Learning team-based quality improvement in a virtual setting: a qualitative study

Objective The objective was to explore students’ perceptions of learning quality improvement (QI) in a virtual setting and identify factors that promote or inhibit virtual learning. Design We used an exploratory case study design with focus group interviews. The data were analysed using a thematic analysis approach, with an analytical framework derived from activity theory and Bloom’s revised taxonomy of six categories of cognitive processes of learning. Setting Postgraduate students participating in a virtual 1-day simulation module to learn QI at two universities in Norway. Participants Four focus groups with a total of 12 participants. Results The students’ descriptions of learning outcomes indicate that the learning activity involved a variety of cognitive activities, including higher-order cognitive processes. We identified three themes pertaining to the students’ experiences of the virtual learning activity: learning through active participation, constructing a virtual learning opportunity and creating a virtual learning environment. The students described that participation and active engagement led to a greater understanding and an integration of theory and practical improvement skills. They reported that to engage in the virtual learning opportunity, it was necessary to create a learning environment where they felt psychologically safe. Conclusion Our findings indicate that it is possible to facilitate collaborative learning integrating theoretical knowledge and practical skills in a virtual setting. Students experienced that engaging in the virtual learning activity contributed to the integration of theoretical knowledge and practical skills. Psychological safety seems to be important for students’ engagement in the virtual learning activity. A virtual learning environment alters prior common norms for interaction based on physical presence, which in turn affect students feeling of psychological safety. Educators need to be aware of this and facilitate a virtual learning environment where students feel comfortable to engage.publishedVersio

The Western Norway mental health interface study: a controlled intervention trial on referral letters between Primary Care and Specialist Mental Health Care

Background: Referral letters are the main communication means between Primary and Specialised Mental Health Care. However, studies of referral letters reveal that they lack important information, and how this lack of information affects the care for patients is unknown. This study aims to explore if and to what degree the quality of referral letters within Mental Health Care for adults can be improved and the potential improvement’s impact on defined patient, professional and organisational related outcomes. Methods and design: A controlled study with pre and post test will be prepared and accomplished to explore the correlation between the content of referral letters and outcomes of the care for the referred patients. The study is performed in accordance with the guideline of the Medical Research Council on development and evaluation of complex interventions. Using a mixed method design, a stepwise model will be conducted: Firstly, process and outcome measures will be developed and tested. Secondly, by these measures, the results from an intervention group of General Practitioners (GPs) who receive a complex quality improvement intervention will be compared with results from a control group who perform “care as usual”. Compliance to the introduced guideline will be measured as a mediator. Discussion: The Western Norway Mental Health Interface Study is among the first trials to evaluate the impact of the quality of referral letters on the organization of care. This study will provide information that will be usable for healthcare managers and clinicians in both Primary and Specialised Care settings.publishedVersio

Recommended content of referral letters from general practitioners to specialised mental health care: a qualitative multi-perspective study

Background: In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients. Methods: Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.Results: The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter. Conclusion: Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes

The impact of referral letter quality on timely access to specialised mental health care: a quantitative study of the reliability of patient triage

Background Patients referred to specialised mental health care are usually triaged based on referral information provided by general practitioners. However, knowledge about this system’s ability to ensure timely access to and equity in specialised mental health care is limited. We aimed to investigate to the degree to which patient triage, based on referral letter information, corresponds to triage based on a hospital specialist’s consultation with the patient, and whether the degree of correspondence is affected by the quality of the referral letter. Methods We gathered information from three specialised mental health centres in Norway regarding patients that were referred and offered health care (N = 264). Data consisted of triage decisions for each patient (i.e., the hospital specialist’s assessment of maximum acceptable waiting time), which were determined on the basis of a) referral information and b) meeting the patient. Referral letter quality was evaluated using the Quality of Referral information-Mental Health checklist. The reliability of priority setting and the impact of referral letter quality on this measure were investigated using descriptive analyses, binary logistic regression and Nadaraya-Watson kernel regression. Results In 143 (54%) cases, the triage decision based on referral information corresponded with the decision based on patient consultation. In 70 (27%) cases, the urgency of need for treatment was underestimated when based on referral information compared with that based on information from patient consultation. Referral letter quality could not explain the differences between the two triage decisions. However, when a cut-off value of 7 on the Quality of Referral information-Mental Health scale was used, low-quality letters were found more frequently among patients whose urgency of need was underestimated, compared with those whose need was overestimated. Conclusions Deciding the urgency of patient need for specialised mental health care based on referral information is a reliable system in many situations. However, the possibility of under- and overestimation is present, implying risks to patient safety and inappropriate use of resources. Improving the content of referral letters does not appear to reduce this risk when the letters are of acceptable quality.publishedVersio

Defining when specialised mental health care is needed: A focus group study

Background: Shared understanding between GPs and hospital specialists concerning when patients need specialised mental health care is important to ensure patients receive appropriate care. The large amount of rejected referrals often indicates a lack of such shared understanding. Aim: To explore how patient representatives, GPs, and mental health specialists understand ‘need for specialised mental health care’, meaning that primary care is no longer sufficient. Design & setting: This qualitative study was conducted in western Norway. The study has a service user-involved research design in which GPs and patient representatives participated in all stages of the research process. Method: Six semi-structured focus group interviews were conducted. The groups were homogenous as they included only the perspectives of either GPs, mental health specialists, or patient representatives. Data were analysed using thematic analysis. Results: The need for specialised mental health care was assessed using two continuums: (a) the patient’s level of functioning and symptoms; and (b) characteristics of the healthcare system and the patient’s informal support networks. Assessment along these continuums were often overruled by the evaluation of expected usefulness of specialised mental health care. In addition, all participants reported they often adapted their definition of need to fit other stakeholders’ interpretations of need. Conclusion: Evaluation of need for specialised mental health care is complex and depends on several factors. This may explain some of the current challenges that exist with regard to equity and timely access to appropriate healthcare interventions.publishedVersio

