Care Delivery Process Research Articles

Adapting Interdisciplinary Transitional Ambulatory Practice to Meet the Challenges of COVID-19.

COVID-19 restructured the health care delivery process, catapulting telemedicine to the mainstream. The Johns Hopkins After Care Clinic (JHACC) continued transprofessional health care delivery in the telemedicine space by shifting to remote, asynchronous collaboration and a triage system. In 1 month after starting telemedicine, the JHACC had 907 encounters for 376 unique patients. Most patients reported satisfaction with their visits. Telemedicine lengthened visit completion times. Providers encountered many failed call attempts and limited access to videoconferencing. Barriers to sustainable interprofessional telemedicine include poor social determinants of health, limited reimbursement for nonphysician health professionals, and increased clinical and administrative time.

Using Innovation to Navigate Waves of COVID-19 Resurgence.

Using Innovation to Navigate Waves of COVID-19 Resurgence.

PNS72 From Volume-to-VALUE in Latin America: A 6-STEP Process

Outline the experience with value-based healthcare (VBHC) in Latin America (LA), define local hurdles to implementation of VBHC, and propose a 6-step process to support institutions transition from volume-to-value payment models. In-depth secondary research identified regional and global benchmarks of VBHC, LA-specific hurdles to implementation and enablers for successful execution. Secondary research findings were validated through in-depth discussions with 5 local experts in Argentina, Brazil, Chile, Colombia, and Mexico. VBHC has the triple aim of lowering costs, improving health, and bettering patient experiences. However, the transition from a well-established fee-for-service to a fee-for-value model is logistically complex and will take time. In LA, experience with VBHC is scarce. Only in Chile and Colombia can the presence of enabling elements for VBHC, such as bundled payments or pay-for-performance (Chile) and quality standardization (Colombia), be nationally identified. In addition, only one executed pilot of a comprehensive VBHC model has been identified with the ‘Albert Einstein Hospital’ in Brazil. Some of the LA-specific challenges faced in the in the transition to VBHC programs are subpar data analytics and information technology (IT) tools, lack of consistency in the care delivery process, aligning stakeholder incentives on quality and cost goals, and healthcare system fragmentation. A 6-step approach has been designed to support institutions transition from volume- to value-based payment models: (1) creating a migration plan, (2) educating and training internal stakeholders, (3) building a robust IT platform , (4) developing standardized care pathways with clear quality indicators, (5) measuring outcomes and costs, and (6) moving to value-based payment models (bundles, pay-for-performance, global capitation, shared savings). VBHC holds great potential, but in the volume to value transition, change is gradual. A 6-step process has been designed that LA institutions can follow to successfully migrate from fee-for-service to fee-for-value models.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC. How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival? We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact. Of 169,775 patients, 7%, 46%, 10%, 24%, and 12%underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60%and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95%CI, 1.41-1.53), 1.29 (95%CI, 1.25-1.33), 1.18 (95%CI, 1.14-1.23), and 1.20 (95%CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95%CI, 1.28-1.42), 1.22 (95%CI, 1.17-1.26), 1.16 (95%CI, 1.11-1.22), and 1.17 (95%CI, 1.12-1.21), respectively (P< .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11%to 26%of the interinstitutional survival disparities. Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Medicine and the human factor

> All life is precious, but it seems that the lives of NHS staff are disposable as long as targets are being met. > > Clare Gerada1 The great William...

Organizational integration, practice capabilities, and outcomes in clinically complex medicare beneficiaries.

