Promote Quality Care Research Articles

Professional and political reflections on the 'grand round': a critical case study.

This case study presents a critical reflective account of a change to working practices in one NHS Trust. To promote quality care and effective clinical decision making, a 'grand round' was introduced in the orthopaedic department. Implementation presented frustrations and challenges for members of the multidisciplinary team. These are explored using transformative learning and critical reflection, enabling connections to be made between micro-level interactions of clinical care and macro-level structures that frame healthcare services. It is important that nurses recognise the escalating impact of a neoliberal agenda, and new public management, that drive UK health policy and politics. The value base of nursing is threatened by a corporate culture that measures performance in terms of institutional targets rather than individual care.

The Impact of Physical Disability on Pregnancy and Childbirth

Women with physical disabilities increasingly aspire to become pregnant and bear children. Limited information about the potential interaction of their disabling conditions with pregnancy and childbirth exists to guide these women and their clinicians. The interview guide was created with questions on topics such as pregnancy complications and secondary conditions, the impact of prior surgeries, experiences with pain relief during labor, and the impact on women's independence and participation in life activities. Interviews were conducted by telephone with 25 women with physical disabilities. They were subsequently transcribed verbatim and analyzed by using Atlas TI. Women generally reported a relatively modest impact of disabling conditions on their pregnancies. Most women were satisfied with the mode of delivery, but they experienced challenges during the labor and delivery process. The women found that careful advanced planning was helpful in managing the impact of their disabling conditions. The involvement of clinicians with disability-related expertise was, in some cases, another factor that contributed to a positive outcome. The importance of advanced planning and the utility of involving clinicians with disability-related expertise suggest that the use of integrated, interdisciplinary team approaches could promote quality care by facilitating improved planning and management. Additional clinical research is needed to provide women and their clinicians with more information on potential complications and options for labor and delivery.

Cleaning and Caring: Contributions in Long-term Residential Care

Cleaning and cleaners make three main contributions to long-term residential care. While cleaning in hospitals has received considerable research attention, much less attention has been paid to connecting cleaning and cleaners with the specific nature of long-term care and resident needs. In this article we explore three critical contributions cleaning and cleaners make to the quality of care in nursing homes. This work is central to infection control. It is also important in maintaining the appearance of the home; in making it home-like, welcoming, and safe. Much less visible is the significant part cleaners play in supporting relational care. Based on ethnographic studies in six countries, we argue that the extent to which cleaners and cleaning promote quality care and worker health is related to the division of labour, team work, training, equipment, and some autonomy.

You Had It Done Where? The Rise of Medical Tourism

You Had It Done Where? The Rise of Medical Tourism

Don't Ignore My Snore: Reducing Perioperative Complications of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a condition associated with decreased muscle tone in the airway, has been linked to postoperative complications. The purpose of the initiative was to develop and implement a guideline for patients identified as high-risk for OSA to reduce complications related to OSA. A multidisciplinary team developed the guideline utilizing the Iowa Model of Evidence-Based Practice to Promote Quality Care. PubMed literature search from 2006-2013 and critique of over 40 articles were completed. A nursing care plan was created from the guideline to facilitate communication of care for this population. Postoperative cardiopulmonary complications related to OSA decreased from 27% to 14.6% after guideline implementation. Guideline and nursing care plan specific to OSA in the perioperative setting improved patient outcomes.

Model of Integrated Care for Children with Special Needs in the Basque Region of Spain

