March 27, 2012

Abstracts
Grants & Awards
Publications
News
Resources

Congratulations to Sandy Cobban who successfully defended her PhD dissertation: Improving Oral care for Elderly Residents of Long Term Care Facilities.

Abstracts
New Article by Lars Wallin A modest start, but a steady rise in research use: a longitudinal study of nurses during the first five years in professional life.
Wallin L, Gustavsson P, Ehrenberg A, Rudman A.
Implementation science : IS 2012 Mar 19;7(1):19

Newly graduated nurses are faced with a challenging work environment that may impede their ability to provide evidence-based practice. However, little is known about the trajectory of registered nurses’ use of research during the first years of professional life. Thus, the aim of the current study was to prospectively examine the extent of nurses’ use of research during the first five years after undergraduate education and specifically assess changes over time. METHOD: Survey data from a prospective cohort of 1,501 Swedish newly graduated nurses within the national LANE study (Longitudinal Analyses of Nursing Education and Entry in Worklife) were used to investigate perceived use of research over the first five years as a nurse. The dependent variables consisted of three single items assessing instrumental, conceptual, and persuasive research use, where the nurses rated their use on a five-point scale, from ‘never’ (1) to ‘on almost every shift’ (5). These data were collected annually and analyzed both descriptively and by longitudinal growth curve analysis. RESULTS: Instrumental use of research was most frequently reported, closely followed by conceptual use, with persuasive use occurring to a considerably lower extent. The development over time showed a substantial general upward trend, which was most apparent for conceptual use, increasing from a mean of 2.6 at year one to 3.6 at year five (unstandardized slope +0.25). However, the descriptive findings indicated that the increase started only after the second year. Instrumental use had a year one mean of 2.8 and a year five mean of 3.5 (unstandardized slope +0.19), and persuasive use showed a year one mean of 1.7 and a year five mean of 2.0 (unstandardized slope +0.09). CONCLUSION: There was a clear trend of increasing research use by nurses during their first five years of practice. The level of the initial ratings also indicated the level of research use in subsequent years. However, it took more than two years of professional development before this increase ‘kicked in.’ These findings support previous research claiming that newly graduated nurses go through a ‘transition shock,’ reducing their ability to use research findings in clinical work.

Another New Article by Lars Wallin Educational support for research utilization and capability beliefs regarding evidence-based practice skills: a national survey of senior nursing students.
Florin J, Ehrenberg A, Wallin L, Gustavsson P.
Journal of advanced nursing 2012 Apr;68(4):888-897

The aim of the study was to investigate Swedish university nursing students’ experience of educational support for research utilization and capability beliefs regarding evidence-based practice skills. Background.  Nursing programmes are offered at 26 universities in Sweden and even though there are common regulations for nursing education at the national level, substantial variations are found in local curricula. Little is known about students’ capability beliefs regarding evidence-based practice skills, particularly in comparison across universities. Methods.  A cross-sectional survey design using self-administered postal questionnaires was conducted in 2006. A total of 1440 students (from 26 different universities) participated, constituting 68% of the national population of nursing students in their 6th and final semester. Results.  Campus education supported the students to a greater extent than clinical education in following the development of knowledge in an area of interest, using research findings, and acquiring knowledge on how to pursue changes in clinical practice. Perceived support during campus education varied between universities. Students reported high capability beliefs regarding evidence-based practice skills, but large differences were found between universities for: stating a searchable question, seeking out relevant knowledge and critically appraising and compiling best knowledge. Conclusion.  The identified differences between universities concerning the students’ perceived support for research utilization and their capability beliefs regarding evidence-based practice skills have implications for curricula, pedagogical perspectives in nursing education and the potential to implement evidence-based practice in healthcare settings. Further studies are warranted to investigate students’ individual characteristics and organizational characteristics as determinants of research utilization support and capability beliefs regarding evidence-based practice skills.

