Unpacking the black box of improvement

During the Salzburg Global Seminar Session 565-Better Health Care: How do we learn about improvement, participants discussed the need to unpack the black box of improvement. The black box refers to the fact that when quality improvement interventions are described or evaluated, there is a tendency to assume a simple, linear path between the intervention and the outcomes it yields. It is also assumed that it is enough to evaluate the results without understanding the process of by which the improvement took place. However, quality improvement interventions are complex, nonlinear and evolve in response to local settings. To accurately assess the effectiveness of quality improvement and disseminate the learning, there must be a greater understanding of the complexity of quality improvement work. To remain consistent with the language used in Salzburg, we refer to this as unpacking the black box of improvement. To illustrate the complexity of improvement, this article introduces four quality improvement case studies. In unpacking the black box, we present and demonstrate how Cynefin framework from complexity theory can be used to categorize and evaluate quality improvement interventions. Many quality improvement projects are implemented in complex contexts, necessitating an approach defined as probesense- respond. In this approach, teams experiment, learn and adapt their changes to their local setting. Quality improvement professionals intuitively use the probe-sense-respond approach in their work but document and evaluate their projects using language for simple or complicated' contexts, rather than the complex contexts in which they work. As a result, evaluations tend to ask 'How can we attribute outcomes to the intervention, rather than 'What were the adaptations that took place. By unpacking the black box of improvement, improvers can more accurately document and describe their interventions, allowing evaluators to ask the right questions and more adequately evaluate quality improvement interventions.Fil: Ramaswamy, Rohit. University of North Carolina; Estados UnidosFil: Reed, Julie. Nihr Clarch Northwest London; Estados UnidosFil: Livesley, Nigel. Institute for Healthcare Improvement; Estados UnidosFil: Boguslavsky, Victor. University Research Co; Estados UnidosFil: Garcia Elorrio, Ezequiel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Sax, Sylvia. University of Heidelberg; AlemaniaFil: Houleymata, Diarra. Applying Science to Strengthen and Improve Systems Project,; MalíFil: Kimble, Leighann. University Research Co; Estados UnidosFil: Parry, Gareth. Institute of Healthcare Improvement; Estados Unido

Collaborative Management of HIV Infection in the Community: An Effort to Improve the Quality of HIV Care

Our hospital led a multidisciplinary community team to improve the quality of care delivered to HIV-infected clients utilizing a disease management approach in a US metropolitan community of 150,000 people. Community needs assessment and client and community surveys were used to define the problems. Patient care flowcharting and the creation of an electronic patient database facilitated patient tracking across the entire community. Clinical guidelines and a consultation and referral immunology clinic standardized care practices. Measurable improvements in the quality of care were noted in multiple areas. Flowchart completion rates rose from 44% to 100%; medication adherence assessment rose from 82% to 100%; immunization rates rose from a mean of 72% to a mean of 87%; PPD screening rose from a low of 35% to a high of 87%; perinatal transmission rates fell from 31% to 4%; and Emergency Department utilization decreased. Two essential components of the effort were the establishment of a full-time leadership position in the form of a clinical nurse practitioner and the creation of an electronic database with flowcharting to standardize the measurement, delivery and tracking of care. The programme has become an example of successful disease management through hospital-community collaboration

The Role of e-Health in Disasters: A Strategy for Education, Training and Integration in Disaster Medicine

This paper describes the origins and progress of an international project to advance disaster eHealth (DEH) – the application of eHealth technologies to enhance the delivery of healthcare in disasters. The study to date has focused on two major themes; the role of DEH in facilitating inter-agency communication in disaster situations, and the fundamental need to promote awareness of DEH in the education of disaster managers and health professionals. The paper deals mainly with on-going research on the second of these themes, surveying the current provision of disaster medicine education, the design considerations for a DEH programme for health professionals, the key curriculum topics, and the optimal delivery mode

State Mandated Prenatal Human Immunodeficiency Virus Screening at a Large Community Hospital

Purpose: To describe the initial experience of state mandated prenatal HIV screening at a large community hospital.Methods: HIV screening was provided to all pregnant women as of October 1, 1999. All HIV-positive women identified received aggressive antiretroviral therapy to reduce the likelihood for vertical transmission. Neonates were screened for HIV at zero, six, and 12 months of age.Results: Seven pregnant women (0.3%) and two additional family members tested positive for HIV. All seven infants born to the identified HIV-positive women have tested negative for infection. We estimated that six of nine cases of HIV infection identified would have been missed under a policy of voluntary HIV screening.Conclusions: Universal screening for HIV in pregnancy is achievable and desirable and provides the best opportunity to minimize the number of new neonatal HIV infections

