Frontiers in health services最新文献

Introduction: Anticipating and addressing implementation challenges is critical to ensuring success of mobile healthcare programs. Mobile Prosthetic and Orthotic (O&P) Care (MoPOC) is a new U.S. Department of Veterans Affairs (VA) program that aims to improve access to VA-based O&P services through a national network of traveling O&P clinicians who deliver care in rural communities. We conducted an iterative evaluation guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to identify challenges and associated strategies for successful implementation of this mobile O&P program.

Methods: MoPOC is delivered by an O&P clinician anchored at a VA medical center (VAMC). Clinicians travel to remote VA clinics and Veteran's homes with a custom vehicle which provides storage and a workshop to modify O&P devices. Each clinician is supported by a program support assistant. MoPOC was implemented in three phases. The qualitative evaluation of MoPOC implementation was conducted as part of a larger evaluation of MoPOC program outcomes. We conducted semi-structured interviews and regular check-ins with MoPOC clinicians, site managers, and stakeholders both prior to implementation and throughout the implementation process. Interviews were recorded and transcribed verbatim. Data was analyzed across sites and comparatively by phase using a rapid matrix analysis to identify themes related to adoption and implementation challenges and key strategies developed to address those challenges.

Results: We identified four key themes related to successful program implementation, each with associated challenges and improvement strategies: (1) "Finding the right sites for MoPOC" through intentional recruitment and site selection; (2) Identifying the "sweet spot": Balancing program capacity, sustainability, and MoPOC clinician satisfaction; (3) Shifting from testing to standardizing; and (4) "Being strategic with hiring" to improve program adoption.

Discussion: Implementation challenges were related to recruiting and selecting successful sites, ensuring timely program adoption, balancing site level adaptation and program standardization, and scaling programs to enhance efficiency, reach, and satisfaction. An iterative approach guided by the RE-AIM framework resulted in program improvement and more rapid implementation in each successive phase. The challenges described in MoPOC implementation may be common issues in implementing new mobile programs in rural areas.

Introduction: The translational gap from the discovery of evidence-based solutions to their implementation in healthcare delivery organizations derives from an incorrect assumption that the need for change among executive, administrative, or clinical personnel is the same as the demand for change. For sickle cell disease (SCD), implementation of evidence-based guidelines is often delayed or obstructed due to lack of demand. This challenge allows for the persistence of resource limitations and care delivery models that do not meet the community's unique needs. Agile Storytelling is a process built on the scientific foundations of behavioral economics, complexity science, and network science to create local demand for the implementation of evidence-based solutions.

Methods: Agile Storytelling includes a design phase and a testing phase. The design phase converts the evidence-based solution into a minimally viable story of a hero, a villain, struggle, drama, and a resolution. The testing phase evaluates the effectiveness of the story via a series of storytelling sprints in the target local healthcare delivery organization. The efficacy of Agile Storytelling was tested in an iterative n-of-1 case study design.

Results: Agile Storytelling was used in a large, urban, healthcare system within the United States to facilitate implementation of national SCD best-practice guidelines. After repeated failures attempting to use national and local data regarding the high societal need to hire a SCD-specific social worker, an Agile change conductor using Agile Storytelling was able to create demand for the new position within a week. This decision has ultimately improved patient outcomes and led to the adoption of a specialized collaborative care team for SCD within the health network.

Discussion: Agile Storytelling can lead to structured, effective, and informed storytelling to create local demand within healthcare delivery organizations.

Background: Care partners are individuals chosen by a person with an illness to support their care during hospitalization. Patients with persistent critical illness have longer than average critical care admission and often other conditions including dysphagia, communication vulnerability, severe physical deconditioning, the need for an artificial airway, and difficulty weaning from invasive mechanical ventilation. Family presence has been identified as important for patients experiencing persistent critical illness in specialized weaning centers. Despite this, the role of care partners in clinical settings for patients with persistent critical illness has not been fully characterized, particularly from the perspectives of patients, care partners, and health care providers. The aim of this study was to gain insights into the roles of care partners during persistent critical illness from the perspectives of patients, care partners, and health care providers.

Methods: We used qualitative descriptive methodology including semi-structured interviews and content analysis. Interviews were audio recorded and transcribed verbatim. Included participants (n = 30) were patient survivors (n = 7), care partners of patient survivors (n = 9), and professionally diverse health care providers (n = 14) of adult patients with persistent critical illness from two specialized units in one community academic hospital in Toronto, Canada.

Results: Participants across all groups described care partner roles that included physical, mental health, cognitive, social, and spiritual support of the patient, including the perceived role of safeguarding the multiple dimensions of care for the patient who is experiencing persistent critical care in specialized care settings.

Discussion: The results of this study are being used to co-design, implement, and evaluate a sustainable care partner program that is acceptable, appropriate, and feasible to implement in clinical settings where the care of patients with persistent critical illness occurs.

