Practitioner Feedback Research Articles

The Writing Series Project: A Model for Supporting Social Work Clinicians in Health Settings to Disseminate Practice Knowledge

Social work clinicians across health care settings are uniquely positioned to disseminate valuable practice experience, thereby contributing to knowledge development within their field of practice and across disciplines. Unfortunately, practitioners tend to shy away from writing and research, and are often reluctant to publicly disseminate their expertise through peer-reviewed journals and conference presentations. To better support health social workers in scholarly endeavors, we developed and implemented The Writing Series Project in southeast Queensland, Australia. This article reports on the development, programmatic challenges and practitioner feedback that offer insight into the benefits and pitfalls that we encountered.

Critically Reflective Work Behavior of Health Care Professionals

Better understanding of critically reflective work behavior (CRWB), an approach for work-related informal learning, is important in order to gain more profound insight in the continuing development of health care professionals. A survey, developed to measure CRWB and its predictors, was distributed to veterinary professionals. The authors specified a model relating CRWB to a Perceived Need for Lifelong Learning, Perceived Workload, and Opportunities for Feedback. Furthermore, research utilization was added to the concept of CRWB. The model was tested against the data, using structural equation modeling (SEM). The model was well represented by the data. Four factors that reflect aspects of CRWB were distinguished: (1) individual CRWB; (2) being critical in interactions with others; (3) cross-checking of information; and (4) openness to new findings. The latter 2 originated from the factor research utilization in CRWB. The Perceived Need for Lifelong Learning predicts CRWB. Neither Perceived Workload nor Opportunities for Feedback of other practitioners was related to CRWB. The results suggest that research utilization, such as cross-checking information and openness to new findings, is essential for CRWB. Furthermore, perceptions of the need for lifelong learning are more relevant for CRWB of health care professionals than qualities of the workplace.

237 Effects of timely practitioner feedback on time to treatment in an early STEMI reperfusion program in Northern Alberta

237 Effects of timely practitioner feedback on time to treatment in an early STEMI reperfusion program in Northern Alberta

Viewpoint: Canʼt Get No Satisfaction? The Real Truth Behind Patient Satisfaction Surveys

Viewpoint: Canʼt Get No Satisfaction? The Real Truth Behind Patient Satisfaction Surveys

Hypertension in the ED: a multifaceted intervention to change provider practice

This project measured the effect of a multifaceted intervention on health care provider identification and treatment of undiagnosed hypertensive patients. The intervention comprised provider education, audit, and feedback. The primary outcomes were pre-/postintervention differences in the proportion of patients presenting with elevated blood pressure who were (1) identified, (2) given blood pressure measurements, (3) counseled regarding behavior change, (4) prescribed medications, and (5) advised of the need for follow-up. These 5 behaviors were selected based on the recommendations in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Rates of all 5 outcomes improved significantly after the intervention, with prevalence differences ranging from 5% to 25%. However, despite increases, rates for each behavior remained low. At no point during the study were all 5 practitioner behaviors documented for an individual patient. In conclusion, while an intervention composed of education and practitioner audit and feedback improved practitioner behaviors in treating patients with elevated blood pressure, additional interventions are needed to bring practitioner behaviors up to the level of JACHO standards.

European Society of Hypertension Practice Guidelines for home blood pressure monitoring

Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

The paradox of readmission: Effect of a quality improvement program in hospitalized patients with heart failure

