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Title
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Learning Networks for Sustainable, Large-Scale Improvement
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Abstract/Description
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Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority. The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders. The mentor model preserves the active sharing that enhances improvement across a large group of facilities working on the same project while enabling individualized attention to teams. The mentor model was tested by implementing the obstetric hemorrhage safety bundle (which consists of 17 key practices in four domains) in multiple California hospitals. A total of 126 hospitals were engaged to simultaneously implement the safety bundle. The adoption rates for the recommended practices in the four action domains were (1) Readiness, 78.9%; (2) Recognition and Prevention, 76.5%; (3) Response, 63.1%; and (4) Reporting and Systems Learning, 58.7%. Mentors (31/40) and participating teams (48 responses from 39/126 hospitals) provided feedback in an exit survey. Among the respondents, 64.5% of mentors and 72.9% of participants agreed that compared to a traditional collaborative structure, the mentor model was better suited for quality improvement at scale. The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals. Health care systems struggle to scale-up and spread effective practices across diverse settings. Failures in scale-up and spread (SUS) are often attributed to a lack of consideration for variation in local contexts among different health care delivery settings. We argue that SUS occurs within complex systems and that self-organization plays an important role in the success, or failure, of SUS. Self-organization is a process whereby local interactions give rise to patterns of organizing. These patterns may be stable or unstable, and they evolve over time. Self-organization is a major contributor to local variations across health care delivery settings. Thus, better understanding of self-organization in the context of SUS is needed. We re-examine two cases of successful SUS: 1) the application of a mobile phone short message service intervention to improve adherence to medications during HIV treatment scale up in resource-limited settings, and 2) MRSA prevention in hospital inpatient settings in the United States. Based on insights from these cases, we discuss the role of interdependencies and sensemaking in leveraging self-organization in SUS initiatives. We argue that self-organization, while not completely controllable, can be influenced, and that improving interdependencies and sensemaking among SUS stakeholders is a strategy for facilitating self-organization processes that increase the probability of spreading effective practices across diverse settings. There is a large and persistent failure to achieve widespread dissemination of evidence-based practices in child health care. Too often studies demonstrating evidence for effective child health care practices are not brought to scale and across different settings and populations. This failure is not due to a lack of knowledge, but rather a failure to bring to bear proven methods in dissemination, diffusion, and implementation (DD&I) science that target the translation of evidence-based medicine to everyday practice. DD&I science offers a framework and a set of tools to identify innovations that are likely to be implemented, and provides methods to better understand the capabilities and preferences of individuals and organizations and the social networks within these organizations that help facilitate widespread adoption. Successful DD&I is dependent on making the intervention context sensitive without losing fidelity to the core components of the intervention. The achievement of these goals calls for new research methods such as pragmatic research trials that combine hypothesis testing with quality improvement, participatory research that engages the target community at the beginning of research design, and other quasi-experimental designs. With the advent of health care reform, it will be extremely important to ensure that the ensuing large demonstration projects that are designed to increase integrated care and better control costs can be rapidly brought to scale across different practices settings, and health plans and will be able to achieve effectiveness in diverse populations. The BC Patient Safety & Quality Council has a mandate to bring health system stakeholders together in a collaborative partnership to improve quality of care. Our experience has demonstrated the value of networks to provide a forum for individuals to “think like a system,” considering the perspectives of others in addressing system issues. This transition from silo-based thinking is important as we move to improve the quality of care at the pace that is required. Substantial innovation related to cancer prevention and treatment has occurred in recent decades. However, these innovations have often come at a significant cost. Cost-utility analysis provides a useful framework to assess if the benefits from innovation are worth the additional cost. This systematic review on published cost-utility analyses related to cancer care is from 1988 through 2013. Analyses were conducted in 2013–2015. This review analyzed data from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), a comprehensive registry with detailed information on 4,339 original cost-utility analyses published in the peer-reviewed medical and economic literature through 2013. There were 721 cancer-related cost-utility analyses published from 1998 through 2013, with roughly 12% of studies focused on primary prevention and 17% focused on secondary prevention. The most often studied cancers were breast cancer (29%); colorectal cancer (11%); and prostate cancer (8%). The median reported incremental cost-effectiveness ratios (in 2014 U.S. dollars) were $25,000 for breast cancer, $24,000 for colorectal cancer, and $34,000 for prostate cancer. The current evidence indicates that there are many interventions that are cost effective across cancer sites and levels of prevention. However, the results highlight the relatively small number of cancer cost-utility analyses devoted to primary prevention compared with secondary or tertiary prevention. The integration of Clinical Decision Support Systems (CDSS) in nowadays clinical environments has not been fully achieved yet. Although numerous approaches and technologies have been proposed since 1960, there are still open gaps that need to be bridged. In this work we present advances from the established state of the art, overcoming some of the most notorious reported difficulties in: (i) automating CDSS, (ii) clinical workflow integration, (iii) maintainability and extensibility of the system, (iv) timely advice, (v) evaluation of the costs and effects of clinical decision support, and (vi) the need of architectures that allow the sharing and reusing of CDSS modules and services. In order to do so, we introduce a new clinical task model oriented to clinical workflow integration, which follows a federated approach. Our work makes use of the reported benefits of semantics in order to fully take advantage of the knowledge present in every stage of clinical tasks and the experience acquired by physicians. In order to introduce a feasible extension of classical CDSS, we present a generic architecture that permits a semantic enhancement, namely Semantic CDSS (S-CDSS). A case study of the proposed architecture in the domain of breast cancer is also presented, pointing some highlights of our methodology. The objective of the study was to evaluate the intra- and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P < .001) and with the mode of delivery (P < .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P < .001) or to establish a link with potential cerebral palsy (P = .003). The experts’ intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46–0.51 and kappa = 0.48–0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11–0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08–0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15–0.32). The intra- and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court. To assess the improvement of knowledge in cardiotocography (CTG) analysis, with the use of a dedicated e-learning program. Multicentre randomized controlled trial conducted in 5 maternity departments of Eastern-Paris Perinatal network. Midwives and obstetricians were recruited on a voluntary basis. At first log-in, they were tested on CTG interpretation and on labor management. They were then randomly allocated to a “training” group (n = 57) with the e-learning program, or to a “no-training” group (n = 56). After three months, a second test was performed. Mean scores at first and second tests, rate of participants in the bottom quartile, and mean scores between doctors and midwives were compared between “training” and “no-training” groups. Seventy-five midwives and 38 obstetricians participated in the study. The mean scores at first test were similar in both groups (32.4 ± 5.2 out of 50 and 32.5 ± 4.6, p = 0.989). After e-learning, the results were significantly higher in the “training” group than in the “no-training” group (mean 37.1 ± 5.5 vs. 32.6 ± 5.7, respectively; p = 0.0026). The number of participants in the bottom quartile reached 36.0% in the “no-training” group, while it decreased to 12.6% in the “training” group (p = 0.032). Doctors had higher results than midwives in the first test (34.9 ± 5.9 vs. 32.4 ± 4.3; p = 0.0048), but not in the second test in the group with training (37.7 ± 6.7 vs. 36.8 ± 4.8; p = 0.64). Training in CTG interpretation using an e-learning program improves the performance of obstetric staff. The possibility of logging-in from any place at any time may favor the use of an e-learning program in maternity staff.
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Date
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2009
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In publication
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The Joint Commission Journal on Quality and Patient Safety
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Volume
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35
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Issue
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5
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Pages
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286-291
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Language
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en
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ISSN
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1553-7250
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Abbreviation
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The Joint Commission Journal on Quality and Patient Safety
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