Understanding the conditions for improvement: research to discover which context influences affect improvement success

Context can be defined as all factors that are not part of a quality improvement intervention itself. More research indicates which aspects are ‘conditions for improvement’, which influence improvement success. However, little is known about which conditions are most important, whether these are different for different quality interventions or whether some become less or more important at different times in carrying out an improvement. Knowing more about these conditions could help speed up and spread improvements and develop the science. This paper proposes ways to build knowledge about the conditions needed for different changes, and to create conditional-attribution explanations to provide qualified generalisations. It describes theory-based, non-experimental research designs. It also suggests that ‘practical improvers’ can make their changes more effective by reflecting on and revising their own ‘assumption-theories’ about the conditions which will help and hinder the improvements they aim to implement

Increasing the generalisability of improvement research with an improvement replication programme

If a quality improvement is found effective in one setting, would the same effects be found elsewhere? Could the same change be implemented in another setting? These are just two of the ‘generalisation questions’ which decision-makers face in considering whether to act on reported improvement. In this paper, some of the issues are considered and a programme of research for testing improvements in different settings is proposed to build theory and practical guidance about implementation and results in different settings

Coordination in networks for improved mental health service

<!-- /* Font Definitions */ @font-face {font-family:Times; panose-1:2 2 6 3 5 4 5 2 3 4; mso-font-charset:0; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-parent:""; margin:0cm; margin-bottom:.0001pt; mso-pagination:widow-orphan; mso-hyphenate:none; font-size:12.0pt; font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-ansi-language:EN-GB; mso-fareast-language:AR-SA;} @page Section1 {size:612.0pt 792.0pt; margin:70.85pt 70.85pt 70.85pt 70.85pt; mso-header-margin:36.0pt; mso-footer-margin:36.0pt; mso-paper-source:0;} div.Section1 {page:Section1;} --><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Background</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: Well-organised clinical cooperation between health and social services has been difficult to achieve in Sweden as in other countries.</span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Purpose</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: This paper presents an empirical study of a mental health coordination network in one area in Stockholm. The aim was to describe the development and nature of coordination within a mental health and social care consortium and to assess the impact on care processes and client outcomes.</span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Method</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: Data was gathered through interviews with coordina­tors from three rehabilitation units. The interviews focused on coordination activities aimed at supporting the clients’ needs and investigated how the coordinators acted according to the consortium's holistic approach. Data on The Camberwell Assess­ment of Need (CAN-S) showing clients’ satisfaction was used to assess on set of outcomes. </span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Findings</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">: The findings revealed different coordination <span>activities and </span>factors both helping and hindering the network coordination activities. One factor helping was the history of local and personal informal cooperation and shared responsibilities evident. Unclear roles and routines hindered cooperation</span></p><p class="MsoNormal"><strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB">Practical</span></strong><span style="font-size: 10pt; font-family: Times; color: black;" lang="EN-GB"> <strong>value</strong>: The contribution is an empirical example and a model for organisations establishing structures for network coordination. One l<span>esson for current policy about integrated health care is to adapt and implement ”pair coordinators” where full structural integration is not possible.</span> </span><span style="font-size: 10pt; font-family: Times;" lang="EN-GB">Another lesson, based on the idea of patient quality by coordinated care, is specific to adapt the work of the local psychiatric addictive team – an independent special team in the psychiatric outpatient care serving psychotic clients with complex addictive problems. </span></p

Collaborating with front-line healthcare professionals: the clinical and cost effectiveness of a theory based approach to the implementation of a national guideline

Background Clinical guidelines are an integral part of healthcare. Whilst much progress has been made in ensuring that guidelines are well developed and disseminated, the gap between routine clinical practice and current guidelines often remains wide. A key reason for this gap is that implementation of guidelines typically requires a change in the behaviour of healthcare professionals – but the behaviour change component is often overlooked. We adopted the Theoretical Domains Framework Implementation (TDFI) approach for supporting behaviour change required for the uptake of a national patient safety guideline to reduce the risk of feeding through misplaced nasogastric tubes. Methods The TDFI approach was used in a pre-post study in three NHS hospitals with a fourth acting as a control (with usual care and no TDFI). The target behavior identified for change was to increase the use of pH testing as the first line method for checking the position of a nasogastric tube. Repeat audits were undertaken in each hospital following intervention implementation. We used Zou’s modified Poisson regression approach with robust standard errors to estimate risk ratios for the use of pH testing. The projected return on investment (ROI) was also calculated. Results Following intervention implementation, the use of pH first line increased significantly across intervention hospitals [risk ratio (95% CI) ranged from 3.1 (1.14 to8.43) p < .05, to 8.14 (3.06 to21.67) p < .001] compared to the control hospital, which remained unchanged [risk ratio (CI) = .77 (.47-1.26) p = .296]. The estimated savings and costs in the first year were £2.56 million and £1.41 respectively, giving an ROI of 82%, and this was projected to increase to 270% over five years. Conclusion The TDFI approach improved the uptake of a patient safety guideline across three hospitals. The TDFI approach is clinically and cost effective in comparison to the usual practice

Bridging the discursive gap between lay and medical discourse in care coordination

For older people with multiple chronic co-morbidities, strategies to coordinate care depend heavily on information exchange. We analyse the information-sharing difficulties arising from differences between patients’ oral narratives and medical sense-making; and whether a modified form of ‘narrative medicine’ might mitigate them. We systematically compared 66 general practice patients’ own narratives of their health problems and care with the contents of their clinical records. Data were collected in England during 2012–13. Patients’ narratives differed from the accounts in their medical record, especially the summary, regarding mobility, falls, mental health, physical frailty and its consequences for accessing care. Parts of patients’ viewpoints were never formally encoded, parts were lost when clinicians de-coded it, parts supplemented, and sometimes the whole narrative was re-framed. These discrepancies appeared to restrict the patient record's utility even for GPs for the purposes of risk stratification, case management, knowing what other care-givers were doing, and coordinating care. The findings suggest combining the encoding/decoding theory of communication with inter-subjectivity and intentionality theories as sequential, complementary elements of an explanation of how patients communicate with clinicians. A revised form of narrative medicine might mitigate the discursive gap and its consequences for care coordination