Congestive heart failure (CHF) is an increasingly common condition associated with significant hospital resource utilization. Initiating better disease management at the time of initial hospital admission has the potential to reduce readmissions. To evaluate the impact of a multifaceted quality improvement program on 12-month hospital utilization in patients admitted to hospital with CHF. Prospective longitudinal study comparing baseline and intervention cohorts. All consecutive patients with CHF discharged alive from 3 metropolitan hospitals during the baseline (October 1, 2000 to April 17, 2001) and intervention (February 15, 2002 to August 31, 2002) study periods. Active prospective case-finding identified 220 baseline and 235 intervention participants; full data was available on 197 baseline and 219 intervention participants. Education and performance feedback for hospital and primary care practitioners; clinical decision support tools; individualized, guideline-based treatment plans; patient education and self-management support; and improved hospital-community integration. Twelve-month all-cause hospital readmission, 12-month mortality, readmission-free survival, heart failure-specific readmission, and total hospital days over 12 months. Intervention patients had a higher rate of all-cause readmission (odds ratio [OR] = 1.65; 95% confidence interval [CI] = 1.10-2.46) but a trend to reduction in mortality (OR = 0.68; 95% CI = 0.44-1.07). There was no difference in frequency of hospitalizations per year, number of hospital days, or the composite outcome of death or readmission. The intervention improved care processes and may have reduced mortality, but at the cost of higher readmission rates. Better understanding of intervention components, intensity, and targeting may optimize the effectiveness of disease management programs.

Effect of an Audit and Feedback Intervention on Hospitalized Oncology Patients' Perception of Nurse Practitioner Care

Although patient satisfaction has been used traditionally as a measure of excellence, research has suggested that the perception of being well cared for is likely a more promising indicator of quality than satisfaction alone. Expectations, physical environment, communication, participation and involvement, technical competence, and the influence of healthcare organizations are factors that may impair patients' ability to distinguish nursing care from their overall healthcare experience. This study evaluated the effect of a nurse practitioner audit and feedback intervention on hospitalized patients' perception of care.

Experiential placements and scaffolding for reflection

AbstractReflection is a cognitive process for organizing ideas and building theory from observations and experiences. Learning within work‐integrated and clinical placements is increasingly required for professional accreditation approval of allied health and other university programmes. Through clinical placements students can develop the knowledge and the practical skills and personal attributes needed for entry into their professions. Relevant to communities of practice, in experiential placements learners actively build on their own life experiences within realistic work‐oriented contexts. Supervising practitioner feedback and guidance potentially accelerate the learning through a process of feedback and skilful questioning to encourage deep reflection. However, there has been little research into the role of reflection within experiential placements, particularly with respect to the preparation of students for the Australian pharmacy profession.A 2007 Australian Learning and Teaching Council‐funded research study was conducted regarding pharmacy experiential placements. The purpose was to map Australian university programmes, analyse handbooks and also consult with about 250 stakeholders from a range of backgrounds in relation to issues and quality indicators.This paper focuses on reflection as one aspect of the Australian pharmacy experiential placement research. It highlights the importance of more comprehensively planned approaches to learning and reflection within experiential placements. This includes university and clinical educator scaffolding and feedback at the pre‐placement, during placement and post‐placement stages.

Registries Might Provide Important Feedback for Individual Practitioners

Registries Might Provide Important Feedback for Individual Practitioners

Implementation of an insulin therapy protocol: Applying the Baldrige approach

One quality initiative that North Mississippi Medical Center (NMMC) included in its application for the Malcolm Baldrige National Quality Award (MBNQA) is described. NMMC is a 650-bed, regional, nonprofit medical center that serves 22 counties in an area with approximately 600,000 people. The hospital received the MBNQA in 2006. NMMC's insulin performance-improvement team recognized a patient safety issue with the use of three insulin sliding scales that did not adequately meet the evidence-based standard of care for diabetes. The team developed a standard sliding-scale order set to enhance patient care and target blood glucose concentrations of 70-120 mg/dL. NMMC's quality initiatives aligned with the seven categories of the Baldrige Criteria for Organizational Performance Excellence-leadership; strategic planning; patient focus; measurement, analysis, and knowledge management; work-force focus; process management; and results. The insulin performance-improvement team included an endocrinologist, nursing staff, information technology staff, and a pharmacist. The goal of the insulin performance- improvement team was to develop a standard sliding insulin scale order set based on literature evidence, clinical knowledge, practitioner feedback, and information technology. The team considered the pharmacy department in the planning and implementation of the project, and pilot programs were conducted to best predict work-force issues. Inservice education was provided to nurses, pharmacists, and physicians over the course of several weeks. The team's attentiveness to time management created a seamless project. The three original sliding scales were discontinued, and the standard NMMC sliding scale was implemented on June 26, 2006. Because the Baldrige approach is versatile and flexible, it helped the insulin performance-improvement team at NMMC meet the challenging demands of health care. The Baldrige approach was successfully used to implement a standard insulin therapy protocol.