Reporting method: Consolidated criteria for reporting qualitative studies (COREQ).

Introduction: The Implementation Research Logic Model (IRLM) aids users in combining, organizing, and specifying the relationships between important constructs in implementation research. The goal of the IRLM is to improve the rigor, reproducibility, and transparency of implementation research projects. The article describing the IRLM was published September 25, 2020 (Implement Sci, Vol 15); it has since been highly cited and included as a required element in multiple funding opportunity announcements from federal agencies. The proliferation of IRLM use across dissemination and implementation research projects and practice provides an excellent opportunity to examine applications across a variety of different contexts. This protocol will result in a description of the impact of the IRLM on the field of dissemination and implementation science and guidance on refinements to the IRLM to increase its utility and impact through (1) a citation analysis, (2) a scoping review, and (3) user surveys and interviews.

Methods and analysis: This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review reporting guidelines (PRISMA-ScR). We plan to conduct a citation search and analysis of the Smith et al. 2020 article and a scoping review. The review search will be conducted in Medline, Embase, CINAHL Complete, Cochrane Library, APA PsycINFO4, ProQuest Dissertations & Theses Global, Scopus and Web of Science Core Collection., and grey literature will be searched to identify studies that use alternative logic models for implementation research. A survey will be developed from the findings of the scoping review and administered to individuals who used the IRLM. Semi-structured interviews will then be conducted with a sample of survey respondents to provide an opportunity for sequential mixed-methods analysis to achieve a deeper understanding of needed IRLM refinements and recommendations.

Ethics and dissemination: Ethics approval for the scoping review and citation analysis is not applicable as only data from published literature will be used and no original data will be collected. For the survey, IRB will be completed once items are developed from the results of the scoping review and citation analysis. Results will be disseminated through peer-reviewed publications, conference presentations, and via online tools.

Registration details: This protocol was registered with OSF, https://osf.io/y94bj (1).

Background: There is a need for improved methodologies on how to longitudinally analyze, interpret and learn from the Surveys on Patient Safety Culture™ (SOPS), developed by the Agency for Healthcare Research and Quality (AHRQ). Typically, SOPS quantify results by the percentage of positive responses, but this approach may miss insights from neutral or negative feedback.

Study design: The SOPS were distributed every two years from 2011 to 2022 to all hospital staff at one academic institution from perioperative services. Differences between rates of "positive" and "negative" scores ("Delta"), and "neutral" responses over time were calculated. The coefficient of determination (R ²) was used to assess the correlation strength of the positive scores as the primary outcomes provided by the SOPS and Delta values over time. Finally, we evaluated patterns (crossing and converging [indicating "worrisome" patterns] vs. diverging [suggesting "desirable" pattern] vs. stable [suggesting "neutral" pattern]) of the longitudinal scores.

Results: A total of 1,035 responses were analyzed [51 and 40 survey items for SOPS v1 and v2 (2022 only), respectively]. Comparing the R ² values of the positive only scores to the Delta scores demonstrated a change in effect size for "Nonpunitive Response to Error" (R ² = 0.290 vs. 0.420). Of the 13 specific categories measured through SOPS, plotting negative vs. positive values elucidated 2 crossing, 2 converging and 2 diverging patterns indicating both a decrease in positive responses and an increase in negative responses rather than neutral.

Conclusion: Longitudinal analysis of the SOPS using the directional measures, Delta and pattern trends can provide organizations with additional key insights regarding culture of patient safety.

Medical errors can occur in many areas of healthcare, including hospitals, clinics, and surgery centers. They can result in negative consequences for patients and their loved ones. Over the years, different methods have been used to reduce medical errors. Zero Trust is an information security model that denies access to applications and data by default. Other industries have successfully used Zero Trust Model (ZTM), and it has been shown to improve outcomes. This editorial analyzes how the ZTM can be introduced to prevent medical errors in healthcare settings. ZTM application in healthcare could potentially revolutionize patient safety by tightly controlling and monitoring access to sensitive patient data and critical systems. By enhancing security measures, the ZTM could address the paramount concerns of patient data privacy and safety in healthcare. The zero-trust approach offers a potential solution by identifying consistent causes of errors and providing viable solutions to prevent their recurrence. In the era of worsening ransomware attacks on healthcare systems, the ZTM could also have enormous implications in other cybersecurity aspects. With this manuscript, the authors advocate for the broader application of ZTM across other facets of healthcare cybersecurity.

Background: The precision child and youth mental health (PCYMH) paradigm has great potential to transform CYMH care and research, but there are numerous concerns about feasibility, sustainablity, and equity. Implementation science and evaluation methodology, particularly participatory logic models created with stakeholders, may help catalyze PCYMH-driven system transformation. This paper aims to: (1) report results of a PCYMH logic model scoping review; (2) present a case study illustrating creation of a participatory logic model for a PCYMH start-up; and (3) share the final model plus lessons learned.

