Problems In Care Delivery Research Articles

Highlighting a Common Quality of Care Delivery Problem: Overuse of Low-value Healthcare Services

Low-value healthcare services (LVHS) are defined as procedures delivered that provide little or no clinical benefit. Overuse of LVHS, or delivery when the risks exceed the benefits, contributes to excessive spending without improved outcomes. Furthermore, overuse contributes to healthcare waste. The primary purpose of this commentary is to (1) examine the problem of LVHS overuse and its impacts on quality care delivery and (2) propose factors to consider in developing quality measures to help reduce overuse and waste and thus improve patient outcomes. To inform and support this commentary, we conducted a limited review of the literature related to LVHS overuse, its consequences, and suggested solutions. Online search engines were used to identify research related to our primary areas of interest. This commentary demonstrates that overuse and associated healthcare waste is growing among selected LVHS. The factors of overuse are multidimensional and poorly understood. Meanwhile, overuse of LVHS has financial consequences and impacts quality of care and outcomes. Overuse of LVHS is common in the United States, leading to waste and suboptimal patient outcomes. Thus a need exists to address overuse and develop measures to capture a larger scope of services.

Tackling Large-Scale Home Health Care Delivery Problem with Uncertainty

In this work, we investigate a multi-period Home Health Care Scheduling Problem (HHCSP) under stochastic service and travel times. We first model the deterministic problem as an integer linear programming model that incorporates real-world requirements, such as time windows, continuity of care, workload fairness, inter-visit temporal dependencies. We then extend the model to cope with uncertainty in durations, by introducing chance constraints into the formulation. We propose efficient solution approaches, which provide quantifiable near-optimal solutions and further handle the uncertainties by employing a sampling-based strategy. We demonstrate the effectiveness of our proposed approaches on instances synthetically generated by real-world dataset for both deterministic and stochastic scenarios.

Development of the major trauma case review tool

BackgroundAs many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure.MethodsDevelopment of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool.ResultsThe final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters.DiscussionThis research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care.ConclusionsThis tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.

Partnerships to Improve Oral Hygiene Practices: Two Complementary Approaches.

The omission of oral care is linked to increased nurse workload and may contribute to serious patient infection and growing healthcare costs. Therefore, ineffective oral care comprises a significant patient safety issue across healthcare settings internationally. As studies have demonstrated a positive relationship between Nurs Leadersh (Tor Ont) and improved patient outcomes, it is imperative that leaders seek effective approaches to facilitate contextual exploration of barriers and facilitators for resolution of oral care delivery problems. One approach to improved processes of oral care is the creative engagement of front-line clinicians in the problems they confront in everyday practice. By drawing upon the role and process of facilitation, we outline two projects, located in Australia and Canada, that engaged front-line nurses, health leaders, and researchers as partners to identify a path to improved oral care delivery. In this paper, we summarize key learnings for nursing leaders about strategies to facilitate delivery of fundamental oral care. We found that facilitation, contextual knowledge and academic-clinician partnerships were essential to the detection and evaluation of oral care delivery problems and the identification of priorities for practice improvement. As collaboration is imperative for sustainable innovation, we summarize strategies of effective leadership for improving oral care delivery.

A Reflection on Research, Theory, Evidence-based Practice, and Quality Improvement

A Reflection on Research, Theory, Evidence-based Practice, and Quality Improvement

Analysis of progress and problems in coordinated care delivery

Authors described the patterns, core measures and mechanisms of coordinated care delivery in the localities and analyzed initial outcomes of this practice. It is found that such practice has optimized distribution of regional healthcare resources, implemented first visit to primary institutions, and the care delivery to separate emergency from outpatient service. In addition, the paper analyzed problems found in localities in terms of policy, public hospitals and primary institutions, and proposed elements required for coordinated care delivery system to succeed, such as enhanced policy support, enhanced multi-departmental coordination, and public hospital reform to explore feasible approaches. Key words: Coordinated care; Public hospital reform