An investigation into the alignment of a South African physiotherapy curriculum and the expectations of the healthcare system

Until 1994, physiotherapy education and training were aligned with the expectations of the South African healthcare system. Subsequent to policy shifts since 1994, the professional role of physiotherapists has expanded. In the absence of guiding strategies to support this change, physiotherapy curricula have remained relatively static. Objective The paper examines the discrepancies between physiotherapy education and training at a South African university post apartheid and the expectations of the healthcare system. Design Located within critical feminist research framings and employing narrative inquiry as the selected methodology, data were produced through multiple methods to obtain multiple perspectives and orientations. Participants This multisectorial data production approach involving student physiotherapists, physiotherapy academics and practising physiotherapists included in-depth focus group interviews, individual interviews, life-history biographies and open-ended questionnaires. The data were analysed separately for each group of research participants (physiotherapy students, practitioners and academics), followed by a cross-sector analysis. Results The analysis illustrated current disciplinary trends and shortcomings of the physiotherapy undergraduate curriculum, whilst highlighting that which is considered valuable and progressive in physiotherapy and health care. The dominant themes that emerged included issues relating to physiotherapy theory and practice, and issues that influenced the construction of relationships in the curriculum. Conclusion The significance of this study lies in the value of student and practitioner feedback to inform curriculum and professional development in the light of sociopolitical changes and healthcare expectations.

Exploring the Possibilities of an Expanded Practice Repertoire in Child Protection

• Summary: This article discusses research that explored an alternative to proceduralized child protection practice informed by the risk paradigm, by expanding the repertoire available to practitioners through combining features of the risk paradigm with social constructionism. This approach incorporates three dimensions: theories of knowledge and power, related professional roles, and practice skills. In this article, we discuss and critically evaluate only the first dimension: theories of knowledge and power. Through dialogue facilitated by semi-structured questions, we explored practitioners' perspectives about the relevance and appropriateness of the alternative approach for practice. • Findings: The practitioners' participation and feedback offer insights into complex connections between `theory' and `practice' with the practitioner as a positioned subject and mediator of practical meanings of formal concepts. • Applications: 1) Recognition of each practitioner's interpretation of formal concepts and how they are applied in actual practice, even within shared organizational contexts. 2) The importance of dialogue to expand the range of possibilities that maintain openness to ongoing learning. 3) The value of theoretical pluralism that may offer greater opportunities for professional discretion, rather than single self-contained approaches that may constrain effective and ethical practice.

The Use of IVIG for Solid Organ Transplantation: An Evidence Based Practice Guideline

