Quality Improvement Approach Research Articles

Impact of Evidence-Based Quality Improvement on Tailoring VA’s Patient-Centered Medical Home Model to Women Veterans’ Needs

BackgroundWomen Veterans’ numerical minority, high rates of military sexual trauma, and gender-specific healthcare needs have complicated implementation of comprehensive primary care (PC) under VA’s patient-centered medical home model, Patient Aligned Care Teams (PACT).ObjectiveWe deployed an evidence-based quality improvement (EBQI) approach to tailor PACT to meet women Veterans’ needs and studied its effects on women’s health (WH) care readiness, team-based care, and burnout.DesignWe evaluated EBQI effectiveness in a cluster randomized trial with unbalanced random allocation of 12 VAMCs (8 EBQI vs. 4 control). Clinicians/staff completed web-based surveys at baseline (2014) and 24 months (2016). We adjusted for individual-level covariates (e.g., years at VA) and weighted for non-response in difference-in-difference analyses for readiness and team-based care overall and by teamlet type (mixed-gender PC-PACTs vs. women-only WH-PACTs), as well as post-only burnout comparisons.ParticipantsWe surveyed all clinicians/staff in general PC and WH clinics.InterventionEBQI involved structured engagement of multilevel, multidisciplinary stakeholders at network, VAMC, and clinic levels toward network-specific QI roadmaps. The research team provided QI training, formative feedback, and external practice facilitation, and support for cross-site collaboration calls to VAMC-level QI teams, which developed roadmap-linked projects adapted to local contexts.Main MeasuresWH care readiness (confidence providing WH care, self-efficacy implementing PACT for women, barriers to providing care for women, gender sensitivity); team-based care (change-readiness, communication, decision-making, PACT-related QI, functioning); burnout.Key ResultsOverall, EBQI had mixed effects which varied substantively by type of PACT. In PC-PACTs, EBQI increased self-efficacy implementing PACT for women and gender sensitivity, even as it lowered confidence. In contrast, in WH-PACTs, EBQI improved change-readiness, team-based communication, and functioning, and was associated with lower burnout.ConclusionsEBQI effectiveness varied, with WH-PACTs experiencing broader benefits and PC-PACTs improving basic WH care readiness. Lower confidence delivering WH care by PC-PACT members warrants further study.Trial RegistrationThe data in this paper represent results from a cluster randomized controlled trial registered in ClinicalTrials.gov (NCT02039856).

Looking Across the Drape: A Novel Quality Improvement Approach to Understanding Surgeon and Anesthesiologist Burnout.

To identify well-being threats for surgeons and anesthesiologists and develop interventions using the quality of life improvement (QOLI) approach. Developing feasible perioperative well-being interventions requires identifying shared and specialty-specific well-being needs. The QOLI framework integrates human-centered design, implementation science, and quality improvement to address well-being needs. Anesthesia and surgery faculty in 8 perioperative departments at an academic medical center completed cross-sectional surveys containing validated measures of well-being and workplace satisfaction, and open-ended questions about professional motivations, pain points, strategies for improvement, and well-being priorities. Using template analysis, we analyzed open-ended survey data and presented resulting themes at a joint-specialty town hall for live voting to identify well-being priorities. One hundred four perioperative faculty completed the survey. Across specialties, higher Mental Health Continuum-Short Form scores (representative of individual global well-being) were associated with higher satisfaction with workplace control, values, decision latitude, and social support. Anesthesiologists reported lower satisfaction and control than surgeons across multiple domains. Template analysis yielded 5 areas for intervention: (1) work culture, (2) work environment/resources, (3) sources of fulfillment, (4) work/life harmony, and (5) financial compensation. Surgeons and anesthesiologists both prioritized high-quality patient care but differed in their other top priorities. The most frequently cited well-being threats for surgeons were operating room inefficiencies/delays and excessive workload, whereas anesthesiologists cited understaffing and unpredictable work hours. Surgeons and anesthesiologists share many needs and priorities, with pain points that are often negatively synergistic. Applying the QOLI approach across specialties allows for well-being interventions that honor complexity and promote the development of feasible solutions.