Selecting a Dynamic Simulation Modeling Method for Health Care Delivery Research—Part 2: Report of the ISPOR Dynamic Simulation Modeling Emerging Good Practices Task Force

In a previous report, the ISPOR Task Force on Dynamic Simulation Modeling Applications in Health Care Delivery Research Emerging Good Practices introduced the fundamentals of dynamic simulation modeling and identified the types of health care delivery problems for which dynamic simulation modeling can be used more effectively than other modeling methods. The hierarchical relationship between the health care delivery system, providers, patients, and other stakeholders exhibits a level of complexity that ought to be captured using dynamic simulation modeling methods. As a tool to help researchers decide whether dynamic simulation modeling is an appropriate method for modeling the effects of an intervention on a health care system, we presented the System, Interactions, Multilevel, Understanding, Loops, Agents, Time, Emergence (SIMULATE) checklist consisting of eight elements. This report builds on the previous work, systematically comparing each of the three most commonly used dynamic simulation modeling methods—system dynamics, discrete-event simulation, and agent-based modeling. We review criteria for selecting the most suitable method depending on 1) the purpose—type of problem and research questions being investigated, 2) the object—scope of the model, and 3) the method to model the object to achieve the purpose. Finally, we provide guidance for emerging good practices for dynamic simulation modeling in the health sector, covering all aspects, from the engagement of decision makers in the model design through model maintenance and upkeep. We conclude by providing some recommendations about the application of these methods to add value to informed decision making, with an emphasis on stakeholder engagement, starting with the problem definition. Finally, we identify areas in which further methodological development will likely occur given the growing “volume, velocity and variety” and availability of “big data” to provide empirical evidence and techniques such as machine learning for parameter estimation in dynamic simulation models. Upon reviewing this report in addition to using the SIMULATE checklist, the readers should be able to identify whether dynamic simulation modeling methods are appropriate to address the problem at hand and to recognize the differences of these methods from those of other, more traditional modeling approaches such as Markov models and decision trees. This report provides an overview of these modeling methods and examples of health care system problems in which such methods have been useful. The primary aim of the report was to aid decisions as to whether these simulation methods are appropriate to address specific health systems problems. The report directs readers to other resources for further education on these individual modeling methods for system interventions in the emerging field of health care delivery science and implementation.

Decreasing time to antibiotics in febrile patients with central lines in the emergency department.

Rapid antibiotic administration is essential for the successful management of patients who have central lines and present with fever. We conducted an emergency department (ED) improvement initiative to deliver antibiotics to 90% of patients within 60 minutes and to minimize process variation. Our setting was an academic ED. We assembled a multidisciplinary team, identified contributing factors to the care delivery problem, determined key drivers and intervention steps, implemented changes, and used strategies to engage ED staff and promote sustainability. Outcomes were analyzed by using a time series design with baseline data and continuous postintervention monitoring. Outcomes included percentage of patients receiving antibiotics within 60 minutes, time to antibiotic administration, and accuracy for triage acuity and chief complaint. An 8-month baseline period revealed that 63% of patients received antibiotics within 60 minutes of arrival, with a mean time to antibiotics of 65 minutes. Multiple Plan-Do-Study-Act (PDSA) cycles were used to improve patient identification and initial management processes. The percentage of patients receiving antibiotics within 60 minutes of arrival was increased to 99% (297 of 301), and mean time to administration decreased to 30 minutes (95% confidence interval: 28-32). These gains were sustained for 24 months. Subanalysis identified a racial discrepancy, with African American patients experiencing significantly longer delays than patients of other races (95 vs 61 minutes; P < .05); this discrepancy was eliminated with our initiative. Our initiative exceeded our goal of 90% antibiotic delivery within 60 minutes for a sustained period of at least 24 months, decreased process variation and mean time to antibiotic administration, and eliminated race-based discrepancies in care.

Introduction to the special issue on psychotherapy, the affordable care act, and mental health parity: obstacles to implementation.

