Hospital staffs' perceptions of an electronic program to engage patients in nutrition care at the bedside: a qualitative study.
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SUBMITTER: Roberts S
PROVIDER: S-EPMC5504779 | biostudies-other | 2017 Jul
REPOSITORIES: biostudies-other
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Project description:Importance:Safety-net health systems across the country are implementing electronic consult (eConsult) systems in which primary care practitioners (PCPs) submit all requests for specialty assistance electronically to be reviewed and discussed with specialists. Evidence suggests that eConsult systems can make significant improvements in specialty access, but the outcomes of these systems for frontline PCPs is poorly understood. Objective:To understand PCP perceptions of the results of eConsult initiation on PCP workflow, specialist access, and patient care. Design, Setting, and Participants:Qualitative interviews were conducted from December 1, 2016, to April 15, 2017, with 40 safety-net PCPs in Los Angeles County who use the Los Angeles County Department of Health Services (DHS) eConsult system. Interviewees were recruited to include diversity in PCP type, practice setting, and employer (DHS employed vs DHS affiliated). Participants were interviewed about their perceptions of clinical workflow, access to specialists, relationships with specialists, and referral decision making. Main Outcomes and Measures:Perceptions of the results of eConsult, including positive and negative themes and remaining perceived gaps in specialty care. Results:Of the 40 participants, 27 (68%) were women; 24 (60%) PCPs performed 5 or more eConsults per week. Primary care practitioners' perceptions of eConsult clustered around 4 main themes: access and timeliness of specialty care, shift of work to PCPs, relationships with specialists, and eConsult interface issues. Many PCPs praised the improved timeliness of specialist input with eConsult, as well as the added clinical and educational value of dialogue with specialists, particularly compared with the limitations of the prior referral process. However, PCPs also consistently perceived that eConsult shifted some of the work of specialty care to them. Many PCPs believed that this extra burden was worth the effort given the benefits of eConsult, such as improved timeliness of care and ability to manage specialty conditions. In contrast, others were frustrated by the increased administrative burden, broadened clinical responsibility, and restructuring of specialty care delivery. Conclusions and Relevance:While associated with improved specialty care access, eConsult systems simultaneously created new challenges for PCPs, such as an increased burden of work in providing specialty care. Primary care practitioners varied in their enthusiasm for these workflow changes with diverging perceptions of the same processes. Our findings provide insights on challenges future primary care transformation efforts may face.
| S-EPMC6145753 | biostudies-literature
Project description:BACKGROUND:In-hospital cardiac arrests (IHCA) occur commonly and are associated with poor survival and variable outcomes. This study aimed to directly survey IHCA responders to understand their perceptions of resuscitation care. METHODS:As part of a quality improvement initiative, we surveyed participating providers of IHCAs at our institution from Jan 2014 to May 2016. The survey included unstructured free text feedback, which was the focus of this study. We systematically coded the free text and organized identifiable latent themes using thematic analysis. We used the natural timeline of an IHCA - pre-arrest, arrest, and post-arrest - for organization of the identifiable latent themes, and created a separate category for holistic remarks that arched across the timeline. RESULTS:We identified 172 IHCAs with a mean of 1.7 responses per arrest (range: 1-8 responses). The mean age of this patient population was 59 years at the time of arrest, and 107 (62%) were men. We identified several themes - [1] issues around code activation and code status characterized the pre-arrest period [2] ,team interactions and issues around supplies/equipment dominated the intra-arrest period, and [3] code cessation and transitions of care typified the post-arrest period. Holistic remarks focused on attentiveness paid by the arrest team to patient comfort and family. Some comments reflected positive experiences but most focused on areas of improvement consistent with the initiative's purpose. In certain cases, we identified a tension between the need to balance established resuscitation protocols with flexibility required by real-life circumstances. CONCLUSIONS:Directly surveying those who participated in IHCAs led to novel insights about their experiences. Our findings suggest that parsing through such qualitative feedback can help hospitals identify areas of improvement, modulate expectations, temper emotions, and refine protocols.