Care coordination has been a cornerstone of primary care for many years, and is essential in providing optimal and cost-effective care, especially for children with special needs. Children with special healthcare needs (CSHCN) are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally. Effective, coordinated care amongst all of the professionals implicated in the care for these children, provided during the first several years of their life, has been correlated improved outcomes for CSHCN and their families.Following the model of early intervention adapted in the Basque Region in 2011, with a focus on early intervention for children 0-6 years old, and care coordination between the health, social, and educational services, the model of integrated care for children with special needs, PAINNE (Proceso de Atención Integrada a Niños y Niñas con Necesidades Especiales) was created in 2012.The overall aim of this project is to implement an integrated model of care for CSHCN, ages 0-6 years, using a quality improvement method to enhance the overall care and satisfaction of the children and families affected. This model promotes quality care towards children and their families in a way that is efficient and sustainable, with the goal of early detection and intervention in situations of risk, ultimately aiming to help these children reach their maximum potential and improve their overall quality of life. Initially this model was implemented in the area of Bilbao, and more recently in the entire province of Vizcaya.Multidisciplinary groups comprised of nearly 90 professionals from the healthcare, social services and education sectors in Bilbao worked together to create appropriate structures for care coordination, reach consensus regarding procedures to offer integrated care and tools to enhance early detection of situations of risk, define key indicators for quality improvement, and create a comprehensive directory of resources in these three sectors. These ideas were published in the Guía PAINNE 2013, and the screening tools agreed upon for the early detection of developmental delays and psychosocial risk factors were incorporated into the electronic medical record (EMR) for routine use in well child visits in the pediatric primary care centers in Bilbao.The positive initial results of this model encouraged its expansion to the entire region of Vizcaya. In 2014, over 200 professionals from the healthcare, social services, education and third sectors began working together to revise, validate, adapt and implement the ideas set forth by the model PAINNE in Bilbao.Only months after this model was implemented in Bilbao, external reviewers (Etorbizi) determined that it was a complex project of great value, actively implicating professionals from the three sectors, and that the methodology was successful in achieving consensus. Foundation New Health rated the project with 4/4 points for its ability to achieve transformability and sustainability, and 3/4 points for creativity, impact of transformation, appropriateness and for the development of an inclusive process. Additional results after the first year of implementation in Bilbao are as follows:• 75% of pediatricians and 56% of nurses in primary care were trained in this integrated model of care• Utilization of screening tools in the EMR for psychosocial risk factors by the primary care team improved from 23,83% of well child visits in 2013 to 71,76% in 2014• Completion of developmental screening tools in the EMR by the primary care teams increased from 25,13% in 2013 to 55,15% in 2014• 93,27% of children referred to early intervention evaluation teams by primary care pediatricians were accepted• The age of referral for suspicion of autism decreased from 3,8 years to 3 yearsPAINNE, the model of integrated care for CHSCN in the Basque region, has shown it to be possible to articulate, promote, and lead a change in the approach to early intervention in order to achieve an integrated response towards this group of children. The process has been successful in coordinating and generating consensus amongst various professionals in different sectors and organizations in Vizcaya, each with its own distinct culture and resources. The systematic incorporation of screening tools in the primary care visits has been effective in reducing the time for identification of developmental delays, including autism. These initial results indicate that this is a care coordination model that is realistic, sustainable, efficient, and allows for quality improvement, making it possible to replicate the model in other regions.

Committee Opinion No. 676 Summary: Health Literacy to Promote Quality of Care

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand the basic health information and services they need to make appropriate health decisions. Multiple factors affect a patient's understanding of health information, including cultural factors, a physician's health know- ledge and communication skills, the demands of the situation, the environment in which the health information is being conveyed, and time constraints. The responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care system, from primary care physicians to community-based or public health organizations. Because of the potential effect of health literacy on patient outcomes, obstetrician-gynecologists should take the appropriate steps to ensure that they communicate in an understandable manner so patients can make informed decisions about their health care.

Nurses' representations of caring for intellectually disabled patients and perceived needs to ensure quality care.

To explore nurses' representations of caring for people with an intellectual disability, intervention strategies they currently use, and to identify needs to ensure quality care. Nurses work in many environments and with diverse clienteles. Certain clienteles have needs that require specific approaches, such as persons who have an intellectual disability. The care offered to these patients can be influenced by the representations held by the nurses caring for them. Qualitative descriptive study. Semi-structured interviews using thematic analysis were conducted with 18 nurses working in hospital and community settings. Nurses are concerned with their ability to recognise the specific nature and complex needs associated with patients' intellectual disabilities, promoting quality care by managing the behavioural and communication challenges, as well as coping with the perceived lack of time and organisation within the work environment. Current strategies involve trying to promote the continuity of care. Participants also identified their learning needs, which are relational and informational in nature. Nurses appear typically mindful of wanting to provide quality care to patients who have an intellectual disability, while recognising that there are many contextual and practical elements that require improvement to ensure the security of these patients. Nurses must be educated to adapt to findings emerging from current research showing that people with an intellectual disability want to be part of their local communities and encourage these persons to do so. This can be facilitated through the adoption of specific guidelines, protocols and care programmes. Further research is needed to develop a better understanding of the expectations of these patients and their caregivers, focusing on self-advocacy as well as health promotion techniques, with the goal of enhancing personalised practice standards and reducing health education inequalities for these patients.

Educational Intervention for an Evidence-Based Nursing Practice of Skin-to-Skin Contact at Birth.

