Unit-based Teams Research Articles

Undertaking Studies Within A Trial to evaluate recruitment and retention strategies for randomised controlled trials: lessons learnt from the PROMETHEUS research programme.

Randomised controlled trials ('trials') are susceptible to poor participant recruitment and retention. Studies Within A Trial are the strongest methods for testing the effectiveness of strategies to improve recruitment and retention. However, relatively few of these have been conducted. PROMoting THE Use of Studies Within A Trial aimed to facilitate at least 25 Studies Within A Trial evaluating recruitment or retention strategies. We share our experience of delivering the PROMoting THE Use of Studies Within A Trial programme, and the lessons learnt for undertaking randomised Studies Within A Trial. A network of 10 Clinical Trials Units and 1 primary care research centre committed to conducting randomised controlled Studies Within A Trial of recruitment and/or retention strategies was established. Promising recruitment and retention strategies were identified from various sources including Cochrane systematic reviews, the Study Within A Trial Repository, and existing prioritisation exercises, which were reviewed by patient and public members to create an initial priority list of seven recruitment and eight retention interventions. Host trial teams could apply for funding and receive support from the PROMoting THE Use of Studies Within A Trial team to undertake Studies Within A Trial. We also tested the feasibility of undertaking co-ordinated Studies Within A Trial, across multiple host trials simultaneously. Clinical trials unit-based trials recruiting or following up participants in any setting in the United Kingdom were eligible. Clinical trials unit-based teams undertaking trials in any clinical context in the United Kingdom. Funding of up to £5000 and support from the PROMoting THE Use of Studies Within A Trial team to design, implement and report Studies Within A Trial. Number of host trials funded. Forty-two Studies Within A Trial were funded (31 host trials), across 12 Clinical Trials Units. The mean cost of a Study Within A Trial was £3535. Twelve Studies Within A Trial tested the same strategy across multiple host trials using a co-ordinated Study Within A Trial design, and four used a factorial design. Two recruitment and five retention strategies were evaluated in more than one host trial. PROMoting THE Use of Studies Within A Trial will add 18% more Studies Within A Trial to the Cochrane systematic review of recruitment strategies, and 79% more Studies Within A Trial to the Cochrane review of retention strategies. For retention, we found that pre-notifying participants by card, letter or e-mail before sending questionnaires was effective, as was the use of pens, and sending personalised text messages to improve questionnaire response. We highlight key lessons learnt to guide others planning Studies Within A Trial, including involving patient and public involvement partners; prioritising and selecting strategies to evaluate and elements to consider when designing a Study Within A Trial; obtaining governance approvals; implementing Studies Within A Trial, including individual and co-ordinated Studies Within A Trials; and reporting Study Within A Trials. The COVID-19 pandemic negatively impacted five Studies Within A Trial, being either delayed (n = 2) or prematurely terminated (n = 3). PROMoting THE Use of Studies Within A Trial significantly increased the evidence base for recruitment and retention strategies. When provided with both funding and practical support, host trial teams successfully implemented Studies Within A Trial. Future research should identify and target gaps in the evidence base, including widening Study Within A Trial uptake, undertaking more complex Studies Within A Trial and translating Study Within A Trial evidence into practice. All Studies Within A Trial in the PROMoting THE Use of Studies Within A Trial programme had to be registered with the Northern Ireland Network for Trials Methodology Research Study Within A Trial Repository. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/55/80) and is published in full in Health Technology Assessment; Vol. 28, No. 2. See the NIHR Funding and Awards website for further award information.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Focusing hospitalist roles on either admitting or rounding facilitates unit-based assignment and is associated with improved discharge efficiency

ABSTRACT Background Unit-based teams may improve care delivery for hospitalized patients but can be challenging to implement broadly across all acute care units in a hospital. Objective To determine the effect of a Lean-guided transition to hospital-wide unit-based assignment on care delivery outcomes. Design, setting, and participants The study was a retrospective time-series with primary outcomes of discharge efficiency, 30-day readmissions, and length of stay, performed at a 336-bed tertiary academic referral hospital in the Pacific Northwest with approximately 17,000 admissions annually. Intervention Implementation of a Lean-guided quality improvement intervention included division of hospitalist duties into ‘admitters’ and ‘rounders,’ with simulated patient flow exercises to determine the optimal staffing model. Main outcomes and measures Discharge efficiency (number of patients discharged by hospitalists divided by the number of hospitalist patient encounter days per month) and 30-day readmissions were compared using the t-test or chi-square, and length of stay was analyzed in a multivariate time-series regression model. Results The intervention was associated with a significant improvement in discharge efficiency, by 0.014 (from 0.168 to 0.181) discharges/encounter (95% CI = 0.024, 0.004), p = 0.009. Mean length of stay decreased by 0.98 days (95% CI 0.50, 1.47) after adjustment for patient age, patient type (medical versus surgical), critical care admissions, and discharge disposition, without a corresponding change in 30-day readmission rate (12.2% (1948/15,902) pre-intervention to 11.7% (397/3379) post-intervention (p = 0.42)). Conclusions Dividing hospitalist roles into admitters and rounders enabled implementation of unit-based teams across the hospital, with corresponding improvements in discharge efficiency and length of stay.

The Roadmap to Success: Creating Unit-Based Teams to Increase Family Centered Rounding and Improve Care Team Communication

The Roadmap to Success: Creating Unit-Based Teams to Increase Family Centered Rounding and Improve Care Team Communication

Evaluating the effects of a high-tech call system on patient-staff communication.

Evaluating the effects of a high-tech call system on patient-staff communication.

Improving the Culture of Safety: Workplace Safety Unit-Based Teams Interventions that Work

Improving the Culture of Safety: Workplace Safety Unit-Based Teams Interventions that Work

Sustained Improvement in Hand Hygiene Compliance Using a Decentralized, Technology-Based Approach

BackgroundWe aimed to use weekly PI calls in conjunction with 24/7 hand hygiene monitoring technology (HHMT) to engage front-line Intensive Care Unit (ICUs) clinicians in improving Hand Hygiene (HH) complianceMethodsHHMT is used to monitor aggregate, unit-based HH compliance in real time and displayed on monitors at the nursing stations at our academic medical center. After installation and validation were completed, unit-based teams of nursing and physician leadership joined weekly 15-minute HH PI calls to discuss their previous week’s compliance rate, next steps in their own PI plan, and share successes and failures. Calls were suspended for 6 months and restarted in early 2017.ResultsGraph representation of weekly HH compliance rates for the ICUs are shown in figure 1. Units AandB underwent physical moves during the break, Unit C had no change, and Unit D moved and consolidated with other ICUs constituting a major change in personnel and patient population. Each ICU participated in 84 calls and recorded approx. 50,000–100,000 HH opportunities during each month resulting in over 8 million opportunities for HH compliance recorded during the call-in periods. Unit A had an average compliance of 39% for the first 4 weeks of calls and 64% during the same 4 week period one year later (P < 0.0001). After 6 months without the calls, HH compliance was 48% (P < 0.0001 compared with baseline compliance) and unit A implemented 20 separate PI interventions over the course of the calls. Compliance was also significantly improved (P < 0.0001 for all comparison to baseline) for units B, C, and D (Unit B: 42% baseline, 71% at 1 year, 67% after the break, 23 interventions; Unit C: 54% baseline, 58% at 1 year, 59% after the break, 19 interventions; Unit D: 41% at baseline, 56% after 1 year, 49% after the break, 19 interventions). Attendance was >90% for nursing leadership and <25% for physician leadership.ConclusionWeekly 15-minute calls were successful in engaging local nursing leadership to undertake performance improvement interventions and significantly improved HH compliance that was sustained over 18 months of calls and did not drop back to baseline even after a 6 month break.Disclosures E. Landon, GOJO: Speaker, travel expenses for speaking; J. P. Ridgway, Gilead FOCUS: Grant Investigator, Grant recipient; A. H. Bartlett, CVS Caremark: Consultant, Consulting fee

Reducing preventable harm: observations on minimizing bloodstream infections

PurposeThe purpose of this paper is to provide a practical framework that health care organizations could use to decrease preventable healthcare-acquired harms.Design/methodology/approachAn existing theory of how hospitals succeeded in reducing rates of central line-associated bloodstream infections was refined, drawing from the literature and experiences in facilitating improvement efforts in thousands of hospitals in and outside the USA.FindingsThe following common interventions were implemented by hospitals able to reduce and sustain low infection rates. Hospital and intensive care unit (ICU) leaders demonstrated and vocalized their commitment to the goal of zero preventable harm. Also, leaders created an enabling infrastructure in the way of a coordinating team to support the improvement work to prevent infections. The team of hospital quality improvement and infection prevention staff provided project management, analytics, improvement science support, and expertise on evidence-based infection prevention practices. A third intervention assembled Comprehensive Unit-based Safety Program teams in ICUs to foster local ownership of the improvement work. The coordinating team also linked unit-based safety teams in and across hospital organizations to form clinical communities to share information and disseminate effective solutions.Practical implicationsThis framework is a feasible approach to drive local efforts to reduce bloodstream infections and other preventable healthcare-acquired harms.Originality/valueImplementing this framework could decrease the significant morbidity, mortality, and costs associated with preventable harms.

Effect of Peer-to-Peer Nurse-Physician Collaboration on Attitudes Toward the Nurse-Physician Relationship.

The goal of this study was to pilot a novel peer-to-peer nurse-physician collaboration program and assess for changes in attitudes toward collaboration among a group of newly licensed nurses and resident physicians (n = 39). The program included large group meetings, with discussion of key concepts related to interprofessional collaboration. In unit-based teams, the registered nurses and physicians developed a quality improvement project to meet a need on their unit. Creating learning activities like this program enable nursing professional development specialists to promote interprofessional collaboration and learning.

Rome was not Built in a Day: Creating a System of Support and Structure for Unit-Based Teams to Thrive

Rome was not Built in a Day: Creating a System of Support and Structure for Unit-Based Teams to Thrive

Workforce Survey of Pediatric Interfacility Transport Systems in the United States.

The interfacility transport of pediatric patients requires a highly skilled and well-trained workforce, of which little is known. The primary study purpose was to characterize the current state of pediatric interfacility transport in the United States including, but not limited to, which team models predominate, what team configurations are used, team training standards, and the use of quality assurance metrics. A descriptive and qualitative Web-based survey questionnaire was developed. Potential participants were identified, and 1 survey was completed per team. In total, 179 teams with pediatric transport capabilities were identified, and 111 responses were recorded (response rate, 62%), of which dedicated teams comprised 77% and unit-based teams comprised 16%. Over 98% reported using a registered nurse as a team member, in comparison to 66% for respiratory therapists and 42% for paramedics. Less than 5% reported utilizing an associate level provider or physician for pediatric transports. The most common team composition was a registered nurse-respiratory therapist combination (30%). Over 55% of the respondents reported performing less than 500 pediatric transports per year. Quality assurance activities were performed by 96% of the respondents. The team composition and training for interfacility transport of pediatric patients is a complex and not well-characterized process; furthermore, the varying organizational models, team composition, and training requirements for teams have not been previously reported. These results will aid in the future development of team standards for pediatric transport and help guide further improvements in this field.

Engaging Frontline Staff in Performance Improvement: The American Organization of Nurse Executives Implementation of Transforming Care at the Bedside Collaborative

Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff. In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used. All units reported establishing unit-based teams, of which >90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative. Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.

To Our Readers

Process improvement stresses the importance of engaging frontline staff in implementing new processes and methods. Yet questions remain on how to incorporate these activities into the workday of hospital staff or how to create and maintain its commitment. In a 15-month American Organization of Nurse Executives collaborative involving frontline medical/surgical staff from 67 hospitals, Transforming Care at the Bedside (TCAB) was evaluated to assess whether participating units successfully implemented recommended change processes, engaged staff, implemented innovations, and generated support from hospital leadership and staff.In a mixed-methods analysis, multiple data sources, including leader surveys, unit staff surveys, administrative data, time study data, and collaborative documents were used.All units reported establishing unit-based teams, of which > 90% succeeded in conducting tests of change, with unit staff selecting topics and making decisions on adoption. Fifty-five percent of unit staff reported participating in unit meetings, and 64%, in tests of change. Unit managers reported substantial increase in staff support for the initiative. An average 36 tests of change were conducted per unit, with 46% of tested innovations sustained, and 20% spread to other units. Some 95% of managers and 97% of chief nursing officers believed that the program had made unit staff more likely to initiate change. Among staff, 83% would encourage adoption of the initiative.Given the strong positive assessment of TCAB, evidence of substantial engagement of staff in the work, and the high volume of innovations tested, implemented, and sustained, TCAB appears to be a productive model for organizing and implementing a program of frontline-led improvement.

A Quasi-experimental Evaluation of Performance Improvement Teams in the Safety-Net

Unit-based teams (UBTs), initially developed by Kaiser Permanente and affiliated unions, are natural work groups of clinicians, managers, and frontline staff who work collaboratively to identify areas for improvement and implement solutions. We evaluated the UBT model implemented by the Los Angeles County Department of Health Services in partnership with its union to engage frontline staff in improving patient care. We conducted a quasi-experimental study, comparing surveys at baseline and 6 months, among personnel in 10 clinics who received UBT training to personnel in 5 control clinics. We also interviewed staff from 5 clinics that received UBT training and 3 control clinics. We conducted 330 surveys and 38 individual, semi-structured interviews with staff at an outpatient facility in South Los Angeles. Each UBT leader received an 8-hour training in basic performance improvement methods, and each UBT was assigned a team "coach." Our outcome measure was 6-month change in the "adaptive reserve" score, the units' self-reported ability to make and sustain change. We analyzed transcripts of the interviews to find common themes regarding the UBT intervention. The survey response rate was 63% (158/252) at baseline and 75% (172/231) at 6 months. There was a significant difference-in-change in adaptive reserve between UBTs and non-UBTs at 6 months (+0.11 vs -0.13; P = .02). Nine of the 10 UBTs reported increases in adaptive reserve and 8 UBTs reported decreased no-show rates or patient length of stay in clinic. Staff overwhelmingly felt the UBTs were a positive intervention because it allowed all levels of staff to have a voice in improvement. Our results indicate that partnership between management and unions to engage frontline staff in teams may be a useful tool to improve delivery of health care in a safety-net setting.

Reorganizing a hospital ward as an accountable care unit.

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

National Survey of Neonatal Transport Teams in the United States

Neonatal transport in the United States is a complex process; however, little is known about the neonatal transport team (NTT) workforce. The purpose of this national study was to describe the US NTT workforce. An exploratory, descriptive design that used a Web-based survey questionnaire was used. We identified 398 NTTs, and 345 (86.7%) were enrolled. One survey was completed per team. Ten NTTs did not complete the survey (response rate: 84.2%). Of the 335 completed surveys, 229 (68.4%) were from unit-based teams and 106 (31.6%) were from dedicated teams. Twenty-six different NTT compositions were used. All except 1 (n = 334) had a registered nurse or a neonatal nurse practitioner as a team member. A registered nurse-respiratory therapist team composition was the most common for unit-based (40.2%) and dedicated (44.3%) teams. Dedicated teams used rotor and fixed-wing modes of travel more frequently, transported further distances, and had higher transport volumes than unit-based teams. The median transport volumes reported suggest that as many as 68 797 critically ill neonates are transported each year. There is wide variation in many aspects of neonatal transport, including orientation, determination of readiness for independent transport, use of protocols to guide transport care, and quality assurance activities. These results will be useful for (1) evaluating existing transport services, (2) guiding necessary changes in training or services, and (3) aiding programs that seek to develop a neonatal transport program.

Advancing Nursing Research Through a Mentorship Program for Staff Nurses

This article describes a unique model of implementing unit-based research teams to provide staff nurses with knowledge, skills, and mentoring. The essential elements of designing and conducting a research study are emphasized in an effort to improve nursing practice and the quality of patient care. The research education and practicum are incorporated into team meetings. This unique model provides greater efficiency and effectiveness of resources and allows for more interactive education than occurs in traditional models. Unit-based nursing teams learn together to design research studies, test hypotheses, and answer clinically relevant research questions, using the scientific process.

Unit-Based Care Teams and the Frequency and Quality of Physician-Nurse Communications

To determine whether reorganizing physicians into unit-based teams in general pediatric wards is associated with greater ability to identify other care team members, increased face-to-face communication between physicians and nurses, greater perception that their patient care concerns were met, and decreased number of pages to residents. Prospective intervention study with data collected before and at 2 time points after implementation of unit-based teams. General pediatric wards at an urban, tertiary care, freestanding children's hospital from April 1, 2008, through June 30, 2009. Pediatric residents rotating in the medical wards (n = 60) and ward-based pediatric nurses (n = 154). We reorganized resident-physician care teams to be based on specific inpatient units, with residents admitting and caring only for patients on their assigned unit. Anonymous physician and nurse self-reports of communication practices and number of pages residents received. In the unit-based team system, physicians were more likely to be able to identify the nurse for their patients with the most complex conditions (62.3% vs 82.8% vs 82.5%, P = .05), to report contacting (27.3% vs 64.9% vs 56.9%, P = .01) and being contacted by (7.7% vs 48.2% vs 55.2%, P = .002) that nurse in person, and to believe their patient care concerns were met (44.2% vs 82.1% vs 81.8%, P = .009). Nurses reported parallel improvements in communication patterns. The mean number of pages per day to residents decreased by 42.1% (19 vs 10 vs 11, P < .001). Unit-based teams improve the frequency and quality of multidisciplinary communication, which may create an improved climate for patient safety.

A Physician Management Infrastructure

THE HEALTH MARKET IS RESPONDING TO THE NEED TO improve the quality of care. Health care leaders are now held accountable for hospital and health system outcomes and this is appropriate. Patient outcomes are determined by the performance of multiple clinicians and the context in which care is delivered. To improve quality of care, physicians, nurses, and managers, each with their distinct knowledge and frames of reference, must collaborate. Despite quality improvement (QI) efforts, empirical evidence that patient outcomes have improved is minimal. One of the reasons for limited progress is insufficient engagement of physicians in QI work, thereby inhibiting successful development and implementation of interventions. Physicians bring unique skills and perspectives to QI, yet their involvement is rare. One barrier to physician involvement is an underdeveloped physician management infrastructure. Hospitals generally have flat physician management structures organized around physicians caring for their individual patients. Physicians are granted privileges to admit patients and oversee their care, and hospitals, in turn, provide nursing care, technology, ancillary staff, and hotel functions. Medical staff are usually organized through a medical executive committee, often including a chief medical officer. Physicians may also serve, most often voluntarily, on hospital committees (eg, quality or pharmacy and therapeutics). Outside this committee structure, however, each physician is generally autonomous, providing and monitoring care for individual patients. A physician management infrastructure is also needed in outpatient settings to establish and manage medical homes and participate in accountable care organizations, and to monitor and improve quality. To improve quality of care, health care organizations need to manage the care of individual patients as well as patient populations. This requires an infrastructure to design interventions, develop performance measures, monitor performance, implement interventions, and monitor their impact. Physicians’ training and their unduplicated perspective on patient care make their contributions essential to assess whether interventions are evidence-based, feasible, and account for patient variation; to ensure evaluation measures are scientifically sound and risks are small; and to develop strong support among the medical staff. In short, physician leadership is needed to practice evidence-based management as well as evidence-based care. The work of improving quality currently rests primarily with hospital administrators and nurses, with physicians assuming a peripheral volunteer role, often questioning the wisdom of these efforts. Physicians need to help lead improvement efforts, yet time physicians spend on QI projects is time lost generating practice revenue. Five changes to the physician infrastructure can meaningfully support quality and the ability to manage patient populations: physician leadership development; greater support for physician quality leaders within care areas and product lines; organized unit-based care teams; continued development of reliable and valid performance measures; and use of these measures to create a chain of accountability from the hospital to physician leaders. The health care industry needs to build physicians’ technical and adaptive skills to lead QI efforts. Physicians can create professional societies to improve the science of health care delivery and participate in formal training. Physician quality leader infrastructure in hospitals could be based on the well-developed nursing management infrastructure in which each patient care area has a nurse manager accountable for staffing and the quality of care in that unit. These unit-level managers report to a departmentlevel manager who reports to a director of nursing. Hospitals can create a similar structure in which a physician is supported for a portion of his/her time to improve quality of care. These physicians can work with nursing and administrative leaders to jointly lead QI efforts as is occurring in some systems. Patient care could be organized into unit-based teams. The patient care area is the microsystem for QI efforts. Many hospital-based QI efforts emerged from the inten-

Advancing Nursing Research Through a Mentorship Program for Staff Nurses

This article describes a unique model of implementing unit-based research teams to provide staff nurses with knowledge, skills, and mentoring. The essential elements of designing and conducting a research study are emphasized in an effort to improve nursing practice and the quality of patient care. The research education and practicum are incorporated into team meetings. This unique model provides greater efficiency and effectiveness of resources and allows for more interactive education than occurs in traditional models. Unit-based nursing teams learn together to design research studies, test hypotheses, and answer clinically relevant research questions, using the scientific process.