To assess the association between clinical integration and financial integration, quality-focused care delivery processes, and beneficiary utilization and outcomes. Multiphysician practices in the 2017-2018 National Survey of Healthcare Organizations and Systems (response rate 47%) and 2017 Medicare claims data. Cross-sectional study of Medicare beneficiaries attributed to physician practices, focusing on two domains of integration: clinical (coordination of patient services, use of protocols, individual clinician measures, access to information) and financial (financial management and planning across operating units). We examined the association between integration domains, the adoption of quality-focused care delivery processes, beneficiary utilization and health-related outcomes, and price-adjusted spending using linear regression adjusting for practice and beneficiary characteristics, weighting to account for sampling and nonresponse. 1604580 fee-for-service Medicare beneficiaries aged 66 or older attributed to 2113 practices. Of these, 414209 beneficiaries were considered clinically complex (frailty or 2+chronic conditions). Financial integration and clinical integration were weakly correlated (correlation coefficient=0.19). Clinical integration was associated with significantly greater adoption of quality-focused care delivery processes, while financial integration was associated with lower adoption of these processes. Integration was not generally associated with reduced utilization or better beneficiary-level health-related outcomes, but both clinical integration and financial integration were associated with lower spending in both the complex and noncomplex cohorts: (clinical complex cohort: -$2518, [95% CI: -3324, -1712]; clinical noncomplex cohort: -$255 [95% CI: -413, -97]; financial complex cohort: -$997 [95% CI: -$1320, -$679]; and financial noncomplex cohort: -$143 [95% CI: -210, -$76]). Higher levels of financial integration were not associated with improved care delivery or with better health-related beneficiary outcomes. Nonfinancial forms of integration deserve greater attention, as practices scoring high in clinical integration are more likely to adopt quality-focused care delivery processes and have greater associated reductions in spending in complex patients.

A comparison of two models of multidisciplinary lung cancer care within a community-based healthcare system.

36 Background: The Multidisciplinary Thoracic Oncology Conference (MTOC) model is easier to implement than the Multidisciplinary Clinic (MDC) model, but does not directly involve patients in decision-making. We compared the processes and outcomes of lung cancer care between patients discussed in a weekly MTOC versus those seen in a MDC. Methods: Prospective observational study of thoroughness of staging, stage confirmation (defined as biopsy of the stage-defining lesion), National Comprehensive Cancer Network guideline-concordant treatment, overall (OS) and event-free (EFS) survival of lung cancer patients in a community healthcare system’s MDC and MTOC from 2014-2019. We used the chi-square test and multivariable logistic regression to evaluate guideline-concordant treatment and stage confirmation; Kaplan-Meier curves and multivariable Cox regression were used to evaluate OS and EFS. We adjusted models for age, sex, race, insurance, smoking status, and histology. Results: 614 patients received care in MDC; 571 in MTOC. MDC patients were older (median age: 69 vs. 67); less likely to be active smokers (44% vs. 47%; p=0.03); more likely to have bimodal (98% v 95%, p=0.02) and trimodal staging (60% v 46%, p&lt;0.0001). The stage-confirmation rate (OR: 1.55; 95% CI: 1.22-1.96) and mediastinal stage confirmation rate (OR: 1.55; 95% CI: 1.23-1.95) were both significantly higher in MDC, even after adjustment (aOR: 1.60; 95% CI: 1.25-2.03); (aOR: 1.58, 95% CI: 1.25-2.00). A higher proportion of patients received guideline-concordant treatment in MDC than in MTOC (82% vs. 73%; OR: 1.63; 95% CI: 1.21-2.20) even after adjustment (aOR: 1.64; 95% CI: 1.20-2.24). However, MTOC patients had significantly better OS (p=0.03) and EFS (p=0.001) than MDC patients and a lower hazard of death (HR: 0.81; 95% CI: 0.67-0.98), even after adjusting for confounding variables (aHR: 0.79 95%CI: 0.66-0.95). Conclusions: Although the processes of lung cancer care delivery were better in MDC than in MTOC, survival was better in MTOC. Patient selection may have played a role in these survival differences. The MTOC model, as implemented, seems competitive with the MDC model and is worthy of further exploration as a more feasible model of multidisciplinary care. [Table: see text]

Implementing culturally competent transplant care and implications for reducing health disparities: A prospective qualitative study.