This article presents the development and evaluation of an educational intervention aiming at an evidence-based practice of skin-to-skin contact at birth among nurses of a maternity care unit. Based on the Iowa Model of Evidence-Based Practice to Promote Quality Care, four educational sessions were developed according to an active-learning pedagogy. Even if the nurses' practice did not fully meet the recommendations for skin-to-skin contact, a pre- and postintervention evaluation showed some positive results, such as a longer duration of skin-to-skin contact immediately after birth, delivery of some routine care directly on mothers' chest, and improved parent education. The educational intervention seems to have enacted some evidence-based nursing practice changes regarding skin-to-skin contact at birth.

Evaluation of Invasive Squamous Cell Carcinoma, Seborrheic Keratosis and Verruca Vulgaris in Superficial Shave Biopsies using p16, p53, p63, and PHLDA1 Immunohistochemistry

Occasionally, the distinction between malignant and benign is challenging in superficial shave biopsies of squamoproliferative lesions. This phenomenon is compounded by the increasing prevalence of conditions encountered that weaken the immune system, such as chemotherapy, immune deficiency diseases, and antirejection medications for organ transplantation that have all been shown to increase the risk of the development of squamous cell carcinoma that are sampled. We collected 30 cases (10 invasive SCC, 10 SK and 10 VV) and performed immunohistochemical staining using a panel approach composed of markers important for proliferation and cell cycle, including Ki-67, p16, p53, and PHLDA1. The results demonstrate that the invasive SCC group was enriched for high PHLDA1 (80% with PHLDA1 score=3, 100% with PHLDA1 score ≥ 2) and high p53 (50% of SCC with p53 score ≥ 2 vs. 60% of SK and 90% of VV with p53 score=1). The SK group was enriched for low p16 (100% with p16 score ≤ 1) and high p63 scores (100% with p63 score=3). A panel approach may be utilized to help in the distinction between benign keratoses and carcinoma and may be increasingly critical to promote quality care.

Medical device-related hospital-acquired pressure ulcers: development of an evidence-based position statement.

Hospital-acquired pressure ulcers (HAPUs) are a problem in the acute care setting causing pain, loss of function, infection, extended hospital stay, and increased costs. In spite of best practice strategies, occurrences of pressure ulcers continue. Many of these HAPUs are related to a medical device. Correct assessment and reporting of device-related HAPUs were identified as an important issue in our organization. Following the Iowa Model for Evidence-Based Practice to Promote Quality Care, a task force was created, a thorough review of current evidence and clinical practice recommendations was performed, and a definition for medical device-related HAPU and an evidence-based position statement were developed. Content of the statement was reviewed by experts and appropriate revisions were made. This position statement provides guidance and structure to accurately identify and report device-related HAPU across our 18 healthcare facilities. Through the intentional focus on pressure ulcer prevention and evidence-based practice in our organization and the use of this position statement, identification and reporting of device-related HAPUs have improved with a decrease in overall HAPU rates of 33% from 2011 and 2012. This article describes the development and implementation of this device-related HAPU position statement within our organization.

Mental ill health in the elderly: medical students’ social representations in the United Kingdom

Objective This study aims to explore medical students’ social representations of mental ill health in older adults. Method It comprises an exploratory and qualitative investigation based on the theory of social representations. Two focus groups with pre-clinical medics (group 1, N=4; group 2, N=4) and 10 individual interviews with clinical medical students were conducted. Thematic analysis at a latent level explored meanings and differences between groups. Results Three overarching themes reflect participants’ representations of mental health problems in later life – mental ill health in old age, polarisation of care, and challenges to care. Primary health care appears as an important strategy to overcome barriers to mental health care in the community. Nevertheless, disqualifying representations, stigma and organization of services constitute the main challenges to quality mental health care in later life. Conclusion This paper highlights the need to address cultural and organizational barriers to promote quality care.

Dementia in the incarcerated elderly adult: innovative solutions to promote quality care.

To provide an overview of the epidemiology, pathophysiology, and diagnostic considerations of Alzheimer's disease (AD) with a special focus on elderly prison inmates. Multiple therapeutic interventions currently used for inmates with AD and a brief protocol for clinicians working with this population are provided. Review of scientific literature. Early detection and appropriate treatment of AD and other dementias are particularly challenging inside of correctional institutions, and a lack of prison-specific guidelines for AD leaves clinicians struggling to deliver innovative, quality care to a vulnerable population of elderly inmates. Clinicians working in prisons can promote optimal safety and health for each inmate through early diagnosis and treatment of those with dementia. Researchers studying dementia need to include the large incarcerated population in the United States in ongoing research and guideline development.

