Improvement Intervention.

This study evaluated the effects of a supervisory intervention on maintenance of appearance and organization in classrooms at a human services program for children and youths. The intervention combined performance feedback to classroom staff, public posting of performance outcomes, and eligibility for a performance-based incentive. Conducted in a multiple-baseline design, intervention was immediately and consistently effective in all classrooms. These findings support organizational behavior management applications within human services programs to improve performance that is related to environmental care.