BackgroundDespite available evidence‐based interventions that decrease health disparities, these interventions are often not implemented. Northwestern Medicine's® Hispanic Kidney Transplant Program (HKTP) is a culturally and linguistically competent intervention designed to reduce disparities in living donor kidney transplantation (LDKT) among Hispanics/Latinos. The HKTP was introduced in two transplant programs in 2016 to evaluate its effectiveness.ObjectiveThis study assessed barriers and facilitators to HKTP implementation preparation.MethodsInterviews and group discussions were conducted with transplant stakeholders (ie administrators, nurses, physicians) during implementation preparation. The Consolidated Framework for Implementation Research (CFIR) guided interview design and qualitative analysis.ResultsForty‐four stakeholders participated in 24 interviews and/or 27 group discussions. New factors, not found in previous implementation preparation research in health‐care settings, emerged as facilitators and barriers to the implementation of culturally competent care. Implementation facilitators included: stakeholders’ focus on a moral imperative to implement the HKTP, personal motivations related to their Hispanic heritage, and perceptions of Hispanic patients’ transplant education needs. Implementation barriers included: stakeholders’ perceptions that Hispanics’ health insurance payer mix would negatively impact revenue, a lack of knowledge about LDKT disparities and patient data disaggregated by ethnicity/race, and a perception that the family discussion component was immoral because of the possibility of coercion.Discussion and ConclusionsOur study identified novel barriers and facilitators to the implementation preparation of a culturally competent care intervention. Healthcare administrators can facilitate organizations’ implementation of culturally competent care interventions by understanding factors challenging care delivery processes and raising clinical team awareness of disparities in LDKT.

Feature: Beating the COVID-19 Surge: How Allina Health Doubled Its ICU Capacity in Eight Weeks.

Feature: Beating the COVID-19 Surge: How Allina Health Doubled Its ICU Capacity in Eight Weeks.

Responding to the COVID-19 pandemic with the Pathway to Excellence® framework

Responding to the COVID-19 pandemic with the Pathway to Excellence® framework

Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses

Introduction: Psychological safety, a shared belief that interpersonal risk-taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near- miss reporting is unclear. Unlike incidents, near misses do not result in patient harm, but do contain cues that highlight contrasting sensemaking: resilience (“we managed to avoid failure”) and vulnerability (“we nearly failed”). Herein, we examine the relationship of psychological safety to near-miss reporting in radiation oncology. Methods: We surveyed radiation oncology department staff in an academic hospital (n=127). The survey assessed psychological safety and presented five scenarios: “standard care” involving no patient harm, three near misses with varied timing of the chance occurrence averting harm (“could have happened”, “fortuitous catch”, “almost happened”), and one “hit” involving harm. Respondents evaluated each event as success or failure and reported willingness to report on a 7-point Likert scale. Our analysis employed ordered logistic regression models. Results: 78 staff (61%) completed the survey. The odds of reporting “hit” (OR: 1.96, 95%?CI 1.19-3.23), “almost happened” (OR: 1.58, 95% CI 1.05-2.38) and “fortuitous catch” (OR: 1.61, 95% CI: 1.10-2.36) were higher in respondents indicating psychological safety. The relationship of psychological safety was not statistically significant for reporting “standard care” (OR: 1.46, 95% CI 0.78-2.71) and “could have happened” (OR: 1.30, 95% CI 0.91-1.88). The odds of reporting were higher when a near miss was discerned as failure (vs. success). Conclusions: Near misses are not all processed and reported equally. Psychological safety seems to influence reporting when an event underscores vulnerability rather than resilience of care delivery processes. Educating healthcare workers to properly identify near misses and fostering psychological safety to encourage reporting would help to improve care and ensure patient safety.

A need-based, multi-level, cross-sectoral framework to explain variations in satisfaction of care needs among people living with dementia

BackgroundProvision of care and support for people with dementia and family carers is complex, given variation in how dementia manifests, progresses and affects people, co-morbidities associated with ageing, as well as individual preferences, needs, and circumstances. The traditional service-led approach, where individual needs are assessed against current service provision, has been recognised as unfit to meet such complexity. As a result, people with dementia and family members often fail to receive adequate support, with needs remaining unmet. Current research lacks a conceptual framework for explaining variation in satisfaction of care needs. This work develops a conceptual framework mapped onto the care delivery process to explain variations in whether, when and why care needs of people with dementia are met and to expose individual-, service-, system-level factors that enable or hinder needs satisfaction.MethodsData collected through 24 in-depth interviews and two focus groups (10 participants) with people with dementia and family carers living in the North East of England (UK) were analysed thematically to develop a typology of care needs. The need most frequently reported for people with dementia (i.e. for support to go out and about) was analysed using themes stemming from the conceptual framework which combined candidacy and discrepancy theories.ResultsThe operationalisation of the framework showed that satisfaction of the need to go out was first determined at the point of service access, affected by issues about navigation, adjudication, permeability, users’ resistance to offers, users’ appearance, and systems-level operating conditions, and, subsequently, at the point of service use, when factors related to service structure and care process determined (dis)satisfaction with service and, hence, further contributed to met or unmet need.ConclusionThe conceptual framework pinpoints causes of variations in satisfaction of care needs which can be addressed when designing interventions and service improvements.