Background Utilization of intravenous immune globulin (IVIG) is increasing in Canada and worldwide despite few and no new labeled indications. In 2007, Canadian Blood Services in collaboration with the National Advisory Committee on Blood and Blood Products convened a panel of solid organ transplantation (SOT) experts (kidney, heart, lung, and liver) and methodologists to develop an evidence-based practice guideline for the use of IVIG in patients undergoing SOT. The objectives of this guideline areto examine the evidence for the use of IVIG in patients who are candidates for SOT and are sensitized to HLA or ABO antigens,to provide guidance for Canadian practitioners involved in the care of these patients and transfusion medicine specialists on the use of IVIG.Methods: The panel identified clinical areas of SOT that would benefit from treatment with IVIG and generated key clinical questions. A systematic, expert and bibliography literature search up to July 2008 was conducted to ensure all relevant publications were included. The panel generated recommendations based on the evidence. The levels of evidence and grading of recommendations were adapted from the Canadian Task Force on Preventative Health Care. To validate conclusions and recommendations, the practice guideline will be sent to physicians involved in solid organ transplantation in Canada and a patient representative. Recommendations from practitioner feedback will be incorporated, and the guideline will be disseminated to all physicians involved in the care of patients receiving solid organ transplantation in Canada to aid implementation of the guideline. The National Advisory Committee of Blood and Blood Products in Canada will subsequently assess the performance of the guideline and will renew the guideline at timely intervals.Results and Conclusions: The research questions developed by the panel were: Is there evidence that the use of IVIG reduces morbidity and mortality for patients undergoing SOT who aresensitized (HLA or ABO)in the perioperative setting and are sensitizedexperiencing acute graft rejection orexperiencing chronic graft rejection? 791 citations were retrieved, and panel members identified 3 additional citations.51 reports and a systematic review were used for this guideline. These reports were limited by inconsistent definitions of sensitization, inconsistent reporting of the type and titre of the antibody, the assays used to detect HLA antibodies, the response criteria and dosing schedules for IVIG. Thus, a consensus process was used to account for the poor evidence. The use of IVIG was associated with decreased sensitization and acceptable morbidity and mortality in living donor kidney transplantation. IVIG has been used with several other modalities for ABO-incompatible kidney transplantation and it was difficult from the existing literature to separate outcomes based on a single modality. There was also limited data on the perioperative use of IVIG in renal transplantation. IVIG was shown to be effective in combination with plasmapheresis for acute antibody mediated rejection of the kidney; however the role of IVIG was not clear for other forms of rejection. There were also several methodological limitations in the literature assessing IVIG for cardiac transplantation and only limited data were available to assess the use of IVIG for lung or liver transplantation. Future studies are needed to define the role of IVIG in solid organ transplantation and should capture the following elements: impact on antibody (specificity and titres), transplant rates, time to transplantation, graft function, graft survival, and rejection (cellular and antibody mediated).

Creating a System to Facilitate Translation of Evidence Into Standardized Clinical Practice: A Preliminary Report

The Institute of Medicine, through its landmark report concerning errors in medicine, suggests that standardization of practice through systematic development and implementation of evidence-based clinical pathways is an effective way of reducing errors in emergency systems. The specialty of emergency medicine is well positioned to develop a complete system of innovative quality improvement, incorporating best practice guidelines with performance measures and practitioner feedback mechanisms to reduce errors and therefore improve quality of care. This article reviews the construction, ongoing development, and initial impact of such a system at a large, urban, university teaching hospital and at 2 affiliated community hospitals. The Committee for Procedural Quality and Evidence-Based Practice was formed within the Department of Emergency Medicine to establish evidence-based guidelines for nursing and provider care. The committee measures the effect of such guidelines, along with other quality measures, through pre- and postguideline patient care medical record audits. These measures are fed back to the providers in a provider-specific, peer-matched "scorecard." The Committee for Procedural Quality and Evidence-Based Practice affects practice and performance within our department. Multiple physician and nursing guidelines have been developed and put into use. Using asthma as an example, time to first nebulizer treatment and time to disposition from the emergency department decreased. Initial therapeutic agent changed and documentation improved. A comprehensive, guideline-driven, evidence-based approach to clinical practice is feasible within the structure of a department of emergency medicine. High-level departmental support with dedicated personnel is necessary for the success of such a system. Internet site development (available at http://www.CPQE.com) for product storage has proven valuable. Patient care has been improved in several ways; however, consistent and complete change in provider behavior remains elusive. Physician scorecards may play a role in altering these phenomena. Emergency medicine can play a leadership role in the development of quality improvement, error reduction, and pay-for-performance systems.

A 10-year history of lung cancer practice guideline development: Process, productivity and impact