Call for Abstracts CIHI: Health Data Users Conference 2012 — Making Connections: Data, People, Technology
Sept 10-11, 2012 Ottawa, ON Deadline midnight April 16, 2012

They are looking for abstracts for poster or oral presentations that will help health care researchers, planners and decision-makers access timely information across organizations and sectors of care.
Abstracts may include but are not limited to the following:

  • insightful interpretations of data
  • new methodologies or modes of delivery and applications of information
  • descriptions of methods that successfully connect people, organizations and data to facilitate decision-making

Grants & Awards
CIHR Age+ Prize 2012-13
Deadline May 1, 2012

The CIHR-Institute of Aging Age+ Prize recognizes excellence in research on aging carried out by emerging Canadian scholars. Up to 15 awards are offered annually to meritorious authors of published, scientific articles on aging. The Age+ Prize is aimed at graduate students, postdoctoral fellows and residents from all disciplines, working in the field of aging. Articles may cover any of the Institute’s priority research topics.

Publications

KT
Health Care Administration and Organization
Health Care Innovation and Quality Assurance
Organizational Change
Research Methodology
Health Care in Canada
Aging

KT
Knowledge sharing in the Dubai Police Force
Seba I, Rowley J, Delbridge R.
Journal of Knowledge Management 2012;16(1):114-128

Purpose: This study aims to contribute to understanding of knowledge management and sharing in the public sector in the Middle East through a case study based investigation of knowledge management initiatives and associated challenges and barriers. Design/methodology/approach: Semi-structured interviews were conducted with 15 police officers of different rank and position. Questions focused on knowledge management strategies and approaches to encouraging employees to exchange and share knowledge, and difficulties associated with encouraging officers to share knowledge. Interviews were either recorded and transcripts created, or notes were taken. A three-stage thematic analysis of the interview transcripts was undertaken. Findings: The Dubai Police Force has made a strategic commitment to the development of knowledge management to enhance performance. It established a Skills Investment Programme in 2003, a Knowledge Management Department in 2005, and more recently, in 2009, a Curriculum Department. However, the evidence from interviews suggests that the force has yet to succeed in embedding a knowledge culture. Four key factors were identified repeatedly as potential barriers to knowledge sharing: organizational structure, leadership, time allocation, and trust. Originality/value: This article demonstrates the importance of leadership, time allocation, and trust in promoting a knowledge culture and encouraging knowledge sharing. In Arab cultures, leadership and trust, and associated rewards such as respect have a particular role to play. © Emerald Group Publishing Limited.

Aspects affecting occupational therapists’ reasoning when implementing research-based evidence in stroke rehabilitation.
Kristensen HK, Borg T, Hounsgaard L.
Scandinavian journal of occupational therapy 2012 Mar;19(2):118-131

Background: When implementing evidence-based practice in occupational therapy the investigation of clinical reasoning provides important information on research utilization. Aim: This study investigates aspects affecting occupational therapists’ reasoning when implementing research-based evidence within stroke rehabilitation. Methods: The study was based on a phenomenological hermeneutical and an action research approach in collaboration with three occupational therapy settings including 25 occupational therapists. Data collection consisted of 41 field observations, 14 individual interviews, and six focus-group interviews. Results: New knowledge concerning the substantial influence of professional values in the occupational therapists’ local cultures was indicated. It was of importance that the therapists as a group are given the opportunity to explicit and critically appraise values and knowledge use in order to develop their practice knowledge and new skills. Moreover personal values and clinical experiences influenced clinical reasoning. Current knowledge of the importance of local cultures and leadership was reinforced. Conclusion: The influence of professional values in the occupational therapists’ local cultures was a substantial factor in the implementation processes. In addition personal values and clinical experiences influenced professional decision-making. Furthermore, the study reinforced current knowledge of the importance of culture and leadership in implementation of research-based clinical guidelines.

The use of tacit and explicit knowledge in public health: a qualitative study.
Kothari A, Rudman D, Dobbins M, Rouse M, Sibbald S, Edwards N.
Implementation science : IS 2012 Mar 20;7(1):20

Planning a public health initiative is both a science and an art. Public health practitioners work in a complex, often time-constrained environment, where formal research literature can be unavailable or uncertain. Consequently, public health practitioners often draw upon other forms of knowledge. METHODS: Through use of one-on-one interviews and focus groups, we aimed to gain a better understanding of how tacit knowledge is used to inform program initiatives in public health. This study was designed as a narrative inquiry, which is based on the assumption that we make sense of the world by telling stories. Four public health units were purposively selected for maximum variation, based on geography and academic affiliation. RESULTS: Analysis revealed different ways in which tacit knowledge was used to plan the public health program or initiative, including discovering the opportunity, bringing a team together, and working out program details (such as partnering, funding). CONCLUSIONS: The findings of this study demonstrate that tacit knowledge is drawn upon, and embedded within, various stages of the process of program planning in public health. The results will be useful in guiding the development of future knowledge translation strategies for public health organizations and decision makers.

Making sense of evidence in management decisions: the role of research-based knowledge on innovation adoption and implementation in healthcare. Study protocol.
Kyratsis Y, Ahmad R, Holmes AH.
Implementation science : IS 2012 Mar 21;7(1):22

We know that patient care can be improved by implementing evidence-based innovations and applying research findings linked to good practice. Successfully implementing innovations in complex organisations, such as the UK’s National Health Service (NHS), is often challenging as multiple contextual dynamics mediate the process. Research studies have explored the challenges of introducing innovations into healthcare settings and have contributed to a better understanding of why potentially useful innovations are not always implemented in practice, even if backed by strong evidence. Mediating factors include health policy and health system influences, organisational factors, and individual and professional attitudes, including decision makers’ perceptions of innovation evidence. There has been limited research on how different forms of evidence are accessed and utilised by organisational decision makers during innovation adoption. We also know little about how diverse healthcare professionals (clinicians, administrators) make sense of evidence and how this collective sensemaking mediates the uptake of innovations. METHODS: The study will involve nine comparative-case study sites of acute care organisations grouped into three regional clusters across England. Each of the purposefully selected sites represents a variety of trust types and organisational contexts. We will use qualitative methods, in-depth interviews, observation of key meetings, and systematic analysis of relevant secondary data to understand the rationale and challenges involved in sourcing and utilising innovation evidence in the empirical setting of infection prevention and control. We will use theories of innovation adoption and sensemaking in organisations to interpret the data. The research will provide lessons for the uptake and continuous use of innovations in the English and international health systems. DISCUSSION: Unlike most innovation studies, which involve single-level analysis, our study will explore the innovation-adoption process at multiple embedded levels: micro (individual), meso (organisational), and macro (interorganisational). By comparing and contrasting across the nine sites, each with different organisational contexts, local networks, leadership styles, and different innovations considered for adoption, the findings of the study will have wide relevance. The research will produce actionable findings responding to the political and economic need for healthcare organisations to be innovation-ready.

Guidance for Evidence-Informed Policies about Health Systems: Assessing How Much Confidence to Place in the Research Evidence
Lewin S, Bosch-Capblanch X, Oliver S, Akl EA, Vist GE, Lavis JN, et al.
PLoS Med 2012 03/20;9(3):e1001187

Summary Points

  • Assessing how much confidence to place in different types of research evidence is key to informing judgements regarding policy options to address health systems problems.
  • Systematic and transparent approaches to such assessments are particularly important given the complexity of many health systems interventions.
  • Useful tools are available to assess how much confidence to place in the different types of research evidence needed to support different steps in the policy-making process; those for assessing evidence of effectiveness are most developed.
  • Tools need to be developed to assist judgements regarding evidence from systematic reviews on other key factors such as the acceptability of policy options to stakeholders, implementation feasibility, and equity.
  • Research is also needed on ways to develop, structure, and present policy options within global health systems guidance.

Health Care Administration & Organization
Frequency of nurse-physician collaborative behaviors in an acute care hospital.
Nair DM, Fitzpatrick JJ, McNulty R, Click ER, Glembocki MM.
Journal of interprofessional care 2012 Mar;26(2):115-120

A new culture bolstering collaborative behavior among nurses and physicians is needed to merge the unique strengths of both professions into opportunities to improve patient outcomes. To meet this challenge it is fundamental to comprehend the current uses of collaborative behaviors among nurses and physicians. The purpose of this descriptive study was to delineate frequently used from infrequently used collaborative behaviors of nurses and physicians in order to generate data to support specific interventions for improving collaborative behavior. The setting was an acute care hospital, and participants included 114 registered nurses and 33 physicians with active privileges. The Nurse-Physician Collaboration Scale was used to measure the frequency of use of nurse-physician collaborative behaviors self-reported by nurses and physicians. The background variables of gender, age, education, ethnicity, years of experience, years practiced at the current acute care hospital, practice setting and professional certification were accessed. In addition to analyzing the frequency of collaborative behaviors, this study compares levels of collaborative behavior reported by nurses and physicians.

A seven country comparison of nurses’ perceptions of their professional practice environment.
Papastavrou E, Efstathiou G, Acaroglu R, DA Luz MD, Berg A, Idvall E, et al.
Journal of nursing management 2011 Sep 8

Aims  To describe and compare nurses’ perceptions of their professional practice environment in seven countries. Background  There is evidence of variation in the nursing professional practice environments internationally. These different work environments affect nurses’ ability to perform and are linked to differing nurse and patient outcomes. Methods  A descriptive, comparative survey was used to collect data from orthopaedic and trauma nurses (n = 1156) in Finland, Cyprus, Greece, Portugal, Sweden, Turkey and Kansas, USA using the 39-item Revised Professional Practice Environment instrument. Results  Differences were found between participants from the northern countries of Europe, Kansas, USA, and the Mediterranean countries regarding perceptions about control over practice. No between-country differences were reported in the internal work motivation among the nurses from any of the participating countries. Conclusions  Although between-country differences in nurses’ professional practice environment were found, difficulties related to demographic, cultural and health system differences and the way in which nursing is defined in each country need to be considered in the interpretation of the results. Implications for Nursing Management  The results support investment to improve nurse’s work environment, which is important for improving the quality of patient care, optimizing patient outcomes and developing the nursing workforce.

Registered nurse job satisfaction and satisfaction with the professional practice model.
McGlynn K, Griffin MQ, Donahue M, Fitzpatrick JJ.
Journal of nursing management 2012 Mar;20(2):260-265

This paper describes the initial assessment of job satisfaction and satisfaction with the professional practice environment of registered nurses working on units where a professional practice model was implemented and the relationship between these two variables. Background  The nursing shortage has been linked to overall job satisfaction and specifically to nurses’ satisfaction with the professional practice environment. Initiatives to increase retention and recruitment and decrease turnover have been linked to work satisfaction among nurses. Methods  A descriptive, cross-sectional design was used with participants (N = 101) from four patient care units; this represented a 55% response rate. Results  The nurses were moderately satisfied with the professional practice environment but had overall low job satisfaction. There was a significant negative relationship between overall work satisfaction and satisfaction with the professional practice environment (P < 0.0001). Conclusions  The introduction of the professional practice model may have raised awareness of the components of job satisfaction that were not being met. Thus, the nurses may have become more knowledgeable about the potential needs in these areas. Implications for nursing management  Nurse managers and leaders must recognize that job satisfaction consists of many dimensions, and each of these dimensions is important to nurse retention. Implementation of a professional practice model may heighten awareness of the missing components within a practice environment and lead to decreased overall satisfaction. A broader understanding of characteristics associated with increased satisfaction may aid in development of organizational change necessary to retain and attract nurses.

Health Care Innovation & Quality Assurance
Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact.
Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C.
Medical care 2012 Mar;50(3):217-226

OBJECTIVES: This study proposes methods for blending design components of clinical effectiveness and implementation research. Such blending can provide benefits over pursuing these lines of research independently; for example, more rapid translational gains, more effective implementation strategies, and more useful information for decision makers. This study proposes a “hybrid effectiveness-implementation” typology, describes a rationale for their use, outlines the design decisions that must be faced, and provides several real-world examples. RESULTS: An effectiveness-implementation hybrid design is one that takes a dual focus a priori in assessing clinical effectiveness and implementation. We propose 3 hybrid types: (1) testing effects of a clinical intervention on relevant outcomes while observing and gathering information on implementation; (2) dual testing of clinical and implementation interventions/strategies; and (3) testing of an implementation strategy while observing and gathering information on the clinical intervention’s impact on relevant outcomes. CONCLUSIONS: The hybrid typology proposed herein must be considered a construct still in evolution. Although traditional clinical effectiveness and implementation trials are likely to remain the most common approach to moving a clinical intervention through from efficacy research to public health impact, judicious use of the proposed hybrid designs could speed the translation of research findings into routine practice.