Applying kansei engineering and text mining to design fresh food logistics services

ABSTRACT The study focuses on identifying the key drivers that can meet consumers’ perceptual demands for fresh food logistics services and how e-retailers balance changing demands. In this light, a service quality improvement approach integrating Kansei engineering and text mining is proposed to span the property and semantic space. The data from the Chinese e-commerce platform is used as 288 service scenarios. Meanwhile, GeoDetector and Kano model are used to build models and find priorities of services. The results show that consumers’ demands are fine-grained and hierarchical. Fresh, fast, affordable, reliable and satisfied demands are the rational. Convenient, thoughtful, pleasant, persistent and surprised demands are the perceptual. Most logistics attributes have a ‘1 + 1 > 2’ effect on consumers’ perceptual demands during the emergency period, and exposure safety and logistics persistence are most significantly affected, having a ‘weak + weak = strong’ effect. Additionally, must-be, one-dimensional, and attractive quality based on the kano model provide more targeted strategies to improve the input-output utility.

Effectiveness of Capacity-Building and Quality Improvement Interventions to Improve Day-of-Birth Care in Kinshasa, Democratic Republic of the Congo.

In sub-Saharan African settings like the Democratic Republic of the Congo, high-quality care during childbirth and the immediate postpartum period is lacking in public facilities, necessitating multipronged interventions to improve care. We used a pre-post design to examine the effectiveness of a low-dose, high-frequency capacity-building and quality improvement (QI) intervention to improve care for women and newborns around the day of birth in 16 health facilities in Kinshasa, Democratic Republic of the Congo. Effectiveness was assessed based on changes in provider skills, key health indicators, and beneficiary satisfaction. To assess changes in the competency of the 188 providers participating in the intervention, we conducted objective structured clinical examinations on care for mothers and newborns on the day of birth, immediate postpartum family planning (PPFP) counseling and method provision, and postabortion care before and after implementation of training and at 6 and 12 months after training. Interrupted time series (ITS) analysis techniques were used to analyze routine health service data for changes in select maternal, newborn, and postpartum outcomes before and after the intervention. To assess changes in clients' perceptions of care, 2 rounds of telephone surveys were administered. Before the intervention, less than 2% of participating providers demonstrated competency in skills. Immediately after training, more than 80% demonstrated competency, and 70% retained competency after 12 months. ITS analyses show the risk of early neonatal death declined significantly by 9% (95% confidence interval [CI]=4%, 13%, P<.001), and likelihood of immediate PPFP uptake increased significantly by 72% (95% CI=53%, 92%, P<.001). Client satisfaction improved by 58% over the life of the project. These findings build on previous studies documenting the effectiveness of clinical capacity-building and QI approaches. If implemented at scale, this approach has the potential to substantively contribute to improving maternal and perinatal health in similar settings.

Metabolic bone disease of prematurity screening and individualized enteral mineral supplementation in high-risk neonates: a quality improvement initiative.

Prompted by an alarmingly low screening rate for metabolic bone disease of prematurity (MBDP), we aimed to increase MBDP screening with serum calcium, phosphorous, and alkaline phosphatase at four to six weeks of life in infants born at <1500 g and <32 gestational weeks from a baseline of 27.37% to 90% within one year. We used the Institute for Healthcare Improvement's Model for Improvement as a framework. A key driver diagram informed the interventions which were carried out through four Plan-Do-Study-Act cycles. There were 129 and 130 neonates in the pre-intervention baseline group and post-intervention MBDP bundle group, respectively. MBDP bundled primary screening rates increased from 27.37% to 95.56% (p < 0.001). Furthermore, 20% of infants had an individualized change in their enteral mineral supplementation after the initiative. An interdisciplinary team-based quality improvement approach was effective in altering clinical practice to improve screening and subsequent treatment for MBDP.

