The development of an international oncofertility competency framework: a model to increase oncofertility implementation

© AlphaMed Press 2019 Background: Despite international evidence about fertility preservation (FP), several barriers still prevent the implementation of equitable FP practice. Currently, oncofertility competencies do not exist. The aim of this study was to develop an oncofertility competency framework that defines the key components of oncofertility care, develops a model for prioritizing service development, and defines the roles that health care professionals (HCPs) play. Materials and Method: A quantitative modified Delphi methodology was used to conduct two rounds of an electronic survey, querying and synthesizing opinions about statements regarding oncofertility care with HCPs and patient and family advocacy groups (PFAs) from 16 countries (12 high and 4 middle income). Statements included the roles of HCPs and priorities for service development care across ten domains (communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, oncofertility training, reproductive survivorship care and fertility-related psychosocial support, supportive care, and ethical frameworks) that represent 33 different elements of care. Results: The first questionnaire was completed by 457 participants (332 HCPs and 125 PFAs). One hundred and thirty-eight participants completed the second questionnaire (122 HCPs and 16 PFAs). Consensus was agreed on 108 oncofertility competencies and the roles HCPs should play in oncofertility care. A three-tier service development model is proposed, with gradual implementation of different components of care. A total of 92.8% of the 108 agreed competencies also had agreement between high and middle income participants. Conclusion: FP guidelines establish best practice but do not consider the skills and requirements to implement these guidelines. The competency framework gives HCPs and services a structure for the training of HCPs and implementation of care, as well as defining a model for prioritizing oncofertility service development. Implications for Practice: Despite international evidence about fertility preservation (FP), several barriers still prevent the implementation of equitable FP practice. The competency framework gives 108 competencies that will allow health care professionals (HCPs) and services a structure for the development of oncofertility care, as well as define the role HCPs play to provide care and support. The framework also proposes a three-tier oncofertility service development model which prioritizes the development of components of oncofertility care into essential, enhanced, and expert services, giving clear recommendations for service development. The competency framework will enhance the implementation of FP guidelines, improving the equitable access to medical and psychological oncofertility care

How Can We Improve Oncofertility Care for Patients? A Systematic Scoping Review of Current International Practice and Models of Care

© The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. BACKGROUND: Fertility preservation (FP) is an important quality of life issue for cancer survivors of reproductive age. Despite the existence of broad international guidelines, the delivery of oncofertility care, particularly amongst paediatric, adolescent and young adult patients, remains a challenge for healthcare professionals (HCPs). The quality of oncofertility care is variable and the uptake and utilization of FP remains low. Available guidelines fall short in providing adequate detail on how oncofertility models of care (MOC) allow for the real-world application of guidelines by HCPs. OBJECTIVE AND RATIONALE: The aim of this study was to systematically review the literature on the components of oncofertility care as defined by patient and clinician representatives, and identify the barriers, facilitators and challenges, so as to improve the implementation of oncofertility services. SEARCH METHODS: A systematic scoping review was conducted on oncofertility MOC literature published in English between 2007 and 2016, relating to 10 domains of care identified through consumer research: communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, training, supportive care during treatment, reproductive care after cancer treatment, psychosocial support and ethical practice of oncofertility care. A wide range of electronic databases (CINAHL, Embase, PsycINFO, PubMed, AEIPT, Education Research Complete, ProQuest and VOCED) were searched in order to synthesize the evidence around delivery of oncofertility care. Related citations and reference lists were searched. The review was undertaken following registration (International prospective register of systematic reviews (PROSPERO) registration number CRD42017055837) and guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). OUTCOMES: A total of 846 potentially relevant studies were identified after the removal of duplicates. All titles and abstracts were screened by a single reviewer and the final 147 papers were screened by two reviewers. Ten papers on established MOC were identified amongst the included papers. Data were extracted from each paper and quality scores were then summarized in the oncofertility MOC summary matrix. The results identified a number of themes for improving MOC in each domain, which included: the importance of patients receiving communication that is of a higher quality and in different formats on their fertility risk and FP options; improving provision of oncofertility care in a timely manner; improving access to age-appropriate care; defining the role and scope of practice of all HCPs; and improving communication between different HCPs. Different forms of decision aids were found useful for assisting patients to understand FP options and weigh up choices. WIDER IMPLICATIONS: This analysis identifies core components for delivery of oncofertility MOC. The provision of oncofertility services requires planning to ensure services have safe and reliable referral pathways and that they are age-appropriate and include medical and psychological oncofertility care into the survivorship period. In order for this to happen, collaboration needs to occur between clinicians, allied HCPs and executives within paediatric and adult hospitals, as well as fertility clinics across both public and private services. Training of both cancer and non-cancer HCPs is needed to improve the knowledge of HCPs, the quality of care provided and the confidence of HCPs with these consultations