The articles in this Special Issue of Psychodynamic Psychiatry were written by members of The Committee on Psychotherapy of the Group for the Advancement of Psychiatry. Susan Lazar, M.D. is past Chair of The Committee; Frank Yeomans, M.D. is current Chair. The Group for the Advancement of Psychiatry (GAP) was created by the American Psychiatric Association shortly after WWII. It is organized in committees whose function is to publish articles and monographs on issues of contemporary interest. Psychodynamic Psychiatry is pleased to publish this Special Issue which is of substantial psychiatric and public health relevance. The journal staff commends the GAP Committee on Psychotherapy for calling attention to an area that requires sustained attention and action from the mental health community. Despite progressive legislation serious problems in psychiatric care delivery remain unsolved. These are systematically discussed in this Special Issue of Psychodynamic Psychiatry. America has a crisis in mental health care. Psychological difficulties are common and often reach clinical proportions. For example, in a definitive investigation, a representative sample of 9,282 Americans was interviewed to ascertain the lifetime prevalence and age of onset of DSM-IV psychiatric disorders. The investigators found that about 50% of the population met criteria for a psychiatric disorder sometime in their lives. The first onset of the disorder was usually during childhood or adolescence (Kessler, Berglund, Denker et al., 2005). In any given year approximately 57.7 million people suffer from mental disorders. These are severe, chronic, and/or recurrent and often coexist with other mental and physical disorders in about 15% of the population (Green, McLaughlin, Berglund et al., 2010; Kim-Cohen, Caspit, Moffit et al., 2003). Mental disorders are the leading cause of disability

SU‐E‐T‐288: Root Cause Analysis for a Wrong Isocenter Error

Purpose:This study is to explore root cause analysis (RCA) in the context of a departmental incident reporting system through a case report of a wrong isocenter. RCA of this incident provides a means to undercover and address underlying causal factors to prevent such an event in the future.Methods:The wrong isocenter error was detected on port films, making it a near‐miss, but the potential impact was severe. Following the modified London Protocol for RCA, we interviewed all the staff involved, including the simulation and treatment therapists, the dosimetrist, the physicist and the physician. A timeline of events leading up to the incident and its discovery was created. We then generated a list of care delivery problems and associated contributing factors. Finally, solutions were identified to address the contributing factors and prevent future recurrences of such an incident.Results:Though not obvious at the outset of this RCA, the main care delivery problem turned out to be a misidentification of the ball‐bearing (BB) location on the treatment planning CT. A metal wire used to mark a drain site was identified as an isocenter mark rather than the BB on the AP surface as intended. Contributing factors include: 1)no policy implemented regarding the location of BBs and metal wire; 2) wires with similar diameter and feature as BBs in CT images; 3)lack of communication when confusion and uncertainties exist. A solution was chosen to help visualize the drain site. When drain site needs to be marked, a marker different from the regular wire will be used (e.g. plastic washer).Conclusion:Through RCA of an incorrect isocenter placement case, we identified the causal factors and also proposed solutions. RCA is a crucial tool for incident learning. This case study serves as valuable guidance for this particular problem and for RCA more generally.

Need to Improve Communication in Breast Cancer Care

Need to Improve Communication in Breast Cancer Care

Building the IJSO: An International Editorial Perspective

Building the IJSO: An International Editorial Perspective

Outcomes of Severely Injured Adult Trauma Patients in an Australian Health Service: Does Trauma Center Level Make a Difference?