Evaluation of a learning collaborative to advance team-based care in Federally Qualified Health Centers

Practising team-based primary care allows Federally Qualified Health Centers (FQHC) in the USA to be accredited as patient-centred medical homes, positioning them for value-based models of shared savings in healthcare...

A Review on Advances in Intra-operative Imaging for Surgery and Therapy: Imagining the Operating Room of the Future.

With the advent of Minimally Invasive Surgery (MIS), intra-operative imaging has become crucial for surgery and therapy guidance, allowing to partially compensate for the lack of information typical of MIS. This paper reviews the advancements in both classical (i.e. ultrasounds, X-ray, optical coherence tomography and magnetic resonance imaging) and more recent (i.e. multispectral, photoacoustic and Raman imaging) intra-operative imaging modalities. Each imaging modality was analyzed, focusing on benefits and disadvantages in terms of compatibility with the operating room, costs, acquisition time and image characteristics. Tables are included to summarize this information. New generation of hybrid surgical room and algorithms for real time/in room image processing were also investigated. Each imaging modality has its own (site- and procedure-specific) peculiarities in terms of spatial and temporal resolution, field of view and contrasted tissues. Besides the benefits that each technique offers for guidance, considerations about operators and patient risk, costs, and extra time required for surgical procedures have to be considered. The current trend is to equip surgical rooms with multimodal imaging systems, so as to integrate multiple information for real-time data extraction and computer-assisted processing. The future of surgery is to enhance surgeons eye to minimize intra- and after-surgery adverse events and provide surgeons with all possible support to objectify and optimize the care-delivery process.

Systematic Patient Navigation Strategies to Scale Breast Cancer Disparity Reduction by Improved Cancer Prevention and Care Delivery Processes.

Patient navigation uses trained personnel to eliminate barriers to timely care across all phases of the health care continuum, thereby reducing health disparities. However, patient navigation has yet to be systematized in implementation models to improve processes of care at scale rather than remain a band-aid approach focused solely on improving care for the individual patient. The 4R systems engineering approach (right information and right treatment to the right patient at the right time) uses project management discipline principles to develop care sequence templates that serve as patient-centered project plans guiding patients and their care team. A case-study approach focused on the underserved patient shows how facilitators to timely breast cancer screening and care pragmatically identified as emergent data by patient navigators can be actionized by iteratively revising 4R care sequence templates to incorporate new insights as they emerge. Using a case study of breast cancer screening of a low-income patient, we illustrate how 4R care sequence templates can be revised to incorporate emergent facilitators to care identified through patient navigation. Use of care sequence templates can inform the care team to optimize a particular patient's care, while functioning as a learning health care system for process improvement of patient care and patient navigation scaling. A learning health care system approach that systematically integrates data patterns emerging from multiple patient navigation experiences through in-person navigators and 4R care sequence templates may improve processes of care and allow patient navigation scaling to reduce cancer disparities.

Effect of Antibiotic Susceptibility and Inhibitory Activity for the Control of Growth and Survival of Microorganisms of Extracts of Calendula officinalis

Extracts from many types of plants show several evidences of beneficial health effects in the living system. Calendula officinalis is a well known medicinal plant in our country. The purpose of this study was to examine the effectiveness of C. officinalis for control of the growth and survival of microorganisms. The inhibition of growth was tested by the paper disc agar diffusion method. Minimum inhibitory concentration (MIC) was determined by the tube dilution method. C. officinalis leaf extract showed inhibition (MIC, inhibitory) to Escherichia coli, Klebsiella pneumoniae, and Bacillus subtilis and to the other bacteria tested. Antimicrobial effects of leaf extract of C. officinalis on some microorganisms including pathogens were investigated. The extract of C. officinalis leaf which is prepared in was tested on bacterial cultures such as B. subtilis, S. lutea, E. coli, K. pneumoniae and also investigated that minimum inhibitory concentration 4µg/ml of leaf extract of C. officinalis in petroleum ether against K. pneumoniae and largest inhibitory zone are created by 512mg/ml chloroform extract against E. coli leaf extract of C. officinalis in petroleum ether has proved better for antibacterial activity. This study demonstrates that the potentiality of C. officinalis as a source of antimicrobials that could be harness for use in the health care delivery process.

