Organizational interventions to implement improvements in patient care: a structured review of reviews

BACKGROUND: Changing the organization of patient care should contribute to improved patient outcomes as functioning of clinical teams and organizational structures are important enablers for improvement. OBJECTIVE: To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care. DESIGN: Structured review of published reviews of rigorous evaluations. DATA SOURCES: Published reviews of studies on organizational interventions. REVIEW METHODS: Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003. Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings. RESULTS: A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain. CONCLUSION: There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty

Holding still, together

This book provides unique insights into how health professionals and people with Parkinson’s disease shape care together. It shows both the courage and vulnerabilities of those who have to face this disease. It consists of photos of people with Parkinson’s disease and their care professionals, both of their interaction and portrayed individually, interwoven with fragments of their dialogue about meaningful care. This book is an integral part of a research project at Radboud university medical center into person-centred care. With it, we hope to contribute to a positive, hopeful vision of ever-improving Parkinson’s care

Overheidstoezicht door de Inspectie voor de Gezondheidszorg

Het rijksoverheidstoezicht door de Inspectie voor de Gezondheidszorg (IGZ) zoals we dat nu kennen heeft zijn wortels in de eerste helft van de negentiende eeuw. In deze bijdrage gaat het over het verleden en de toekomst van het overheidstoezicht door de IGZ als een van de actoren binnen de complexe sturingsrelaties in de gezondheidszorg. De sectorschets is geschreven in opdracht van de Wetenschappelijke Raad voor het Regeringsbeleid (WRR). Tijdens het schrijfproces heeft de WRR een expertbijeenkomst georganiseerd met de auteurs en deskundigen uit het toezicht, de zorg en de wetenschap. De tijdens deze bijeenkomst gemaakte opmerkingen zijn verwerkt in de tekst. De auteurs zijn verantwoordelijk voor de inhoud van de sectorschets

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Ben van Steenkiste, Richard Grol, Trudy van der WeijdenCentre for Quality of Care Research, School for Public Health and Primary Care (Caphri), Maastricht University, Maastricht, The NetherlandsBackground: Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use.Objectives: Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies.Selection criteria: Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses.Outcome measure: Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction.Data collection and analysis: An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007.Main results: The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support.Conclusions: Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.Keywords: systematic review, implementation, cardiovascular diseases, primary preventio

Family practice nurses supporting self-management in older patients with mild osteoarthritis: a randomized trial

Contains fulltext : 70275.pdf ( ) (Open Access)BACKGROUND: Supporting self-management intends to improve life-style, which is beneficial for patients with mild osteoarthritis (OA). We evaluated a nurse-based intervention on older OA patients' self-management with the aim to assess its effects on mobility and functioning. METHODS: Randomized controlled trial of patients (> or = 65 years) with mild hip or knee OA from nine family practices in the Netherlands. Intervention consisted of supporting patients' self-management of OA symptoms using a practice-based nurse. Outcome measures were patients' mobility, using the Timed Up and Go test (TUG), and patient reported functioning, using an arthritis specific scale (Dutch AIMS2 SF). RESULTS: Fifty-one patients were randomized to the intervention group and 53 to the control group. Patient-reported functioning improved on four scales in the intervention group compared to one scale in the control group. However, this result was not significant. Mobility improved in both groups, without a significant difference between the two groups. There were no differences between the groups regarding consultations with family physicians or physiotherapists, or medication use. CONCLUSION: A nurse-based intervention on older OA patients' self-management did not improve self-reported functioning, mobility or patients' use of health care resources

Knowledge translation in health: how implementation science could contribute more

Background: Despite increasing interest in research on how to translate knowledge into practice and improve healthcare, the accumulation of scientific knowledge in this field is slow. Few substantial new insights have become available in the last decade. Main body: Various problems hinder development in this field. There is a frequent misfit between problems and approaches to implementation, resulting in the use of implementation strategies that do not match with the targeted problems. The proliferation of concepts, theories and frameworks for knowledge transfer – many of which are untested – has not advanced the field. Stakeholder involvement is regarded as crucial for successful knowledge implementation, but many approaches are poorly specified and unvalidated. Despite the apparent decreased appreciation of rigorous designs for effect evaluation, such as randomized trials, these should remain within the portfolio of implementation research. Outcome measures for knowledge implementation tend to be crude, but it is important to integrate patient preferences and the increased precision of knowledge. Conclusions: We suggest that the research enterprise be redesigned in several ways to address these problems and enhance scientific progress in the interests of patients and populations. It is crucially important to establish substantial programmes of research on implementation and improvement in healthcare, and better recognize the societal and practical benefits of research

Association between obesity, quality of life, physical activity and health service utilization in primary care patients with osteoarthritis