The Geriatric Trauma Institute: reducing the increasing burden of senior trauma care

BackgroundOwing to parallel advances in health care and an aging population, geriatric injury has become an increasing burden to trauma systems, suggesting that specific clinical pathways may improve the care of this cohort. We created a dedicated Geriatric Trauma Institute, with multidisciplinary support, as a part of our existing trauma program, theorizing that the Geriatric Trauma Institute would promote quality care, reduce the length of stay, and reduce hospital charges. MethodsWe performed a retrospective analysis of the prospective database of our level 1 trauma center. Patients aged 65 years or older were identified over 12 months, representing 5 months prior and also after the implementation of the new program. ResultsThe mean length of stay was reduced for admissions to a nontrauma vs geriatric trauma service (5.64 vs 4.43 days; P = .03), generating a charge reduction of 21.4% in only the first 5 months after program implementation. ConclusionsOur preliminary findings, which require longer-term analysis, suggest that a dedicated geriatric trauma multidisciplinary system promotes quality patient care, improves throughput, and results in significant cost savings via reduced length of stay and concomitant hospital charges.

Determining the Return on Investment for Evidence‐Based Practice: An Essential Skill for All Clinicians

Determining the Return on Investment for Evidence‐Based Practice: An Essential Skill for All Clinicians

Promoting quality care for recently resettled populations: curriculum development for internal medicine residents.

Residents report they lack preparation for caring for an increasingly diverse US population. In response, a variety of curricula have been developed to integrate cultural competency into medical training programs. To date, none of these curricula has specifically addressed members of recently resettled populations. A preliminary assessment was conducted among internal medicine (IM) residents at 1 program (N = 147). Based on 2 conceptual frameworks and the survey results, a pilot curriculum was developed and integrated into the interns' ambulatory block education within the general IM track (n = 9). It included (1) online information made available to all hospital staff; (2) 4 interactive didactic sessions; and (3) increased exposure to newly arrived patients. The curriculum was qualitatively evaluated through 2 focus groups. The preliminary assessment was completed by 101 of 147 residents (69%), with 61% of respondents indicating they felt that they received less than adequate education in this area. Eight of the 9 interns exposed to the new curriculum participated in the focus groups. Overall, respondents reported they thought patient care had improved for recently resettled populations and across their patient panels after exposure to the curriculum. This study demonstrated that an intervention that included didactics and enhanced exposure to a diverse population improved IM interns' perceptions of care for all patients, including recently settled individuals.

The Affordable Care Act: Primary Care and the Doctor of Nursing Practice Nurse

The passage of the 2010 Patient Protection and Affordable Care Act (ACA) initiated the transformation of the United States healthcare system. The ACA fosters a preventive healthcare model that emphasizes primary care, funds community health initiatives, and promotes quality care. These changes increase the need for well-prepared healthcare professionals. Advanced Practice Registered Nurses (APRNs) who hold the Doctor of Nursing Practice (DNP) degree are prepared to meet this increased need by providing leadership in community health centers, serving on interdisciplinary teams, and advocating for and directing future policy initiates. In this article, the authors consider how the ACA will serve as a prevention model, describe the role of DNP nurses as primary care providers, explain how preventive healthcare can be enhanced through the use of a primary care model, and address associated challenges related to increasing preventive care in our healthcare system. They also discuss DNP nurse leadership opportunities related to community-based programs and policy strategies to strengthen primary care delivery. The authors conclude by noting the professional and legal barriers that need to be removed before DNP nurses will be able to provide the care they have been prepared to offer.

The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing

Evidence-based practice (EBP) improves the quality of patient care and helps control healthcare costs. Numerous EBP models exist to assist nurses and other healthcare providers to integrate best evidence into clinical practice. The Iowa Model of Evidence-Based Practice to Promote Quality Care is one model that should be considered. Using an actual clinical example, this article describes how the Iowa Model can be used effectively to implement an actual practice change at the unit or organizational level.

NURSES' ROLES IN ANTICIPATORY PRESCRIBING IN END OF LIFE CARE

BackgroundIn the UK, a key approach to improving symptom control in end of life care in the community has been the use of ‘anticipatory’ or ‘just in case’ prescriptions. There...

Keynoter's View: Not Just Testing, Certification Promotes Quality Care in PA/LTC Setting

Caring for the Ages is the official newspaper of AMDA and provides long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care medicine.