Impact of an Adherence Program on the Health and Outlook of HIV-Infected Patients Failing Antiretroviral Therapy

Background: We prospectively studied the impact of an adherence counselor on the outcome of patients failing antiretroviral therapy because of nonadherence. Methods: Forty-six patients, identified as chronically nonadherent were enrolled. Individual attention was provided using the information, motivation and behavioral methodology. HIV RNA (viral load, in copies/mL), CD4 count (in cells/[mm.sup.3]), and body weight before and after the adherence counselor were measured. Qualitative outcome and patient satisfaction were assessed by deidentified third-party interviews. Results: Over half completed at least 1 year; only 8 patients were lost to follow-up. Mean CD4 counts increased significantly (P \u3c .05) for completers at 6 and 12 months. Viral loads decreased between baseline and 6 months. Most clients reported subjective benefit from working with the adherence counselor. Conclusion: Although few clients showed complete virologic suppression, the value of an adherence counselor was validated. Longer term adherence programs should be evaluated

THE ROLE OF EHEALTH IN DISASTERS: A STRATEGY FOR EDUCATION, TRAINING AND INTEGRATION IN DISASTER MEDICINE

This paper describes the origins and progress of an international project to advance disaster eHealth (DEH) – the application of eHealth technologies to enhance the delivery of healthcare in disasters. The study to date has focused on two major themes; the role of DEH in facilitating inter-agency communication in disaster situations, and the fundamental need to promote awareness of DEH in the education of disaster managers and health professionals. The paper deals mainly with on-going research on the second of these themes, surveying the current provision of disaster medicine education, the design considerations for a DEH programme for health professionals, the key curriculum topics, and the optimal delivery mode

Review of key initiatives and approaches to adaptation planning at the national level in semi-arid areas

The paper reviews country-level and multi-country projects supported by international agencies, examining the priorities and goals in national adaptation and sectorial planning documents. The analysis compares adaptation needs with current trends in national, regional and global projects and collaborations. The paper focuses on addressing research gaps, specifically looking at international support for adaptation actions in semi-arid regions, and reflecting on the vulnerability of these countries to the impacts of climate change. Outcomes indicate that global, regional and national initiatives are distributed unequally and that countries in Central and West Africa and Central Asia currently exhibit low participation, especially in national projects

Review of key initiatives and approaches to adaptation planning at the national level in semi-arid areas

The semi-arid areas found in a large number of countries and regions of Africa and South and Central Asia display high vulnerability to climate change with considerable adaptation needs. Research outcomes indicate that global, regional and national initiatives are distributed unequally, and that these regions in Africa and Asia currently exhibit low participation, especially in national projects. In this paper, country-level and multi-country projects supported by international agencies are reviewed, along with priorities and goals presented in national adaptation and sectorial planning documents. Priorities listed in documents but not captured in current initiatives include human health, pastoralism, security and migration

Career success across the globe: Insights from the 5C project

The Cross-Cultural Collaboration on Contemporary Careers (5C Project) conducted in-depth, longitudinal qualitative research into what career success means to people in a diverse range of countries; specifically: Australia, Austria, Belgium, Brazil, Canada, China, Colombia, Costa Rica, Finland, France, Germany, Greece, India, Israel, Italy, Japan, Korea, Malaysia, Mexico, Netherlands, Nigeria, Norway, Philippines, Portugal, Russian Federation, Serbia, Slovakia, Slovenia, South Africa, Spain, Thailand, Turkey, UK, and USA. This paper presents the seven major meanings of career success that emerged across these diverse global cultures and thus may be deemed relevant all around the world. These are financial security (being able to consistently provide the basic necessities for living), financial achievement (steadily making more money, wealth, incentives, and perks), learning and development (via continuous informal learning on the job and/or formal training and education), work-life-balance (between work and non-work, relationships, activities and interests), positive relationships (as signified by, for instance, enjoying working with people who you respect and admire), positive impact (by helping others in one’s immediate social environment and/or leaving some sort of legacy to a community, or society more broadly), and entrepreneurship founding one’s own enterprise or being able to invent and develop one’s own projects within the work context). We describe examples of each from different cultures and offer practical implications of these meanings for the primary stakeholders of career research: individuals, organizations, as well as counselors, coaches and consultants