Typologies in GPs’ referral practice

Background: GPs’ individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Methods: Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP’s age, gender, specialty in family medicine and location as independent variables. Results: Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients’ pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. Conclusions: Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence.publishedVersio

The Effect of Intensive Implementation Support on Fidelity for Four Evidence‑Based Psychosis Treatments: A Cluster Randomized Trial

Abstract Purpose: Service providers need effective strategies to implement evidence-based practices (EBPs) with high fidelity. This study aimed to evaluate an intensive implementation support strategy to increase fidelity to EBP standards in treatment of patients with psychosis. Methods: The study used a cluster randomized design with pairwise assignment of practices within each of 39 Norwegian mental health clinics. Each site chose two of four practices for implementation: physical health care, antipsychotic medication management, family psychoeducation, illness management and recovery. One practice was assigned to the experimental condition (toolkits, clinical training, implementation facilitation, data-based feedback) and the other to the control condition (manual only). The outcome measure was fidelity to the EBP, measured at baseline and after 6, 12, and 18 months, analyzed using linear mixed models and effect sizes. Results: The increase in fidelity scores (within a range 1-5) from baseline to 18 months was significantly greater for experimental sites than for control sites for the combined four practices, with mean difference in change of 0.86 with 95% CI (0.21; 1.50), p = 0.009). Effect sizes for increase in group difference of mean fidelity scores were 2.24 for illness management and recovery, 0.68 for physical health care, 0.71 for antipsychotic medication management, and 0.27 for family psychoeducation. Most improvements occurred during the first 12 months. Conclusions: Intensive implementation strategies (toolkits, clinical training, implementation facilitation, data-based feedback) over 12 months can facilitate the implementation of EBPs for psychosis treatment. The approach may be more effective for some practices than for others. Keywords: Evidence-based practice; Fidelity scale; Implementation support; Mental health services; Psychoses. © 2021. The Author(s).publishedVersio

Bridging the Gap between Primary Care and Specialized Mental Health Care. A mixed method study of the quality of referral information and the referral letters’ potential impact on quality of care

Background. A major cause of adverse events in health care is insufficient information transference between health professionals. Despite the cardinal role of referral letters as the means of communication between primary care and specialized mental health care, earlier studies have shown that these letters often lack essential information. The impact of this lack of communication on patient care is unknown. The present study primarily aims to explore what information referral letters from primary health care professionals to specialized mental health care services for adults ideally should include. Secondly, an instrument to measure the quality of these letters will be developed and tested. Finally, indicators to measure the impact of referral letters on the quality of specialised mental health care will be created. Design and methods. Using a mixed method design, we employed qualitative group interview methods, literature reviews and quantitative rating technics. In addition to health professionals we involved patient representatives and managers in all steps of the study. We adapted the RAND/UCLA Appropriateness Method to develop indicators of specialised mental health care quality. The study was conducted in western Norway. Results. Nineteen information items were regarded as essential in referral letters from primary care providers to specialized mental health care professionals, including personal information, case history and social situation, present state and results, somatic health, treatment efforts and involved professional network, as well as the patient's own goals and preferences. The instrument developed to measure the quality of the referral letters was found to be both valid and reliable. For assessing the impact of the referral letters, we found appropriateness of priority decisions and delays to be essential factors of mental health care quality. Thus, we recommend four indicators: correctness of priority between patients, delay in assessing referral, delay to onset of care, and appropriateness of referral. Discussion. The present study recommends a greater emphasis on information to facilitate coordination of care interventions and services and on patient involvement than existing standards for referral letters to specialised mental health care. The developed indicators on potential impact of referral letter quality are in accordance with the existing literature on quality of the referral process. However, our results only include process indicators, not outcome indicators. Limitations in the generalizability of the selection of the most essential information items and indicators are possible. Conclusion. Based on the international definition of quality in health care and on reported challenges to health care regarding coordination, cooperation and timely access, our study indicates that sufficient referral communication is a key factor that enhances high quality health care. Compliance to the recommended 19 information items is expected to improve timely access and decrease delays in the process of care. The developed measurements enable both exploration of the referral information's impact on mental health care quality and provision of valid data for systematic improvement to practice. However, the challenges we experienced in defining valid indicators highlight the importance of thorough preparation of measurements and process evaluation as recommended by new guidelines for research into complex health service interventions. Further research is needed to explore a) the strength of the association between referral information, our recommended process indicators, and patient outcome; b) the effects of systematic interventions to improve the content of referral letters; and c) to what degree our results are valid to other contexts and for other patient groups than those explored in the present study

"Som man roper i skogen får man svar" En case-studie om BrukerPlans egnethet for å kartlegge befolkningens behov for rusbehandling og –omsorg

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The consultants' role in the referring process with general practitioners: partners or adjudicators? a qualitative study

Background: Within the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs). Methods: A qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012. Results: The consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted. Conclusions: Better communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners