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Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

ABSTRACT: OBJECTIVE:Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience. SUBJECTS:Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10). METHODS:Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items. RESULTS:We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation. CONCLUSIONS:PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

SUBMITTER: Quigley DD

PROVIDER: S-EPMC6724179 | biostudies-literature | 2017 Jul/Sep

REPOSITORIES: biostudies-literature

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Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

Quigley Denise D DD Palimaru Alina I AI Chen Alex Y AY Hays Ron D RD

Quality management in health care 20170701 3

<h4>Objective</h4>Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience.<h4>Subjects</h4>Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10).<h4>Methods</h4>Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and m ...[more]

PMID: 28665905

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Project description:Team-based care has emerged as a promising strategy for primary care practices to provide high-quality care. We examine changes in patient experience of care and recommended cancer screening rates associated with a primary care transformation initiative that established team-based care. Our observational study included 13 academically affiliated primary care practices in the Boston, Massachusetts area that participated in 2 learning collaboratives: the first (2012-2014) aimed to establish team-based primary care, while the second (2014-2016) focused on improving patient safety and cancer screening. We identified 37 comparison practices of similar size and network affiliation. Using a difference-in-differences approach, we compared pre (2013) and post (2015) patient experience and recommended cancer screening rates between intervention and comparison practices. We estimated linear regression models, using inverse probability weighting to balance on observable differences. Massachusetts Health Quality Partners data on patient experience comes from surveys (with communication, integration, knowledge of patient, access, office staff, and willingness to recommend domains), and its data on screening rates for breast, colorectal, and cervical cancers is derived from chart abstraction. Relative to comparison practices, the communication score in intervention practices increased by 1.47 percentage points on a 100-point scale (P = .02) between pre and post periods. We did not detect immediate improvements in other measures of patient experience of care and recommended cancer screening rates. Communication may be the first dimension of patient experience that improves following establishment of team-based primary care, and changing care processes may require more time or attention in the transition to team-based care. Our findings also suggest a need to better understand the variation in implementation factors that facilitate some practices' successful transitions to team-based care, and to use teams effectively to improve cancer screening processes.

Project description:BackgroundImplementation of evidence-based practice in clinical practice is crucial. Nurses and midwives play a vital role in using updated evidence. However, limited support and barriers to implementing evidence-based practice hamper the use of up-to-date evidence in clinical decision-making practice. Therefore, this study aimed to explore the implementation of evidence-based practice of nurses and midwives working in public hospitals.MethodsA qualitative descriptive study was conducted to explore the experience of implementing evidence-based practice among nurses and midwives working in public hospitals. A total of 86 participants, of which, 25 in-depth interviews, 5 FGDs having 47 participants and 14 participants were involved during observations, were considered in Amhara Region public hospitals from November 17, 2019 to April 25, 2020. The observational data, interview and FGD transcripts were imported into NVivo 12 plus to manage and analyze the data using the Computer-Assisted Data Analysis Software Program (CAQDAS). The data were analyzed through thematic content analysis.ResultsNurses and midwives perceived that implementation of evidence-based practice is the use of research findings, guidelines, hospital protocols, books, and expert experience in clinical decision-making practice. However, there was limited support for the implementation of evidence-based practice by nurses and midwives. The lack of knowledge and skill to use evidence like research findings, time mismanagement, the lack of motivation, the lack of resources and training were the perceived barriers to the implementation of evidence-based practice. Stick to the traditional practice due to lack of incentive and unclear job description between diploma and BSc nurses and midwives were the perceived causes of the lack of motivation.ConclusionsThe experience of evidence-based practice of nurses and midwives indicated that there was limited support for the implementation of evidence-based practice. However, research findings were rarely used in clinical decision-making practice The Knowledge, attitude towards implementing evidence-based practice, lack of resources and training, time mismanagement and lack of motivation were the barriers to the implementation of evidence-based practice. Therefore, the promotion of adopting the implementation of evidence-based practice and training on the identified barriers are mandatory.

Project description:Cardiopulmonary resuscitation (CPR) outcomes have not been prospectively described since implementation of the Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines. This study aimed to prospectively describe CPR outcomes and document arrest variables in dogs and cats at a U.S. veterinary teaching hospital since implementation of the RECOVER guidelines using the 2016 veterinary Utstein-style CPR reporting guidelines. One-hundred and seventy-two dogs and 47 cats that experienced cardiopulmonary arrest (CPA) underwent CPR following implementation of the RECOVER guidelines and were prospectively included. Supervising clinicians completed a data form for CPR events immediately following completion of CPR from December 2013 to June 2018. Seventy-five (44%) dogs and 26 (55%) cats attained return of spontaneous circulation (ROSC), 45 dogs (26%) and 16 cats (34%) had ROSC ? 20 min, 13 dogs (8%) and 10 cats (21%) were alive 24 h after CPR, and 12 dogs (7%) and 9 cats (19%) survived to hospital discharge. The most common cause of death in animals with ROSC ? 20 min was euthanasia. Patient outcomes were not significantly different since publication of the RECOVER guidelines except for a higher feline survival to hospital discharge rate. Dogs (p = 0.02) but not cats with initial shockable rhythms had increased rates of ROSC while the development of a shockable rhythm during CPR efforts was not associated with ROSC (p = 0.30). In closed chest CPR an end-tidal carbon dioxide (EtCO2) value of >16.5 mmHg was associated with a 75% sensitivity and 64% specificity for achieving ROSC. Since publication of the RECOVER guidelines, CPR practice did not clinically significantly change at our institution and no improvement of already high ROSC rates was noted. The percentage of cats surviving to hospital discharge was higher than previously reported and the reason for this improvement is not evident with these results. Euthanasia remains a major confounding factor in assessing intermediate and long-term CPR outcomes in dogs and cats.

Project description:BackgroundReviews of guideline implementation recommend matching strategies to the specific setting, but provide little specific guidance about how to do so. We hypothesized that the highest level of guideline-concordant care would be achieved where implementation strategies fit well with physicians' cognitive styles.MethodsWe conducted an observational study of the implementation of guidelines for hypertension management among patients with diabetes at 43 Veterans' Health Administration medical center primary care clinics. Clinic leaders provided information about all implementation strategies employed at their sites. Guidelines implementation strategies were classified as education, motivation/incentive, or barrier reduction using a pre-specified system. Physician's cognitive styles were measured on three scales: evidence vs. experience as the basis of knowledge, sensitivity to pragmatic concerns, and conformity to local practices. Doctors' decisions were designated guideline-concordant if the patient's blood pressure was within goal range, or if the blood pressure was out of range and a dose change or medication change was initiated, or if the patient was already using medications from three classes.ResultsThe final sample included 163 physicians and 1,174 patients. All of the participating sites used one or more educational approaches to implement the guidelines. Over 90% of the sites also provided group or individual feedback on physician performance on the guidelines, and over 75% implemented some type of reminder system. A minority of sites used monetary incentives, penalties, or barrier reduction. The only type of intervention that was associated with increased guideline-concordant care in a logistic model was barrier reduction (p < 0.02). The interaction between physicians' conformity scale scores and the effect of barrier reduction was significant (p < 0.05); physicians ranking lower on the conformity scale responded more to barrier reduction.ConclusionGuidelines implementation strategies that were designed to reduce physician time pressure and task complexity were the only ones that improved performance. Education may have been necessary but was clearly not sufficient, and more was not better. Incentives had no discernible effect. Measurable physician characteristics strongly affected response to implementation strategies.

Project description:BackgroundMobile health (mHealth) is an emerging field of scientific interest worldwide. Potential benefits include increased patient engagement, improved clinical outcomes, and reduced health care costs. However, mHealth is often studied in projects or trials, and structural implantation in clinical practice is less common.ObjectiveThe purpose of this paper is to outline the design of the Box and its implementation and use in an outpatient clinic setting. The impact on logistical outcomes and patient and provider satisfaction is discussed.MethodsIn 2016, an mHealth care track including smartphone-compatible devices, named the Box, was implemented in the cardiology department of a tertiary medical center in the Netherlands. Patients with myocardial infarction, rhythm disorders, cardiac surgery, heart failure, and congenital heart disease received devices to measure daily weight, blood pressure, heart rate, temperature, and oxygen saturation. In addition, professional and patient user comments on the experience with the care track were obtained via structured interviews.ResultsFrom 2016 to April 2020, a total of 1140 patients were connected to the mHealth care track. On average, a Box cost €350 (US $375), not including extra staff costs. The median patient age was 60.8 (IQR 52.9-69.3) years, and 73.59% (839/1140) were male. A median of 260 (IQR 105-641) measurements was taken on a median of 189 (IQR 98-372) days. Patients praised the ease of use of the devices and felt more involved with their illness and care. Professionals reported more productive outpatient consultations as well as improved insight into health parameters such as blood pressure and weight. A feedback loop from the hospital to patient to focus on measurements was commented as an important improvement by both patients and professionals.ConclusionsIn this study, the design and implementation of an mHealth care track for outpatient follow-up of patients with various cardiovascular diseases is described. Data from these 4 years indicate that mHealth is feasible to incorporate in outpatient management and is generally well-accepted by patients and providers. Limitations include the need for manual measurement data checks and the risk of data overload. Moreover, the tertiary care setting in which the Box was introduced may limit the external validity of logistical and financial end points to other medical centers. More evidence is needed to show the effects of mHealth on clinical outcomes and on cost-effectiveness.

Project description:OBJECTIVE:There are differences in the adoption rates of less invasive surfactant administration (LISA) worldwide. We aimed to describe and analyze the process of LISA introduction at the country level. METHODS:A standardized training program (33 courses covering >500 neonatologists) was followed by a cohort study. Data regarding consecutive LISA procedures were acquired over 12 months in 31 tertiary neonatal centers, using a dedicated on-line platform. RESULTS:Of 500 LISA procedures, 75% were performed by specialists and 25% by residents. The mean percentage share of LISA in all surfactant therapies was 24%, which represents a 6-fold increase compared to previous years. After 12 months, 76% of the procedures were rated "easy/very easy" vs 59% at baseline (p<0.05). Surfactant re-treatment rate was 15%. Twenty-three percent of infants required mechanical ventilation within 72 hours of life. Oxygen desaturation and surfactant reflux were the most frequent complications. Unlike previous reports describing exclusive use of nasal continuous positive airway pressure (nCPAP) during LISA, majority of procedures (63%) were carried out using nasal intermittent positive pressure ventilation (NIPPV) or Bilevel Positive Airway Pressure (BiPAP). Efficacy of LISA with NIPPV or BiPAP was not significantly different from that with nCPAP (22.4% vs 24.5% of cases requiring intubation). Ventilation was provided with nasal cannulas or nasal masks (90%) and rarely with "RAM" cannulas or nasopharyngeal tubes. Rigid catheters were preferred (88.4%); tracheal insertion was successful at first attempt in 87% of cases. Majority of infants (79%) received no premedication prior to the procedure and almost all were given caffeine citrate. Median time of instillation was 1.5 minutes. CONCLUSIONS:The LISA procedure does not appear to be technically difficult to master. Training combining theory with practical exercises is an efficient implementation strategy. Variations in adoption rates indicate the need for additional, more personalized teachings in some centers.

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Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

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Implementation of Practice Transformation: Patient Experience According to Practice Leaders.

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