Accelerating Use of Self-measured Blood Pressure Monitoring (SMBP) Through Clinical-Community Care Models

Self-measured blood pressure monitoring (SMBP), the regular measurement of blood pressure by a patient outside the clinical setting, plus additional support, is a proven, cost-effective but underutilized strategy to improve hypertension outcomes. To accelerate SMBP use, the Centers for Disease Control and Prevention (CDC) funded the National Association of Community Health Centers, the YMCA of the USA, and Association of State and Territorial Health Officials to develop cross-sector care models to offer SMBP to patients with hypertension. The project aimed to increase the use of SMBP through the coordinated action of health department leaders, community organizations and clinical providers. From 1/31/2017 to 6/30/2018, nine health centers in Kentucky, Missouri, and New York partnered with seven local Y associations (local Y) and their local health departments to design and implement care models that adapted existing primary care SMBP practices by leveraging capacities and resources in community and public health organizations. Nine collaborative care models emerged, shaped by available community assets, strategic priorities, and organizational culture. Overall, 1421 patients were recommended for SMBP; of those, 795 completed at least one cycle of SMBP (BP measurements morning and evening for at least three consecutive days). Of those recommended for SMBP, 308 patients were referred to a local Y to receive additional SMBP and healthy lifestyle support. Community and public health organizations can be brought into the health care delivery process and can play valuable roles in supporting patients in SMBP.

“Unnecessary” Medications: The Never-Ending Pandemic

“Unnecessary” Medications: The Never-Ending Pandemic

Clinicians Report Barriers and Facilitators to High-Quality Ambulatory Oncology Care.

Ambulatory oncology practices treat thousands of Americans on a daily basis with high-risk and high-cost antineoplastic agents. However, we know relatively little about these diverse practices and the organizational structures influencing care delivery. The aim of this study was to examine clinician-reported factors within ambulatory oncology practices that affect care delivery processes and outcomes for patients and clinicians. Survey data were collected in 2017 from 298 clinicians (nurses, physicians, nurse practitioners, and physician assistants) across 29 ambulatory practices in Michigan. Clinicians provided written comments about favorable and unfavorable aspects of their work environments that affected their ability to deliver high-quality care. We conducted inductive content analysis and used the Systems Engineering Initiative for Patient Safety work system model to organize and explain our findings. Clinicians reported factors within all 5 work-system components of the Systems Engineering Initiative for Patient Safety model that affected care delivery and outcomes. Common themes surfaced, such as unfavorable aspects including staffing inadequacy and high patient volume, limited physical space, electronic health record usability issues, and order entry. Frequent favorable aspects focused on the skills of colleagues, collaboration, and teamwork. Some clinicians explicitly reported how work system factors were relational and influenced patient, clinician, and organizational outcomes. These findings show how work-system components are interactive and relational reflecting the complex nature of care delivery. Data obtained from frontline clinicians can support leaders in making organizational changes that are congruent with clinician observations of practices' strengths and opportunities for improvement.

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales.

Opioid substitution treatment is used in many countries as an effective harm minimization strategy. There is a need for more information about patient safety incidents and the resulting harm relating to this treatment. We aimed to characterize patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care by: (i) identifying the sources and nature of harm and (ii) describing and interpreting themes to identify priorities to focus future improvement work. Mixed-methods study examining patient safety incident reports involving opioid substitution treatment with either methadone or buprenorphine in community-based care. Data submitted between 2005 and 2015 from the National Reporting and Learning System (NRLS), a national repository of patient safety incident reports from across England and Wales. A total of 2284 reports were identified involving patients receiving community-based opioid substitution treatment. Incident type, contributory factors, incident outcome and severity of harm. Analysis involved data coding, processing and iterative generation of data summaries using descriptive statistical and thematic analysis. Most risks of harm from opioid substitution treatment came from failure in one of four processes of care delivery: prescribing opioid substitution (n=151); supervised dispensing (n=248); non-supervised dispensing (n=318); and monitoring and communication (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n=91 of 127, 72%). Staff- (e.g. slips during task execution, not following protocols) and organization-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for more than half of incidents. Risks of harm in delivering opioid substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid substitution, supervised dispensing, non-supervised dispensing and monitoring and communication.