Methods: Phase 1: Preparation for the logic model comprised several steps to develop a preliminary draft: scoping review of PCYMH logic models; two literature reviews (PCYMH and implementation science research); an environmental scan of our organization's PCYMH research; a gap analysis of our technological capability to support PCYMH research; and 57 stakeholder interviews assessing PCYMH perspectives and readiness. Phase 2: Participatory creation of the logic model integrated Phase 1 information into a draft from which the final logic model was completed through iterative stakeholder co-creation.

Results: Phase 1: The scoping review identified 0 documents. The PCYMH literature review informed our Problem and Impact Statements. Reviewing implementation and evaluation literature resulted in selection of the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Behavior Change Wheel (BCW) frameworks to guide model development. Only 1.2% (5/414) of the organization's research projects involved PCYMH. Three technological infrastructure gaps were identified as barriers to developing PCYMH research. Stakeholder readiness interviews identified three themes that were incorporated into the draft. Phase 2: Eight co-creation cycles with 36 stakeholders representing 13 groups and a consensus decision-making process were used to produce the final participatory logic model.

Conclusions: This is the first study to report the development of a participatory logic model for a PCYMH program, detailing involvement of stakeholders from initial planning stages to the final consensus-based product. We learned that creating a participatory logic model is time- and labour-intensive and requires a multi-disciplinary team, but the process produced stakeholder-program relationships that enabled us to quickly build and implement the PCYMH start-up. Our processes and final model can inform similar efforts at other sites.

Background: Cardiac rehabilitation (CR) services aim to improve heart disease patients' health and quality of life and reduce the risk of further cardiac events. Depression and anxiety are common among CR patients but psychological treatments have usually had small effects. In contrast, the recent NIHR-funded PATHWAY trial found that group Metacognitive Therapy (MCT) was associated with improvements in anxiety and depression when added to CR and was more effective than usual CR alone. The next stage is to test implementation of MCT within the National Health Service through the creation of a network of CR beacon sites. The study will test the quality of data capture following addition of a new MCT data-field to the national audit of cardiac rehabilitation (NACR), examine level of adoption at sites, examine mental health outcomes benchmarked against usual CR and the PATHWAY data, examine the enablers and barriers to implementation and the expected resource requirements. The study has been registered: NCT05956912 (13th July, 2023).

Methods: Beacon sites will be recruited as preliminary adopters of group MCT from NHS CR services in England. A national invitation for expressions of interest from CR services will be issued and those meeting eligibility criteria will be considered for inclusion. Two staff at each site will receive training in MCT, and mixed-methods will be used to address questions concerning the quality of patient data recorded, level of adoption at sites, the characteristics of patients attending MCT, the impact of adding MCT to CR on mental health outcomes, and patient, healthcare staff and commissioner views of barriers/enablers to implementation. Exploration of implementation will be informed by Normalisation Process Theory.

Discussion: The study will support development of an NHS roll-out strategy, assess the mental health outcomes associated with MCT, examine treatment fidelity in real-world settings, and evaluate revised data collection structures that can be used to assess the impact of national-level implementation.

Trial registration: NCT05956912; 13^th July 2023.

Introduction: Health insurance is a key instrument for a health system on its path to achieving universal health coverage (UHC) and protects individuals from catastrophic health expenditures, especially in health emergencies. However, there are other dimensions to care access beyond financial accessibility. In this study, we assess the geographical accessibility of comprehensive emergency obstetric care (CEmOC) within the Lagos State Health Insurance Scheme.

Methods: We geocoded functional public and private CEmOC facilities, established facilities registered on the insurance panel as of December 2022, and assembled population distribution for women of childbearing age. We used Google Maps Platform's internal directions application programming interface to obtain driving times to facilities. State- and local government area (LGA)-level median travel time (MTT) and a number of CEmOC facilities reachable within 30 min were obtained for peak travel hours.

Results: Across Lagos State, MTT to the nearest public CEmOC was 25 min, reduced to 17 min with private facilities added to the insurance panel. MTT to the nearest public facility in LGAs ranged from 9 min (Lagos Island) to 51 min (Ojo) (median = 25 min). With private facilities added, MTT ranged from 5 min (Agege and Ajeromi-Ifelodun) to 36 min (Ibeju-Lekki) (median = 13 min). On average, no public CEmOC facility was reachable within 30 min of driving for women living in 6 of 20 LGAs. With private facilities included in the scheme, reachable facilities within 30 min remained zero in one LGA (Ibeju-Lekki).

Conclusions: Our innovative approach offers policy-relevant evidence to optimise insurance coverage, support efforts in advancing UHC, ensure coverage for CEmOC, and improve health system performance.