Implementing a Satisfying APP-led BMT Survivorship Clinic: Outcome Analysis and Leadership Theory Intervention

Abstract

With a projected half a million blood and marrow transplant (BMT) survivors in the United States by 2030 (Battiwalla, Tichelli, & Majhail, 2017) transplant centers are challenged with increased demands for improved patient access to high quality long-term follow-up care (Skendzel, 2016). This unique group of survivors has a distinct risk profile for post-treatment complications from exposure to highly toxic levels of chemotherapy and radiation (Sun et al., 2010). Additionally, lack of access to survivorship care increases the risk of poor outcomes for marginalized, high risk, and underserved groups (Bevans et al., 2017; Smith & Hall, 2015). To expand access, mitigate health disparities, and reduce morbidity (Majhail et al., 2012) amongst adult BMT recipients at the University of Minnesota, an advanced practice provider (APP)-led survivorship clinic was created and implemented. Leadership in the initiative included a nurse practitioner on the team, BMT physician, and a nurse researcher with a background in interprofessional teamwork. The purpose of this quality improvement (QI) initiative was to implement an APP-led survivorship clinic, evaluate implementation goals, and improve patient and provider outcomes following a theory-guided approach. The implementation process included 4 plan-do-study-act (PDSA; Langley et al., 2009) cycles, with outcomes evaluated in cycles 3 and 4. The project included collecting electronic survey data from both survivors (n = 22 responses) and APPs (n = 14 responses) following an interrupted QI design. Satisfaction was determined using a modified version of the validated (Sansoni, et al., 2011) Short Assessment of Patient Satisfaction (SAPS, University of Melbourne, 2011) with scores \u3e 19 considered satisfying. A modified version of the validated (Peres, Pham, & Phillips, 2013) Systems Usability Scale (SUS; Brooke, 1996) was used to measure provider perceived usability of the electronic care plan templates. Additionally, 10-point Likert scales, binary, and open-ended questions were used to assess satisfaction, patient self-management, and survivorship care plan (SCP) utility. Data analysis was conducted using descriptive statistics, reporting median scores and percentages for the most common results. For open-ended questions, qualitative analysis was used to identify themes (Skendzel, Holtan, & Finch-Guthrie, 2019). Implementation outcomes were met in all areas except APP satisfaction (n = 7, median 13, range 6-19). Patients were overall satisfied with the visit (n = 11, median SAPS 25, range 19-28). Additionally, 100% of patients were very satisfied with the effect of their care, found the SCP useful, and reported improved post-visit self-efficacy. Unfortunately, provider dissatisfaction has been associated with poor patient perceived quality of care (McHugh & Stimpfel, 2012) and adverse outcomes (Laschinger & Leiter, 2006; McHugh, Aiken, Eckenhoff, & Burns, 2016) in the literature. To improve this critical outcome, Path-Goal Theory (PGT; House, 1996) and Transformational Leadership (TFL; Bass & Reggio, 2006) were applied in a leadership intervention with the APP team. Following the intervention, APP satisfaction dramatically increased with a median SAPS of 21 (n = 7, range 14-22). Additionally, only 15% of APPs reported there was an opportunity to enhance their satisfaction and 71% were satisfied with the care they provided, compared to 68% and 29% respectively. Patient satisfaction scores remained high with a median SAPS of 22 (n = 11, range 15-28). Using theoretical frameworks to guide practice, and a multidisciplinary approach, nurse leaders can implement survivorship care that is satisfying for patients and providers. Currently, there is a gap in the literature that examines the use of theoretical frameworks for developing BMT survivorship models. Our findings provide support for future research regarding the use of PGT and TFL to guide leadership interventions during the implementation process