Trauma centers are designated to provide systematized multidisciplinary care to injured patients. Effective trauma systems reduce patient mortality by facilitating the treatment of injured patients at appropriately resourced hospitals. Several U.S. studies report reduced mortality among patients admitted directly to a level I trauma center compared with those admitted to hospitals with less resources. It has yet to be shown whether there is an outcome benefit associated with the "level of hospital" initially treating severely injured trauma patients in Australia. This study was designed to determine whether the level of trauma center providing treatment impacts mortality and/or hospital length of stay. Outcomes were evaluated for severely injured trauma patients with an Injury Severity Score (ISS) > 15 using NSW Institute of Trauma and Injury Management data from 2002-2007 for our regional health service. To assess the association between trauma centers and binary outcomes, a logistic regression model was used. To assess the association between trauma centers and continuous outcomes, a multivariable linear regression model was used. Sex, age, and ISS were included as covariates in all models. There were 1,986 trauma presentations during the 6-year period. Patients presenting to a level III trauma center had a significantly higher risk of death than those presenting to the level I center, regardless of age, sex, ISS, or prehospital time. Peer review of deaths at the level III center identified problems in care delivery in 15 cases associated with technical errors, delay in decision making, or errors of judgement. Severely injured patients treated at a level III center had a higher mortality rate than those treated at a level I center. Most problems identified occurred in the emergency department and were related to delays in care provision. This research highlights the importance of efficient prehospital, in-hospital, and regional trauma systems, performance monitoring, peer review, and adherence to protocols and guidelines.

Coming soon: nowhere to hide for hospital managers

Hospital and health care managers and administrators will in future be measured against mandatory core standards and judged on outcomes, with little place to hide and less room to shift responsibility, the country’s new standards certification chief warned last month. Dr Carol Marshal, Director of the Office of Healthcare Standards Compliance (OHSC), in the national Department of Health has the full backing of her Director General, Precious Matsotso. This emerged in a speech the pair co-wrote for a health care safety conference in Cape Town last month. It became clear from the speech, delivered on Matsoso’s behalf by Marshal and in a later interview with Marshal, that the ‘slap on the wrist’ approach – driven by a plethora of patient safety policies/guidelines and the absence of a uniform, credible means of probing health care delivery problems – could soon be history.

Action research and soft systems methodology for studying problems in emergency care delivery

This article describes the use of action research (AR) and soft systems methodology (SSM) for studying and taking action in complex and unstructured problem situations. Drawing from AR and SSM principles, it proposes a research methodology to study and improve problematic flows of patients in emergency departments using operations management concepts. Three examples illustrate the methodology: analysis and improvement actions in acute radiology service, the design and introduction of a central status board and tests of an advanced triage system. This article concludes that an action mode of research is worthy of being pursued further, in emergency departments and beyond.

Using system analysis to build a safety culture: improving the reliability of epidural analgesia

A potentially dangerous situation was revealed by an incident report describing the use of an inappropriate device to administer post-operative epidural analgesia to a patient on a surgical ward. The incident occurred in a 1200-bed university affiliated tertiary hospital (Geneva University Hospitals, HUG) and involved three clinical departments: anaesthesiology, the surgical intensive care unit and urology. A multidisciplinary system analysis was carried out to identify care-delivery problems and contributory factors. Corrective actions were devised on the basis of their ability to prevent and absorb unsafe situations. The system analysis identified three care-delivery problems in relation to the management of epidural analgesia. It enabled medical and nursing managers to adopt an interdepartmental set of corrective actions: a common protocol for post-operative epidural analgesia, leading to the exclusive use of patient-controlled epidural analgesia (PCEA) pumps; greater availability of the patient-controlled pumps; the dissemination of guidelines; permanent proactive training of nurses by the acute-pain team; the clarification of medical responsibilities; and a common help-line phone number for all surgical departments. The analysis provided a convincing exposure of various care-delivery problems and their corresponding contributory factors, as well as an opportunity to address a systemic issue in a multidisciplinary way. By thus facilitating decisions and corrective actions, the analysis was instrumental in strengthening our safety culture.