Abstract TMP42: Reducing 30-day Stroke Readmissions Using a Multi-Step Quality Improvement Approach

Background: Thirty-day all-cause readmissions occur in about 12% of acute ischemic stroke (AIS) patients, are associated with a 4-fold increase in mortality, and are associated with increased cost utilization. Therefore, reducing 30-day readmissions in AIS patients is of paramount importance. In this study, we aimed to test the effect of a multi-step quality improvement (QI) initiative on readmission rates in hospitalized AIS patients. Methods: We included all patients discharged from a Comprehensive Stroke Center with a diagnosis of AIS or TIA over a 3-year period. The pre-intervention period was 1/1/2020 - 9/30/2021. The approach was instituted on 10/1/2021. After a 3-month washout, the post-intervention period was 1/1/2022 - 6/30/2023. Intervention measures are below.1. An inpatient checklist was instituted to help providers identify and address common problems before AIS/TIA patients were discharged.2. Complex patients discharged home would receive a call shortly after discharge to ensure good understanding of their care and next steps. Such patients were also scheduled to follow up in a rapid access clinic within 2 weeks of discharge.3. Complex patients discharged to a facility required a handoff call to the facility’s accepting provider.4. All readmissions were reviewed in our monthly QI meeting, with efforts to identify preventable causes.We used t-tests to compare mean observed to expected (O:E) length of stay and mortality metrics between the pre- and post-intervention periods. We used Chi Square tests to compare overall readmission rates. Results: Over the study period, 2532 patients were discharged with a principal diagnosis of AIS or TIA, and the all-cause 30-day readmission rate was 8.8% (223/2532). Compared to pre-intervention, the post-intervention period had a lower 30-day readmission rate (7.6% vs. 10.2%, p = 0.023), a non-significantly lower mean O:E mortality rate (0.71 vs. 0.82, p = 0.252), and a non-significantly lower mean O:E hospital length of stay (0.92 vs. 0.88, p = 0.13). Conclusion: At a Comprehensive Stroke Center, a multi-step approach for transitions of care was associated with reduced all-cause readmission rates without increasing hospital length of stay or mortality. Our findings require external validation.

117. Making it Easy to Say Yes: Using a Quality Improvement Approach to Boost Immunization Rates and Examine Equity in an Adolescent Medicine Practice

117. Making it Easy to Say Yes: Using a Quality Improvement Approach to Boost Immunization Rates and Examine Equity in an Adolescent Medicine Practice

Initiation Rate of First-hour Breastfeeding in Healthy Term and Near Term Babies: Outcome Assessment After Quality Improvement Methods in Secondary Care District Hospital

Objective To improve the rate of first-hour breastfeeding in term and near-term healthy neonates by a quality improvement (QI) study at Secondary Care District Hospital. Design QI study. Setting Labor room-operation theatre of a secondary care district hospital. Participants Stable newborns ≥35 weeks of gestation born by normal vaginal delivery and by cesarean section under spinal anesthesia. Procedure A team of nurses, pediatricians, obstetricians, and anesthetists analyzed possible reasons for delayed initiation of breastfeeding by flow chart and Fishbone analysis. Various change ideas were tested through sequential Plan-Do-Study-Act cycles. Outcome measure Proportion of eligible babies breastfed within 1 hour of delivery. Results The rate of first-hour initiation of breastfeeding increased from 69% to 88% in normal vaginal deliveries and from 17% to 61% in the cesarian section over the study period, which were sustained up to 80% in normal vaginal deliveries (NVD) and 55% in lower segment cesarean section. Conclusions A QI approach was able to accomplish sustained improvement in first-hour breastfeeding rates in normal and cesarean deliveries.

Remote area nurses' experiences of workplace safety in very remote primary health clinics: A qualitative study.

To explore Remote Area Nurses' experiences of the implementation of workplace health and safety policies and risk mitigation strategies in Australian very remote primary health clinics. This qualitative study used online semi-structured interviews, with participants purposively sampled to maximize variation in work location and service type. Data were analysed using a reflexive thematic analysis approach. Coding was carried out inductively, with NVivo 12 aiding data management. The interviews were conducted from 24 Februrary 2021 to 06 March 2021 with Remote Area Nurses from very remote primary health clinics in Australia. Fifteen Remote Area Nurses participated in the study. Thematic analysis revealed varied approaches to workplace safety among the different health services and regions. While the spread of 'never alone' policies in many clinics addressed one of the significant risks faced by Remote Area Nurses, gaps remained even for hazards specifically highlighted in existing work health and safety legislation. Meaningful collaboration with staff and the community, local orientation, preparation for the role and providing quality care were protective factors for staff safety. Understaffing, unsafe infrastructure and inadequate equipment were common concerns among Remote Area Nurses. Health services need to prioritize workplace safety and take a continuous quality improvement approach to its implementation. This will include ensuring safety strategies are appropriate for the local context, improving infrastructure maintenance, and establishing sustainable second responder systems such as a pool of drivers with local knowledge. Poor personal safety contributes to burnout and high turnover of staff. Nurses' insights into the barriers and enablers of current workplace safety strategies will aid policymakers and employers in future improvements. COREQ reporting guidelines were followed. A panel of six Remote Area Nurses collaborated in the development of this project.

