Upgrading chronic care : exploring challenges in rheumatology care management.

Introduction: The literature on chronic care describes a gap between what patients need and what healthcare provides. In rheumatoid arthritis, major medical advances have taken place in recent years which have made it possible to successfully treat more patients. However, these advances have led to organizational challenges in the man-agement of healthcare delivery. Aim: To explore the challenges in rheumatology care management by studying users’ perceptions of the Feed Forward System (FFS) principles (Study I), simulation model-ing as a tool for chronic care improvement (Study II and Study IV), and a way to test new chronic care processes (Study III). Method: Qualitative and quantitative research methods were used to explore the chal-lenges faced by providers and their patients at Swedish rheumatology clinics. Methods include interviews, a focus group discussion, questionnaires, a meta-analysis, and simu-lation modeling. Content analysis was used to analyze qualitative data. Findings: Patients became more involved in and informed about their own care when they used the FFS. Providers said that it offered an overview of past treatments and their effects, as well as support for treatment decisions (Study I). Simulation modeling provided a way to test the effects of moving from time-centric to need-centric processes in rheumatology care (Study III). Simulation modeling was also shown to support healthcare improvement by visualizing the effects of planned changes, communicating these changes to management, and engaging providers to explore and test innovative solutions (Study II and IV). Discussion: Feed Forward Systems and simulation modeling represent an upgrade of how to manage the challenges inherent to rheumatology care. FFS encourage patient empowerment, self-management, and shared decision making, as well as support learn-ing for patients and providers alike. Simulation modeling helps manage complex prob-lems and facilitates learning for providers and managers. This is enabled through the shared features of FFS and simulation modeling: (1) the transformation of data into knowledge, (2) a mutual communication platform for multiple stakeholder involve-ment, (3) provision of real time feedback that enables action in clinical practice, and (4) self-correction that generates learning opportunities. Conclusion: The introduction of FFS and simulation modeling has implications at the clinical level and the patient level of rheumatology care. Upgrading chronic care where it is delivered, at both levels, can contribute to improvements in care management – changing the healthcare system from within

Team behaviors in emergency care: a qualitative study using behavior analysis of what makes team work

<p>Abstract</p> <p>Objective</p> <p>Teamwork has been suggested as a promising approach to improving care processes in emergency departments (ED). However, for teamwork to yield expected results, implementation must involve behavior changes. The aim of this study is to use behavior analysis to qualitatively examine how teamwork plays out in practice and to understand eventual discrepancies between planned and actual behaviors.</p> <p>Methods</p> <p>The study was set in a Swedish university hospital ED during the initial phase of implementation of teamwork. The intervention focused on changing the environment and redesigning the work process to enable teamwork. Each team was responsible for entire care episodes, i.e. from patient arrival to discharge from the ED. Data was collected through 3 days of observations structured around an observation scheme. Behavior analysis was used to pinpoint key teamwork behaviors for consistent implementation of teamwork and to analyze the contingencies that decreased or increased the likelihood of these behaviors.</p> <p>Results</p> <p>We found a great discrepancy between the planned and the observed teamwork processes. 60% of the 44 team patients observed were handled solely by the appointed team members. Only 36% of the observed patient care processes started according to the description in the planned teamwork process, that is, with taking patient history together. Beside this behavior, meeting in a defined team room and communicating with team members were shown to be essential for the consistent implementation of teamwork. Factors that decreased the likelihood of these key behaviors included waiting for other team members or having trouble locating each other. Getting work done without delay and having an overview of the patient care process increased team behaviors. Moreover, explicit instructions on when team members should interact and communicate increased adherence to the planned process.</p> <p>Conclusions</p> <p>This study illustrates how behavior analysis can be used to understand discrepancies between planned and observed behaviors. By examining the contextual conditions that may influence behaviors, improvements in implementation strategies can be suggested. Thereby, the adherence to a planned intervention can be improved, and/or revisions of the intervention be suggested.</p

Persons with rheumatoid arthritis challenge the relevance of the health assessment questionnaire: a qualitative study of patient perception

Abstract Background The Stanford Health Assessment Questionnaire-Disability Index (HAQ) is widely used to measure functional ability in persons with Rheumatoid Arthritis (RA). The instrument was developed with limited involvement from persons with RA, and their perception of the instrument has not been studied in depth. The aim of this study was to explore how persons with RA experience the use of the HAQ in care. Methods The study used secondary data analysis. Persons with RA participated in semi-structured interviews in previous research projects. Thirty-nine interviews were included based on data fit, and thematic analysis applied. Results The participants questioned the relevance of the HAQ but nevertheless experienced that the instrument had a profound effect on their understanding of health and how care is delivered. The analysis resulted in three themes: Problems with individual items, meaning of the summative score, and effects on care and health perceptions. Conclusions To make the HAQ relevant to persons with RA, it needs to be revised or to include an option to select items most meaningful to the respondent. To ensure relevance, the HAQ update should preferably be co-created by researchers, clinicians and persons with RA

Staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in quality improvement : A focus group discussion study at two hospital settings in Sweden

Objective: To explore healthcare staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in improvement efforts. Design: Two focus group discussions were performed. Settings: Two settings were included: a rheumatology department and an orthopaedic section both situated in Sweden. Participants: Healthcare staff and managers (n=13) from the two settings. Interventions: Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modelling. Results from the respective simulation model were then presented and discussed in the following focus group discussion. Results: Categories from the content analysis are presented according to the following research questions: how and when simulation modelling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modelling could act as a tool for support and a way to visualise problems, potential solutions and their effects. Regarding when, simulation modelling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in improvement work. Conclusions: Its potential as an information and communication tool and as an instrument for pedagogic work with healthcare improvement render a broader application and value of simulation modelling than previously reported

Data from: Staffs’ and managers’ perceptions of how and when discrete event simulation modeling can be used as a decision support in quality improvement: a focus group discussion study at two hospital settings in Sweden

Objective To explore healthcare staffs’ and managers’ perceptions of how and when discrete event simulation modeling can be used as a decision support in improvement efforts. Design Two focus group discussions were performed. Setting Two settings were included: a rheumatology department and an orthopedic section both situated in Sweden. Participants Healthcare staff and managers (n=13) from the two settings. Interventions Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modeling. Results from the respective simulation model were then presented and discussed in the following focus group discussion. Results Categories from the content analysis are presented according to the following research questions: how and when simulation modeling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modeling could act as a tool for support and a way to visualize problems, potential solutions and their effects. Regarding when, simulation modeling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in the improvement work. Conclusions Its potential as an information and communication tool and as an instrument for pedagogic work within healthcare improvement render a broader application and value of simulation modeling than previously reported

Patients are doing it for themselves : A survey on disease-specific knowledge acquisition among people with Parkinson's disease in Sweden.

Effective self-management is key to living well with Parkinson's disease and one important aspect is disease-specific knowledge. This article explores how people with Parkinson's disease in Sweden (1) acquire disease-specific knowledge and (2) use Parkinson's disease-related healthcare. Data were collected through an online survey, which had 346 respondents (16-87 years old, median age: 68 years, 51% male; time since diagnosis: 0-31 years, median time: 7 years). Our results show that disease-specific knowledge is mainly found online, especially for women with Parkinson's disease and people with Parkinson's disease of working age, that most people with Parkinson's disease in Sweden see their neurologist for 1 h or less per year and only one in two people with Parkinson's disease has regular contact with other Parkinson's disease-related healthcare professionals. We also find that people with Parkinson's disease reporting higher levels of specific knowledge also are more likely to be satisfied with the amount of time they get with their neurologist, regardless of the amount of time

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Operational strategies to manage non-elective orthopaedic surgical flows : A simulation modelling study

Objectives To explore the value of simulation modelling in evaluating the effects of strategies to plan and schedule operating room (OR) resources aimed at reducing time to surgery for non-elective orthopaedic inpatients at a Swedish hospital. Methods We applied discrete-event simulation modelling. The model was populated with real world data from a university hospital with a strong focus on reducing waiting time to surgery for patients with hip fracture. The system modelled concerned two patient groups that share the same OR resources: hip-fracture and other non-elective orthopaedic patients in need of surgical treatment. We simulated three scenarios based on the literature and interaction with staff and managers: (1) baseline; (2) reduced turnover time between surgeries by 20â €..min and (3) one extra OR during the day, Monday to Friday. The outcome variables were waiting time to surgery and the percentage of patients who waited longer than 24â €..hours for surgery. Results The mean waiting time in hours was significantly reduced from 16.2â €..hours in scenario 1 (baseline) to 13.3â €..hours in scenario 2 and 13.6â €..hours in scenario 3 for hip-fracture surgery and from 26.0â €..hours in baseline to 18.9â €..hours in scenario 2 and 18.5â €..hours in scenario 3 for other non-elective patients. The percentage of patients who were treated within 24â €..hours significantly increased from 86.4% (baseline) to 96.1% (scenario 2) and 95.1% (scenario 3) for hip-fracture patients and from 60.2% (baseline) to 79.8% (scenario 2) and 79.8% (scenario 3) for patients with other non-elective patients. Conclusions Healthcare managers who strive to improve the timelines of non-elective orthopaedic surgeries may benefit from using simulation modelling to analyse different strategies to support their decisions. In this specific case, the simulation results showed that the reduction of surgery turnover times could yield the same results as an extra OR. © 2017 Published by the BMJ Publishing Group Limited.open access</p