The Role of individual diligence in improving safety

Purpose: This paper aims to be a theoretical examination of the role of individuals in sponsoring and facilitating effective, systemic change in organisations. Using reports of a number of high-profile initiatives to improve patient safety, it seeks to analyse the role of individual health care professionals in developing and facilitating new systems of care that improve safety and quality. Design/methodology/approach: The paper uses recent work in sociology that is concerned with the phenomenon of "sociological citizenship". The authors test whether successful initiators of change in health care can be described as sociological citizens. This notion of sociological citizens is applied to a number of highly successful initiatives to improve safety and quality to extrapolate the factors associated with individual clinician leadership, which may have affected the success of such endeavours. Findings: In each of the examples analysed the initiators of change can be characterised as sociological citizens. In reviewing the roles of these charismatic individuals it is evident that they see the relational interdependence between the individuals and organisations and that they use this information to achieve both professional and organisational objectives. Research limitations/implications: The paper uses a case study method to investigate the usefulness of the role of sociological citizenship in interventions that aim to improve patient safety. The paper reviews the key concepts and uses of the concept of sociological citizenship to produce a framework against which the case studies were assessed. Practical implications: The authors suggest that a goal of policy for improving patient safety should be directed to the problem of how hospitals and health care organisations can create the conditions for encouraging the individual diligence and care that is needed to support reliable, safe health care practices. Social implications: Improving the safety and quality of health care is an important public health initiative. It has also proven to be difficult to achieve sustained reductions in the harm caused by the occurrence of adverse events in health care. The process of linking individual diligence with service outcomes may help to overcome one of the enduring struggles of health care systems around the world: the policy-practice divide. Originality/value: The paper directs attention towards the role of sociological citizenship in health care systems and organisations.14 page(s

A root cause analysis of clinical error: Confronting the disjunction between formal rules and situated clinical activity

This paper presents evidence from a root cause analysis (RCA) team meeting that was recently conducted in a Sydney Metropolitan Teaching Hospital to investigate an iatrogenic morphine overdose. Analysis of the meeting transcript reveals on three levels that clinical members of the team struggle with framing the uncertain and contradictory details of situated clinical activity and translating these first into 'root causes', and then into recommendations for practice change. This analysis puts two challenges into special relief. First, RCA team members find themselves in the unusual position of having to derive organizational-managerial generalizations from the specifics of in situ activity. Second, they are constrained by the expectation inscribed into RCA that their recommendations result in 'systems improvements' assumed to flow forth from an extension of formal rules and spread of procedures. We argue that this perspective misrecognizes the importance of RCA as a means to engender solutions that leave the procedural detail of clinical processes unspecified, and produce cross-hospital discussions about the organizational dimensions of care.Root cause analysis Hospital clinicians Clinical error Organizational learning Australia

Turning the medical gaze in upon itself: Root cause analysis and the investigation of clinical error

In this paper, we discuss how a technique borrowed from defense and manufacturing is being deployed in hospitals across the industrialized world to investigate clinical errors. We open with a discussion of the levers used by policy makers to mandate that clinicians not just report errors, but also gather to investigate those errors using root cause analysis (RCA). We focus on the tensions created for clinicians as they are expected to formulate 'systems solutions' that go beyond blame. In addressing these matters, we present a discourse analysis of data derived during an evaluation of the NSW Health Safety Improvement Program. Data include transcripts of RCA meetings which were recorded in a local metropolitan teaching hospital. From this analysis we move back to the argument that RCA involves clinicians in 'immaterial labour', or the production of communication and information, and that this new labour realizes two important developments. First, because RCA is anchored in the principle of health care practitioners not just scrutinizing each other, but scrutinizing each others' errors, RCA is a challenging task. Second, thanks to turning the clinical gaze in on the clinical observer, RCA engenders a new level of reflexivity of clinical self and of clinical practice. We conclude with asking whether this reflexivity will lock the clinical gaze into a micro-sociology of error, or whether it will enable this gaze to influence matters superordinate to the specifics of practice and the design of clinical treatments; that is, the over-arching governance and structuring of hospital care.Clinical incidents Root cause analysis Australia Discourse analysis