Implementation and impact of rapid SARS-CoV-2 point of care test on patient flow in the frailty pathway; A quality improvement approach.

To maintain patient flow during the COVID-19 pandemic, rapid and accurate decisions for the safe triage of geriatrics patients was essential as turnaround times for laboratory testing was ineffective at supporting rapid clinical decision-making for transfer of care. Thus, to mitigate and inform these clinical decisions, a quality improvement collaborative project with the geriatrics and virology department was conducted at the Frailty Assessment Unit (FAU) at Aberdeen Royal Infirmary. The goal was to facilitate patient triage during transfer of care with the introduction of Point of Care testing (POCT). The interventions which resulted in significant improvements were based on the fishbone problem solving approach and the driver diagram with change ideas informing the five Plan, Do, Study and Act (PDSA) cycles. The QI intervention was crucial in supporting clinical staff decision making during transfers for 95% of patients who had been clinically judged as asymptomatic for COVID-19 infection. High staff engagement was observed with 83% of staff suggesting the process map was easy to follow and 92% of clinical staff agreed it contained sufficient information to support the testing process. With POCT introduction, the proportion of patients who were transferred with an early POCT result increased by 20% in the Rosewell House group and by 65% in the community Hospitals group, once governance arrangements were in place. Finally, the considerable uptake of POCT by the ward consequently led to a decrease of up to 86% in the number of samples sent to the laboratory for rapid SARS-CoV-2 testing. The quality improvement project provided a rapid and reliable SARS-CoV-2 triage tool and was effectively integrated into the geriatrics triage algorithm to facilitate patient placement and flow.

Reducing catheter-associated urinary tract infections in a large health system: a quality improvement approach using a fractal management system

Abstract Objective: Although preventable through established infection control practices, catheter-associated urinary tract infections (CAUTIs) remain prevalent in acute-care settings. Our goal was to improve the CAUTI rates through multiple hospitals through implementing sustainable practices, including enhancing communication, provider engagement, accountability, and transparency in reporting to achieve long-term improvements. Design: Quality improvement with multiple levels of interventions Setting: A health system in northern Ohio with 21 affiliated hospitals across 16 counties. Patients: Adult patients admitted to the hospital between June 2020 and June 2023. Methods: A broad set of quality improvement (QI) strategies was developed by an interdisciplinary team and guided by the Fractal Management System framework to ensure accountability, communication, and alignment across teams and facilities. Key drivers were indwelling urinary catheter (IUC) alternatives, insertion, maintenance, removal, and smart diagnostics. The main outcome measures were standardized infection ratios (SIR) and standardized utilization ratio (SUR), comparing period 1 (P1, June 2020 to December 2021) and period 2 (P2, January 2022 to June 2023). Results: Enhanced communication and management played crucial roles in minimizing IUC placement. Updated policies and protocols, coupled with clear guidelines and decision support tools, facilitated effective urinary management. Performance tracking and visual management boards provided real-time insights, while collaborative efforts, including staff huddles and multidisciplinary teamwork, ensured consistent adherence to best practices. Conclusions: A systemwide QI initiative focused on enhanced communication, management, and collaboration contributed to improved SIR and reduced CAUTI rates across multiple hospitals, highlighting the impact of strong communication and proactive management in healthcare settings.

Advancing Equitable Ambulatory Telehealth Through Dashboard Development.

Telehealth has the potential to improve access to health care by mitigating barriers related to geography, time, and finances. However, the increased adoption of ambulatory telehealth has inadvertently widened access gaps for socially disadvantaged and marginalized populations. Quality improvement approaches are a valuable strategy to address health care access inequities and disparities, involving data-driven implementation, assessment, and adaptation of tests of change over time. Because these iterative changes and interventions are data-driven, a critical element of quality improvement requires ongoing data collection and monitoring. This perspective describes the development and validation processes of a telehealth equity dashboard. This dashboard is currently available for use by our health system leaders, providers, and clinic staff. The overall objective of this dashboard is to identify and track inequities and to improve equitable ambulatory telehealth access across diverse patient groups. Lessons learned from creating this dashboard can inform other health care systems of how to develop and validate telehealth data feedback systems to promote quality improvement efforts to advance telehealth equity and accessibility.