17044 Background: CCO's Program in Evidence-based Care at McMaster University, has developed and disseminated clinical guidance documents through provincial DSGs for 10 years. The 37 member Lung DSG includes medical oncologists (17), radiation oncologists (11), thoracic surgeons (4), nurses (2), and a research coordinator. Pathologists (3), community/patient representatives (2), a medical resident and medical sociologist have previously been members. Methods: The LDSG has used the practice guideline (PG) development cycle described by Browman GP et al (JCO 1998; 16(3):1226–31). Results: 31 reports have been published in peer-reviewed journals, including 25 guidelines; all PGs are posted on the CCO website. Topics were initially selected on the basis of known practice variability (chemotherapy for Stage IV NSCLC) or clinical controversy (combined modality therapy for Stage III NSCLC); PGs for single chemotherapy drugs (6) or chemotherapy usage in specific situations (7) have dominated DSG activity; 5 PGs on radiotherapy alone and 3 on RT as part of CMT have been completed; recent PGs have been written for rare tumours (mesothelioma, thymoma) and diagnostic imaging (PET). Initially, PGs were based solely on published RCT evidence. Evidence from publicly accessible abstracts/meeting presentations, and Phase II trials (in the absence of higher quality evidence) is now considered. For rare tumours (thymoma), the DSG has used a Delphi consensus methodology. Knowledge transfer occurs through the DSG meeting process (twice yearly face-to-face; 2–4 teleconferences), practitioner feedback (PF), publications, presentations and web posting. PF using a standardized feedback questionnaire is generally high (59.9%) but varies by PG and discipline; PF is incorporated into final guideline documents. Guideline recommendations for the use of vinorelbine, gemcitabine, taxanes and erlotinib in NSCLC have been successful in securing government funding. No significant financial relationships to disclose.

Use of systemic therapy in women with recurrent ovarian cancer—Development of a national clinical practice guideline

16033 Background: To develop a national guideline on the use of systemic therapy for women with recurrent ovarian cancer. Methods: In March 2005, the Society of Gynecologic Oncologists of Canada (GOC) held a workshop with clinicians and methodologists to begin the process of defining specific recommendations for the management of recurrent ovarian cancer in the Canadian context. An adaptation process developed by the Canadian Strategy for Cancer Control (CSCC) Clinical practice Guidelines Action Group (CPG-AG) was used. Guideline adaptation modifies existing guidelines to fit a local organizational and cultural context. A draft guideline was developed and sent to practitioners from across Canada for feedback. Relevant comments were incorporated. Results: A literature review identified seven guidelines which were assessed for quality by six reviewers using the AGREE instrument. Data on guideline quality, currency and content (recommendations) was used by the pan-Canadian panel in an informal consensus process which resulted in the initial draft of a guideline. A sub-panel reviewed the draft and made further edits to ensure the guideline's appropriateness for a national context. Practitioner feedback was requested from 165 health care providers who treat ovarian cancer from across Canada. Overall response rate was 37%. Respondents included gynecologic oncologists (62.5%), medical oncologists (25%), radiation oncologists (3%), internal medicine (3%), gynecologists (1%) and psychosocial oncology (1%). Overall response to the guideline was positive. All comments were reviewed by the sub-panel and the guideline was edited appropriately. Conclusions: This was the first undertaking of the creation of an interdisciplinary guideline in gynecologic oncology with input from health care providers from across Canada. Feedback from the panel and external practitioners indicated that this was a worthwhile process. Our goal was to vet this work in the Canadian context so as to inform provincial decision-makers concerning access to expensive systemic therapy. The guideline has been endorsed by the national organization and will be available to practitioners and decision makers on the organization's website. No significant financial relationships to disclose.

Regional models of care for systemic therapy: Standards for organization and delivery

17057 Background: Rapidly expanding indications for cancer systemic therapy combined with human resource and facility constraints require innovative approaches to deliver safe, patient-centred, and evidence-based care across Ontario, a province covering 1 million sq km, organized into 14 regions, each with about 1 million inhabitants. A systemic therapy project team recommended the best way to organize the delivery of ambulatory systemic therapy in Ontario. Methods: A core multidisciplinary panel reviewed the evidence and developed standards. The panel used evidence-based analysis of relevant publications, an environmental scan of other existing recommendations and expert opinion based on experience and consensus to formulate a standards document to guide treatment delivery. This was reviewed and amended by the full project team. The document was circulated to oncologists, family practitioners, internists, pharmacists, nurses and administrators who work in or have responsibility for systemic therapy in the regions for practitioner feedback. Results: A Regional Systemic Therapy Program (STP) Model was developed in which Integrated Cancer programs (ICPs) provide comprehensive cancer services, leadership of quality and overall organisation/coordination for the region. STPs include ICPs directly linked to satellite centres and also affiliated to centres with their own systemic therapy programs to provide appropriate systemic therapy services for all regions under a common set of standards. Five levels of care are recommended, with complexity and availability of services differentiating the levels. For each level, standards were established for; 1-Providers and their roles, 2-Education for providers, 3-Service type and complexity, 4-Service volumes, 5- Quality assurance and safety, 6-Facility requirements, 7-Administrative and organizational responsibilities. The intent is to provide the same standard of care in the most appropriate setting within the appropriate time frame. STPs will implement, monitor and evaluate quality indicators. Conclusions: A detailed review of the document including results of practitioner feedback as well as survey results from the 14 STPs to determine whether standards are being currently met will be presented. No significant financial relationships to disclose.