| S-EPMC7045452 | biostudies-literature
Project description:BackgroundConversations about goals, values and priorities with patients that are seriously ill are associated with improved palliative healthcare. The Serious Illness Care Program is a multi-component program that can facilitate more, better, and earlier conversations between clinicians and seriously ill patients. For successful and sustainable implementation of the Serious Illness Care Program, it is important to consider how stakeholders perceive it. The aim of our study was to explore physicians' perceptions and experiences of implementing the Serious Illness Care Program.MethodsData were collected through four focus group discussions with physicians (n = 14) working at a hospital where the Serious Illness Care program was in the process of being implemented. Data were analyzed with inductive thematic analysis.ResultsPhysicians' perceptions of the implementation encompassed three thematic areas: hovering between preparedness and unpreparedness, being impacted and being impactful, and picking pieces or embracing it at all.ConclusionsThis study identified key aspects related to the individual physician, the care team, the impact on the patient, and the organizational support that were perceived to influence the implementation and sustainable integration of the Serious Illness Care Program. Describing these aspects provides insight into how the Serious Illness Care Program is implemented in practice and indicates areas for future training and development.Trial registrationNot applicable.
| S-EPMC10717999 | biostudies-literature
Project description:OBJECTIVES:General practitioners (GPs) play a key role in heart failure (HF) management. Despite multiple guidelines, the management of patients with HF in primary care is suboptimal. Therefore, all the qualitative evidence concerning GPs' perceptions of managing HF in primary care was synthesised to identify barriers and facilitators for optimal care, and ideas for improvement. DESIGN:Qualitative evidence synthesis. METHODS:Searches of MEDLINE, EMBASE, Web of Science and CINAHL databases up to 20/12/2015 were conducted. The Critical Appraisal Skills Programme's checklist for qualitative research was used for quality assessment. Thematic analysis was used as method of analysis. RESULTS:Of 5427 articles, 18 qualitative articles were included. Findings were organised in HF-specific factors, patient factors, physician factors and contextual factors. GPs' uncertainty in all areas of HF management was highlighted. HF management started with an uncertain diagnosis, leading to difficulties with communication, treatment and advance care planning. Lack of access to specialised care and lack of knowledge were identified as important contributors to this uncertainty. In an effort to overcome this, strategies bringing evidence into practice should be promoted. GPs expressed the need for a multidisciplinary chronic care approach for HF. However, mixed experiences were noted with regard to interprofessional collaboration. CONCLUSIONS:The main challenges identified in this synthesis were how to deal with GPs' uncertainty about clinical practice, how to bring evidence into practice and how to work together as a multiprofessional team. These barriers were situated predominantly on the physician and contextual level. Targets to improve GPs' HF care were identified.
| S-EPMC5168518 | biostudies-other
Project description:BackgroundPatient portals are a promising instrument to improve patient-centered care, as they provide patients information and tools that can help them better manage their health. The implementation of portals in both the inpatient and outpatient setting gives health care providers an opportunity to support patients both during hospitalization and after discharge. Thus, there is a need to better understand how inpatient and outpatient portals are used across care contexts.ObjectiveThis study aimed to examine patients' perceptions of using inpatient and outpatient portals across the care settings, including how they used the portals and the benefits and concerns associated with portal use.MethodsThis study was conducted in a large Midwestern academic medical center consisting of seven hospitals. We interviewed 120 patients who had used an inpatient portal during their hospitalization, at 15 days and 6 months postdischarge, to determine their perspectives of portal use in both hospital and outpatient settings. Interview transcripts were analyzed inductively and deductively by using team coding processes consistent with a grounded theory approach.ResultsInterviews focused on three main areas of portal use: experience with the portal features, perceived benefits, and concerns. Responses at 15 days (n=60) and 6 months (n=60) postdischarge were consistent with respect to perceptions about portal use. Patients identified viewing their health information, managing their schedule, and communicating with providers as notable activities. Convenience, access to information, and better engagement in care were indicated as benefits. Concerns were related to technology issues and privacy/security risks.ConclusionsImplementation of inpatient portals as a complement to outpatient portals is increasing and can enable patients to better manage aspects of their care. Although care processes vary substantively across settings, the benefits of convenience, improved access to information, and better engagement in care provide opportunities for portal use across care settings to support patient-centered care.