P01.13: First‐trimester diagnosis of Pallister‐Killian syndrome presenting with complex congenital heart defect and increased nuchal translucency

Objective: A critical review of the mechanisms involved in a 1sttrimester screening programme with the aim of preventing screening failures. Methods: A complete systems analysis of the combined 1st-trimester nuchal translucency and maternal serum biochemistry screening programme in one of the units of the hospital trust was performed. Using the London protocol, beginning with a focus on the audited unit results and followed through to making recommendations and implementation. Three broad steps were involved in the initial analysis – 1)Identifying areas of potential for active screening failures 2) Identifying the contributory factors 3) Identifying the organisational factors The relevant factors were then collated and recommendations made. This was finally followed by an implementation of the action plan. Results: Various care delivery problems were recorded with the 1st-trimester screening programme. Many of these issues were organisational. There may therefore be a significant risk for latent failures in such screening programmes. This in turn may lead to recurrent untoward screening incidents with their associated potential for screening deterioration or breakdown. This study found that as emphasised by the 1st-trimester screening pioneers, the Fetal Medicine Foundation, regular audit of screening activity is highly essential to identify deviational trends early and enable prompt analysis and correction, to maintain cost-benefit in 1st-trimester screening. The use of Systems Analysis, such as the London Protocol, was helpful in correcting deviant trends in screening. Conclusions: There are strict protocols in place for the prevention of 1st-trimester screening programme failures. In view of the associated potential for litigation and large payouts, these must be adhered to closely, to avoid breakdowns and maintain service delivery.

P01.12: Maintaining a nuchal translucency screening service—the role of systems analysis

failures. Methods: A complete systems analysis of the combined 1st-trimester nuchal translucency and maternal serum biochemistry screening programme in one of the units of the hospital trust was performed. Using the London protocol, beginning with a focus on the audited unit results and followed through to making recommendations and implementation. Three broad steps were involved in the initial analysis ‐ 1)Identifying areas of potential for active screening failures 2) Identifying the contributory factors 3) Identifying the organisational factors The relevant factors were then collated and recommendations made. This was finally followed by an implementation of the action plan. Results: Various care delivery problems were recorded with the 1st-trimester screening programme. Many of these issues were organisational. There may therefore be a significant risk for latent failures in such screening programmes. This in turn may lead to recurrent untoward screening incidents with their associated potentialforscreening deteriorationor breakdown. This study found that as emphasised by the 1st-trimester screening pioneers, the Fetal Medicine Foundation, regular audit of screening activity is highly essential to identify deviational trends early and enable prompt analysis and correction, to maintain cost-benefit in 1st-trimester screening. The use of Systems Analysis, such as the London Protocol, was helpful in correcting deviant trends in screening. Conclusions: There are strict protocols in place for the prevention of 1st-trimester screening programme failures. In view of the associated potential for litigation and large payouts, these must be adhered to closely, to avoid breakdowns and maintain service delivery.

Towards Improving Medical Care for People with Intellectual Disability Living in the Community: Possibilities of Integrated Care

Background Ongoing deinstitutionalization has resulted in several problems in medical care delivery to people with intellectual disability, such as an increased workload for general practitioners (GPs) and a lack of active co‐ordination and co‐operation between healthcare professionals. A major consequence is the incidence of untreated yet treatable medical conditions. An integrated care approach may provide a means for better co‐ordination and delivery of care. The aim is to review recent integrated care initiatives and their significance for people with intellectual disability.Method A literature search was conducted to trace relevant literature on integrated care for people with intellectual disability published between 1995 and 2003.Results Although integrated care appears to offer potential for eliminating fragmentation and discontinuity in medical care for people with intellectual disability and for reducing GP workload, there are few published studies which have evaluated its implementation with people with intellectual disability.Conclusions Even though the potential advantages of integrated care are well known, the applicability of this approach for people with intellectual disability has still to be demonstrated.

How clients choises influence cancer care in northern Aboriginal communities

Objectives. To illustrate how personal choice, or client self-reliance, is a determining factor in the management of cancer patients’ care in northern Aboriginal communities. Study design. Multiple-site study done in the northwestern part of the Canadian Province of Ontario. Method. In-depth interviews with professionals and paraprofessionals involved in community-based delivery of cancer care. Results. Study details how perceived care options, gender, awareness of disease and treatment, reaction to system-linked problems in care delivery, as well as cultural preferences influence clients’ choices and care outcomes. Conclusion. The study underlines the interdependence between personal choice and the health care system; “bad” experiences with the system cause clients to disengage from care, while client disengagement results in reduced care options.