Use of systemic therapy in women with recurrent ovarian cancer—Development of a national clinical practice guideline

Objective To develop a guidance document concerning the use of systemic therapy for women with recurrent ovarian cancer that would be applicable for the Canadian health care system. This will be done using a standardized systematic review process, guideline evaluation instruments, multi-disciplinary expert consensus opinion and evidence-rating systems. Data selection The primary data sources were MEDLINE, National Guideline Clearinghouse and Cochrane Library. Methods Clinical practice guidelines, technology assessments, systematic reviews and randomized controlled trials addressing systemic therapy for women with recurrent ovarian cancer were eligible. Data extraction Data was identified and extracted by the methodology team and reviewed by the authors. Results were reviewed and discussed by members of an expert working group comprised of a multidisciplinary and geographic divergent group of practitioners. Data synthesis The existing 7 practice guidelines underwent formal evaluation for quality, currency and content using the AGREE tool. Recommendations with evidence-ratings were developed. This data was used by a pan-Canadian panel in an informal consensus process, which resulted in the initial draft of a guideline. The guideline team reviewed the draft and made further edits to ensure the guideline's appropriateness for a national context. Practitioner feedback was requested from 165 health care providers who treat ovarian cancer from across Canada. Overall response rate was 37% and was very positive. Comments were reviewed and the guideline was edited appropriately. Conclusion The development of a national practice guideline on the use of systemic therapy for recurrent ovarian cancer was feasible using systematic literature review, expert consensus, guideline evaluation instruments, evidence-rating systems, independent internal and external review measures and final approval by a national discipline specific society (GOC). Recommendations for practice are offered.

Improving medication safety: influence of a patient‐specific prescriber feedback program on rate of medication reviews performed by Australian general medical practitioners

To determine if patient-specific prescriber feedback for general medical practitioners (GPs), supported by educational material mailed to their patients, would increase home medicines review (HMR) rates. An observational study was conducted using the Repatriation Pharmaceutical Benefits Scheme (RPBS) Pharmacy Claims Database. The intervention group (n = 40 270) included all veterans aged >/=65 years, dispensed >/=5 unique medicines each month over a 4 month period. Comparison group veterans (n = 49,227) were those who did not have >/=5 or more unique medicines dispensed each month, but did have at least one prescription each month and >/=20 prescriptions over 4 months, of which five were unique medicines, Intervention GPs (n = 11,384) were subdivided into 2 groups: GPs with intervention veterans (n = 2097) and GPs with both intervention and comparison group veterans (n = 9287). The comparison group of GPs (n = 3630) were primary prescribers to the comparison veterans only. Rates of HMRs pre and post-intervention and the number of new GPs participating in HMR services were examined. There was a significant increase in HMR rates in intervention group, from 2.2 per 1000 in the pre-period to 4.6 per 1000 per month in the post-intervention period (Rate Ratio (RR) 2.06, 95% Confidence Interval (CI) (1.90, 2.22), p < 0.0001). HMR rates increased in the intervention group compared with the comparison group (p < 0.0001). HMR rates increased in the intervention group GPs compared with the comparison group (RR 1.79, 95% CI (1.58, 2.02), p < 0.0001). Patient-specific feedback provided to GPs, supported by educational material mailed directly to their patients increased HMR rates for targeted veterans and increased GP participation in the delivery of HMRs.