| S-EPMC6592494 | biostudies-literature
Project description:Background: Few studies of hospital-based implementation assess sustainability or collect formal implementation outcomes, in part because the emphasis is often on initial adoption and rapid cycles of improvement. The purpose of this process evaluation was to assess the implementation of a pharmacy-led, hospital-wide program and contribute to the literature by collecting formal implementation outcomes, including sustainability. Methods: This was a qualitative process evaluation of a program that delivers discharge medications and related education to hospitalized patients' bedside prior to discharge. Semi-structured interviews were conducted with the program's key stakeholders to assess the program's implementation barriers and facilitators as well as its potential for sustainability. An interview guide was created based on the RE-AIM constructs of Reach, Adoption, Implementation, and Maintenance. Effectiveness was not assessed due to an ongoing effectiveness evaluation by another team. Each interview was coded by two independent coders and any discrepancy was adjudicated by a third, independent coder. Results: Twelve stakeholders were approached and all agreed to be interviewed. Related to providers' decisions to adopt the program, key themes emerged around the different priorities of nurses and physicians, which has implications for how program leadership promoted the program to these different stakeholder groups. Key implementation barriers included the nature of hospital provider rotations and turnover, which led to confusion on who could use the program and to whom providers should direct program-related questions. Key implementation facilitators included the enthusiasm of program staff and identified champions on the units. Themes related to maintenance or sustainability included the need to continually generate buy-in and educate providers about the program and allowing program staff and leadership to remain nimble and adapt their operations to meet evolving needs. Conclusions: The results suggest that in an environment in which rapidly achieving improvement is often the focus more than maintaining that improvement, strategies to achieve successful implementation may not be sufficient to achieve successful sustainment. New strategies are likely needed to address the unique barriers to sustaining a program once initial adoption and implementation is complete.
| S-EPMC6988304 | biostudies-literature
Project description:BackgroundAlthough the previous quantitative study revealed that social isolation was negatively associated with patient experience of primary care, the underlying reasons for this phenomenon remain unclear. In the present study, we aimed to explore the reasons underlying the influence of social isolation on patient experience in the primary care setting.MethodsThis study was a qualitative study and part of a mixed methods research. Semistructured telephone interviews were performed. We recruited participants among eligible participants in the previous quantitative survey who were classified as being socially isolated. Data were transcribed verbatim and analyzed thematically by two independent researchers until saturation was reached.ResultsEight socially isolated patients in the research were interviewed. In the thematic analysis, three major themes emerged as reasons underlying the influence of social isolation on patient experience of primary care: restriction of information about local primary care physicians, finding a usual primary care physician haphazardly, and superficial relationship with a usual primary care physician.ConclusionsThis study identified three major themes, which are beneficial to expand our understanding of socially isolated patients' perceptions of primary care. These findings can be used to improve patient experience of primary care in socially isolated patients.
| S-EPMC6732495 | biostudies-literature
Project description:BackgroundChronic limb-threatening ischaemia (CLTI) is a condition associated with significant risks of lower limb loss and mortality, which increase with delays in management. Guidance recommends urgent referral and assessment, but delays are evident at every stage of the CLTI patient pathway. This study uses qualitative methods to explore hospital clinicians' experiences and perceptions of the existing CLTI pathway.MethodsA qualitative interview study was conducted. Semi-structured interviews were undertaken with 13 clinicians involved in the assessment of patients referred to hospital with suspected CLTI, identified via purposive sampling from English vascular surgery units. Clinicians included podiatrists, vascular specialist nurses and doctors. Reflexive thematic analysis was performed on the data from a critical realist position.ResultsThe need for speed was the single overarching theme identified. Four linked underlying themes were also identified; 1. Vascular surgery as the poor relation (compared to cancer and other specialties), with a sub-theme of CLTI being a challenging diagnosis. 2. Some patients are more equal than others, with sub-themes of diabetes vs. non-diabetes, hub vs. spoke and frailty vs. non-frail. 3. Life in the National Health Service (NHS) is tough, with sub-themes of lack of resource and we're all under pressure. 4. Non-surgeons can help.ConclusionsThe underlying themes generated from the rich interview data describe barriers to timely referral, assessment and management of CLTI, as well as the utility of non-surgical roles such as podiatrists and vascular specialist nurses as a potential solution for delays. The overarching theme of the need for speed highlights the meaning given to adverse consequences of delays in management of CLTI by clinicians involved in its assessment. Future improvement projects aimed at the CLTI pathway should take these findings into account.