OBJECTIVE: To assess the association of obesity with quality of life, health service utilization and physical activity in a large sample of primary care patients with osteoarthritis (OA). METHODS: Data were retrieved from the PraxArt project, representing a cohort of 1021 primary care patients with OA. In 978 patients, height and weight were measured and the Body Mass Index (BMI) was calculated. The AIMS2-SF was used to assess quality of life (QoL). Data about health service utilization (HSU) were retrieved by means of patients' medical files. Concomitant depression was assessed by means of the Patient Health Questionnaire (PHQ-9). Patients were grouped into normal weight, overweight and obese according to the definition of the WHO and compared by means of analysis of covariance (ANCOVA). RESULTS: Obese and overweight persons achieved significantly higher scores on the AIMS2-SF lower body scale, the symptom, the affect and the work scale, indicating an increased burden by OA. The PHQ-9 score increased significantly over the three weight-groups, indicating a positive association of BMI and depression. With increasing BMI, the number of comorbidities increased and physical activity decreased significantly. After controlling for covariates, contacts to orthopaedics and performed x-rays remained significantly higher in obese patients, but not contacts to general practitioners. CONCLUSION: The results display a strong association of QoL and BMI, resulting in increased use of the health care system. Thus, the study emphasizes the need for appropriate approaches in primary care to break the vicious circle of overweight, depression, decreasing physical inactivity and decreasing QoL

Developing a facilitation model to promote organisational development in primary care practices

BACKGROUND: The relationship between effective organisation of general practices and health improvement is widely accepted. The Maturity Matrix is an instrument designed to assess organisational development in general practice settings and to stimulate quality improvement. It is undertaken by a practice team with the aid of a facilitator. There is a tradition in the primary care systems in many countries of using practice visitors to educate practice teams about how to improve. However the role of practice visitors as facilitators who enable teams to plan practice-led organisational development using quality improvement instruments is less well understood. The objectives of the study were to develop and explore a facilitation model to support practice teams in stimulating organisational development using a quality improvement instrument called the Maturity Matrix. A qualitative study based on transcript analysis was adopted. METHOD: A model of facilitation was constructed based on a review of relevant literature. Audio tapes of Maturity Matrix assessment sessions with general practices were transcribed and facilitator skills were compared to the model. The sample consisted of two facilitators working with twelve general practices based in UK primary care. RESULTS: The facilitation model suggested that four areas describing eighteen skills were important. The four areas are structuring the session, obtaining consensus, handling group dynamics and enabling team learning. Facilitators effectively employed skills associated with the first three areas, but less able to consistently stimulate team learning. CONCLUSION: This study suggests that facilitators need careful preparation for their role and practices need protected time in order to make best use of practice-led quality improvement instruments. The role of practice visitor as a facilitator is becoming important as the need to engender ownership of the quality improvement process by practices increases

Holding still, together

This book provides unique insights into how health professionals and people with Parkinson’s disease shape care together. It shows both the courage and vulnerabilities of those who have to face this disease. It consists of photos of people with Parkinson’s disease and their care professionals, both of their interaction and portrayed individually, interwoven with fragments of their dialogue about meaningful care. This book is an integral part of a research project at Radboud university medical center into person-centred care. With it, we hope to contribute to a positive, hopeful vision of ever-improving Parkinson’s care

Development and pilot of an internationally standardized measure of cardiovascular risk management in European primary care

Contains fulltext : 97806.pdf (publisher's version ) (Open Access)BACKGROUND: Primary care can play an important role in providing cardiovascular risk management in patients with established Cardiovascular Diseases (CVD), patients with a known high risk of developing CVD, and potentially for individuals with a low risk of developing CVD, but who have unhealthy lifestyles. To describe and compare cardiovascular risk management, internationally valid quality indicators and standardized measures are needed. As part of a large project in 9 European countries (EPA-Cardio), we have developed and tested a set of standardized measures, linked to previously developed quality indicators. METHODS: A structured stepwise procedure was followed to develop measures. First, the research team allocated 106 validated quality indicators to one of the three target populations (established CVD, at high risk, at low risk) and to different data-collection methods (data abstraction from the medical records, a patient survey, an interview with lead practice GP/a practice survey). Secondly, we selected a number of other validated measures to enrich the assessment. A pilot study was performed to test the feasibility. Finally, we revised the measures based on the findings. RESULTS: The EPA-Cardio measures consisted of abstraction forms from the medical-records data of established Coronary Heart Disease (CHD)-patients--and high-risk groups, a patient questionnaire for each of the 3 groups, an interview questionnaire for the lead GP and a questionnaire for practice teams. The measures were feasible and accepted by general practices from different countries. CONCLUSIONS: An internationally standardized measure of cardiovascular risk management, linked to validated quality indicators and tested for feasibility in general practice, is now available. Careful development and pilot testing of the measures are crucial in international studies of quality of healthcare