A deep learning approach using an ensemble model to autocreate an image-based hip fracture registry.

With more than 300,000 patients per year in the United States alone, hip fractures are one of the most common injuries occurring in the elderly. The incidence is predicted to rise to 6 million cases per annum worldwide by 2050. Many fracture registries have been established, serving as tools for quality surveillance and evaluating patient outcomes. Most registries are based on billing and procedural codes, prone to under-reporting of cases. Deep learning (DL) is able to interpret radiographic images and assist in fracture detection; we propose to conduct a DL-based approach intended to autocreate a fracture registry, specifically for the hip fracture population. Conventional radiographs (n = 18,834) from 2919 patients from Massachusetts General Brigham hospitals were extracted (images designated as hip radiographs within the medical record). We designed a cascade model consisting of 3 submodules for image view classification (MI), postoperative implant detection (MII), and proximal femoral fracture detection (MIII), including data augmentation and scaling, and convolutional neural networks for model development. An ensemble model of 10 models (based on ResNet, VGG, DenseNet, and EfficientNet architectures) was created to detect the presence of a fracture. The accuracy of the developed submodules reached 92%-100%; visual explanations of model predictions were generated through gradient-based methods. Time for the automated model-based fracture-labeling was 0.03 seconds/image, compared with an average of 12 seconds/image for human annotation as calculated in our preprocessing stages. This semisupervised DL approach labeled hip fractures with high accuracy. This mitigates the burden of annotations in a large data set, which is time-consuming and prone to under-reporting. The DL approach may prove beneficial for future efforts to autocreate construct registries that outperform current diagnosis and procedural codes. Clinicians and researchers can use the developed DL approach for quality improvement, diagnostic and prognostic research purposes, and building clinical decision support tools.

Sequential Compression Device Compliance for Venous Thromboembolism in High-Risk Trauma: A Quality Improvement Study.

Hospital-acquired, perioperative venous thromboembolism is a recognized patient safety indicator in the adult trauma patient population. Mechanical prophylaxis has been identified as a standard intervention to reduce the incidence of venous thromboembolism when prescribed along with anticoagulation or if anticoagulation is contraindicated in the surgical population. Adherence to consistent mechanical prophylaxis remains a nursing issue impacted by numerous factors in patient care. The purpose of this quality improvement project was to improve the compliance of sequential compression device utilization to decrease the hospital-acquired, perioperative venous thromboembolism rate in the adult hospitalized trauma patient population. A pre- and postintervention quality improvement approach utilized a nurse-led strategy to engage multidisciplinary team members to increase the consistency of sequential compression device utilization on patients within trauma units. The patient safety indicator rate per 1,000 for hospital-acquired, perioperative venous thromboembolism was monitored for improvement. The patient safety indicator rate per 1,000 for hospital-acquired, perioperative venous thromboembolism demonstrated a decline from 10.60 to 4.95 rate per 1,000 over 12 months. In the trauma units, sequential compression device compliance increased from an initial direct observation audit of only 12% to an average of 65% compliance rate during the last 16-week audits. We found that a multidisciplinary, nurse-driven approach in the trauma units was effective in improving the compliance of sequential compression device utilization and impacted the hospital acquired, perioperative venous thromboembolism rate in the adult trauma patient population.

Adopting a quality improvement approach to patient safety incidents

Adopting a quality improvement approach to patient safety incidents

A Mixed Methods Evaluation of a Quality Improvement Model to Optimize Perinatal and Primary Care in the Community Health Setting.