| S-EPMC10507819 | biostudies-literature
Project description:BackgroundElectronic referrals or e-referrals can be defined as the electronic transmission of patient data and clinical requests between health service providers. National electronic referral systems have proved challenging to implement due to problems of fit between the technical systems proposed and the existing sociotechnical systems. In seeming contradiction to a sociotechnical approach, the Irish Health Service Executive initiated an incremental implementation of a National Electronic Referral Programme (NERP), with step 1 including only the technical capability for general practitioners to submit electronic referral requests to hospital outpatient departments. The technology component of the program was specified, but any changes required to embed that technology in the existing sociotechnical system were not specified.ObjectiveThis study aimed to theoretically frame the lessons learned from the NERP step 1 on the design and implementation of a national health information technology program.MethodsA case study design was employed, using qualitative interviews with key stakeholders of the NERP step 1 (N=41). A theory-driven thematic analysis of the interview data was conducted, using Barker et al's Framework for Going to Full Scale.ResultsThe NERP step 1 was broadly welcomed by key stakeholders as the first step in the implementation of electronic referrals-delivering improvements in the speed, completeness of demographic information, and legibility and traceability of referral requests. National leadership and digitalized health records in general practice were critical enabling factors. Inhibiting factors included policy uncertainty about the future organizational structures within which electronic referrals would be implemented; the need to establish a central referral office consistent with these organizational structures; outstanding interoperability issues between the electronic referral solution and hospital patient administration systems; and an anticipated need to develop specialist referral templates for some specialties. A lack of specification of the sociotechnical elements of the NERP step 1 inhibited the necessary testing and refinement of the change package used to implement the program.ConclusionsThe key strengths of the NERP step 1 are patient safety benefits. The NERP was progressed beyond the pilot stage despite limited resources and outstanding interoperability issues. In addition, a new electronic health unit in Ireland (eHealth Ireland) gained credibility in delivering national health information technology programs. Limitations of the program are its poor integration in the wider policy and quality improvement agenda of the Health Service Executive. The lack of specification of the sociotechnical elements of the program created challenges in communicating the program scope to key stakeholders and restricted the ability of program managers and implementers to test and refine the change package. This study concludes that while the sociotechnical elements of a national health information technology program do not need to be specified in tandem with technical elements, they do need to be specified early in the implementation process so that the change package used to implement the program can be tested and refined.
| S-EPMC6070727 | biostudies-literature
Project description:Background Insufficient transfer of medicines information is a common challenge at discharge from hospital. Following discharge, home dwelling patients are expected to manage their medicines themselves and adequate counselling is an important prerequisite for patient empowerment and self-efficacy for medicines management. Objective The aim was to identify patients' needs for medicines information after discharge from hospital, including the patients' perception and appraisal of the information they received at discharge. Setting The study enrolled patients discharged from three medical wards at a secondary care hospital in Oslo, Norway. Method Patients were included at the hospital, at or close to the day of discharge and qualitative, semi-structured interviews were performed during the first 2 weeks after discharge. Eligible patients were receiving medicines treatment on admission and after discharge, were handling the medicines themselves, and discharged to their own home. Data were collected in 2017. Interviews were analysed with thematic analysis inspired by Systematic Text Condensation. Main outcome measure Patients' perceptions of medicines information. Results In total, 12 patients were interviewed. They were discharged in equal numbers from the three wards, representing both sexes and a broad age range. Patients perceive medicines information as a continuum and not limited to specific encounters, like the discharge conversation. They gain information in several ways; by receiving information from health care professionals, through observations, and by seeking it themselves. Some thought they could have been better informed about adverse reactions and how to manage life while being a medicines user. Others felt they did not want or need more information. Patients employ various strategies for coping with their use of medicines, influencing their self-efficacy towards medicine management. Conclusion Medicines information should focus on empowering the patients throughout the hospital stay and not solely at discharge, taking into account the individual patient's needs for information, preferences and prior knowledge.
| S-EPMC7878245 | biostudies-literature