Many maternal deaths occur beyond the acute birth encounter. There are opportunities for improving maternal health outcomes through facilitated quality improvement efforts in community settings, particularly in the postpartum period. We used a mixed methods approach to evaluate a collaborative quality improvement (QI) model in 6 Chicago Federally Qualified Health Centers (FQHCs) that implemented workflows optimizing care continuity in the extended postpartum period for high-risk prenatal patients. The Quality Improvement Learning Collaborative focused on the implementation of a registry of high-risk prenatal patients to link them to primary care and was implemented in 2021; study data were collected in 2021-2022. We conducted a quantitative evaluation of FQHC-reported aggregate structure, process, and outcomes data at baseline (2020) and monthly (2021). Qualitative analysis of semistructured interviews of participating FQHC staff focused on the experience of participating in the collaborative. At baseline, none of the 6 participating FQHCs had integrated workflows connecting high-risk prenatal patients to primary care; by the end of implementation of the QI intervention, such workflows had been implemented at 19 sites across all 6 FQHCs, and 54 staff were trained in using these workflows. The share of high-risk patients transitioned to primary care within 6 months of delivery significantly increased from 25% at baseline to 72% by the end of implementation. Qualitative analysis of interviews with 11 key informants revealed buy-in, intervention flexibility, and collaboration as facilitators of successful engagement, and staffing and data infrastructure as participation barriers. Our findings show that a flexible and collaborative QI approach in the FQHC setting can help optimize care delivery. Future evaluations should incorporate the patient experience and patient-level data for comprehensive analysis.

Building a Better System to Support Family Caregivers: Engaging Multi-level Interdisciplinary Stakeholders in Micro, Meso, and Macro Level Learning Health System Design.&amp;nbsp;&amp;nbsp;

The current Canadian healthcare workforce shortage and care crisis demands innovative solutions, yet it takes 17 years for healthcare innovations to reach 50% adoption in clinical practice. Healthcare workforce shortage solutions include expanding team-based care, moving integrated services closer to home[, and including Family Caregivers [FCGs] as partners on the care team, rather than treating them as visitors or patient accompaniments. Integrating FCGs as partners on the healthcare team improves patient care, health, and well-being, reduces the length of hospital stays, supports aging in the right place, promotes effective communication, and reduces healthcare providers’ workload. While FCGs and the people they care for require integrated care and services coordinated around their comprehensive needs, research confirms that FCGs remain invisible, and often marginalized by healthcare systems.&#x0D; Aim: Detail the micro-meso-macro-level elements and roles needed for building integrated FCG support systems.&#x0D; Results: As FCGs, the people they care for, and their care trajectories are diverse, an integrated system to support FCGs includes: 1) macro-level policy leadership 2) meso-level FCG-friendly communities, community organizations, health and social care systems, and providers trained to support FCGs; 3) micro-level assessment of FCGs needs and supports tailored to needs/goals, and 4) evaluation and practice improvement research. Three critical elements to Health Learning Approaches are: 1) Prioritize service needs and a design improvement approach; 2) Strengthen and link the assets required to operationalize rapid learning and a quality improvement approach, and 3) Establish a network of rapid-learning champions to drive and sustain action. Our Alberta-based Caregiver-Centered Care Research Program works at collaborating with stakeholders interested in enacting a collective impact approach to build a better system of all the essential elements of integrated health and social care programs and services needed to support FCG's well-being and sustain their caregiving. First, we convened a series of consultations to prioritize approaches to support FCGs. Stakeholders prioritized competency-based education for healthcare providers about person-centered care for FCGs. Accordingly, we engaged FCGs, researchers, health and social care providers/leaders, and policymakers to co-design and deliver free, online Foundational and Advanced education about providing person-centered care for FCGs to health and social care providers. Now, we need to strengthen our network and link assets. We convened a series of six webinars designed to raise awareness of FCGs' work, the need for systemic FCGs support, and to consult stakeholders about the next steps to integrate health and social care systems to support FCGs (October 20 – November 29, 2022). The webinars have also built our network of Canadian collaborators.&#x0D; Conclusions: The collaboration required to build a better system to support Canadian FCGs takes facilitation and time. The learning health system framework seems appropriate to approach the complex system and culture changes required more efficiently and effectively. &#x0D; Implications: Learning Health Systems and co-design by communities of patients, FCGs, health and social care providers/leaders, and researchers are currently regarded as a superior approach to improving healthcare and health outcomes. A strength of our team is collaborative, trusting relationships. &#x0D;

Integrated care pathways between primary, secondary and tertiary health care for Aboriginal and Torres Strait Islander Australians

Empirical evidence and current policy documents strongly indicate a requirement for greater healthcare integration for Aboriginal and Torres Strait Islander people as an extension of the current coordinated care models. System fragmentation and the documented evidence of inadequate care transitions of many Aboriginal and Torres Strait Islander patients test the adequacy and flexibility of health systems to provide access and effective, efficient and appropriate care. Integration across organisations and sectors in the health system is necessary for coordinated patient-centred care that improves patient experiences and health outcomes and adds value to the system by delivering efficiencies. In this project, we aimed to better understand integrated care as a significant quality improvement approach in delivering care between the primary, secondary and tertiary care systems for Aboriginal and Torres Strait Islander people as the first step to real-world design and implementation. Firstly, we used a ‘participatory’ systematic review methodology to identify care processes and effective components needed to support integrated care models between primary, secondary and tertiary care. We focused on the processes involved in its implementation, delivery, and outcomes and impact to develop a conceptual model. Engagement with healthcare providers and community members grounded the theoretical model in real-world contexts. We then tested the model using a jury approach and wargaming, a soft simulation method. The structural reforms needed to ensure effective multistakeholder, multilevel integrated care implementation were identified and priority setting for implementation considered. We will present the developed integrated care model and discuss the inherent opportunities and challenges for implementation.

Extent of integration of nutrition assessment counselling and support interventions in the health system and respective drivers: A case of Tororo district, Uganda.

Uganda embraced Nutrition Assessment Counselling and Support (NACS) since 2009 as a health system strengthening approach to improve health and nutrition outcomes. However, scant evidence exists on NACS integration and drivers. This study therefore assessed the extent of NACS integration in the health system and identified key drivers and barriers. A mixed method design was employed. In a facilitated panel discussions at each of the 17 health facilities, 4-5 health staff participated, responding to a semi-structured questionnaire. Integration was assessed on a 5-point scoring scale of 1 for not done nor integrated, 2-4 for partial and 5 for fully integration. Data was captured, analysed in microsoft excel and presented using as bar and spider charts. Integration drivers were identified deductively from key informant and in-depth interviews using Atlas.ti 9 and thematic analysis. The NACS integration across the health facility level was partial at a score of 2.9 indicating a weak integration into the health system. Integration across the health system building blocks was partial at; service delivery (3.8), health work force (3.7), health information (3.3), community support system (3.0), governance and leadership (3.0) signifying that NACS activities are provided by Ministry of Health but sub-optimal due to weak capacities. Health financing (2.2) and Health supplies (1.5) were the least integrated due to partner dependence. Under service delivery, deworming (5) was fully integrated and provided by Ministry of Health. The key drivers for integration were; good leadership, financing, competent staff, quality improvement approaches, nutrition talks, community dialogues, nutrition logistics and supplies. The NACS integration in the health system was generally low and lacked adequate support. Governance, financing and community follow-up under service delivery require more government investment for enhanced integration.

IDENTIFYING, DEVELOPING, AND IMPLEMENTING CARE PLANS CONSISTENT WITH GOALS, PRIORITIES, AND PREFERENCES

Abstract NASEM’s first recommendation to reform nursing home (NH) care is to deliver comprehensive, person-centered, equitable care that ensures residents’ health, quality of life, and safety, promotes autonomy, and manages risks. The NH Code of Federal Regulations requires person-centered care (PCC). However, while there are existing structures (i.e. MDS 3.0) to support care planning clinical needs, most NHs lack tools and procedures to systematically identify and provide care that aligns with resident goals, priorities, and preferences (GPPs). This is especially true for GPPs that reflect personhood and the human desire for autonomy. Our subcommittee aims to change the culture of care planning in NHs to integrate residents and families in co-developing holistic, person-centered care plans that centralize residents’ GPPs in ways that promote and support personhood. Our subcommittee will develop and test a) a standardized GPP care planning process that includes enhanced approaches to identification, documentation, communication, and implementation of resident GPPs; b) a repository of tools to support identification and documentation of resident GPPs; and c) training to prepare staff to understand and recognize resident GPPs. We will collaborate with other Moving Forward Committees to develop approaches to evaluating and measuring quality in care planning with inclusion of health information technology . When completed, the proposed work will provide evidence of successful and feasible quality improvement approaches to care planning resident GPPs that can augment existing federal requirements and can inform future policy changes or guidance to surveyors.