Methods for the guideline-based development of quality indicators–a systematic review.
Kotter T, Blozik E, Scherer M.
Implementation science : IS 2012 Mar 21;7(1):21

Quality indicators (QIs) are used in many healthcare settings to measure, compare, and improve quality of care. For the efficient development of high-quality QIs, rigorous, approved, and evidence-based development methods are needed. Clinical practice guidelines are a suitable source to derive QIs from, but no gold standard for guideline-based QI development exists. This review aims to identify, describe, and compare methodological approaches to guideline-based QI development. METHODS: We systematically searched medical literature databases (Medline, EMBASE, and CINAHL) and grey literature. Two researchers selected publications reporting methodological approaches to guideline-based QI development. In order to describe and compare methodological approaches used in these publications, we extracted detailed information on common steps of guideline-based QI development (topic selection, guideline selection, extraction of recommendations, QI selection, practice test, and implementation) to predesigned extraction tables. Results and Discussion From 8,697 hits in the database search and several grey literature documents, we selected 48 relevant references. The studies were of heterogeneous type and quality. We found no randomized controlled trial or other studies comparing the ability of different methodological approaches to guideline-based development to generate high-quality QIs. The relevant publications featured a wide variety of methodological approaches to guideline-based QI development, especially regarding guideline selection and extraction of recommendations. Only a few studies reported patient involvement. CONCLUSION: Further research is needed to determine which elements of the methodological approaches identified, described, and compared in this review are best suited to constitute a gold standard for guideline-based QI development. For this research, we provide a comprehensive groundwork.

Does public disclosure of quality indicators influence hospitals’ inclination to enhance results?
Smolders KH, Den Ouden AL, Nugteren WA, Van Der Wal G.
International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua 2012 Apr;24(2):129-134

The national guideline on oesophageal carcinoma’s recommendation of a minimum number of 10 resections per year and the intervention of the Dutch Health Care Inspectorate have highlighted hospitals’ ‘need to score’ on the public quality indicator for the annual number of oesophageal resections. To determine whether low-volume hospitals are inclined to adjust their numbers, we studied the difference between the reported and actual numbers of oesophageal resections in 2005 and 2006. DESIGN: A retrospective cohort study. Hospitals were asked to submit all operative reports on resections from 2005 to 2006. Two pairs of evaluators independently labelled all anonymous operative reports from the selected hospitals as resection or non-resection. SETTING: Hospitals in the Netherlands. PARTICIPANTS: Ten hospitals that reported 10 or 11 resections in 2006, or an average of fewer than 10 resections per year in the period 2003-2006. INTERVENTIONS: None. Main outcome measure(s) Difference between the reported and actual numbers of oesophageal resections in 2005 and 2006. RESULTS: Oesophageal resection criteria were not met in 7% of the 179 operative reports from the 10 selected hospitals. The difference between the reported and actual numbers of resections in 2005 was not significant, while in 2006 it was. Of the hospitals studied, 70% actually performed fewer resections than they reported. CONCLUSION: Our results support the assumption that low-volume hospitals are inclined to adjust their numbers when, because outcomes are public, pressure to report a sufficient number is high. So, external verification of data is essential when this ‘need to score’ is high.

The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.
Wiltsey Stirman S, Kimberly J, Cook N, Calloway A, Castro F, Charns M.
Implementation science : IS 2012 Mar 14;7(1):17

The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research. METHODS: Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized. RESULTS: Although “sustainability” was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves. CONCLUSIONS: Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.

Organizational Change
Organizational factors associated with screening for military sexual trauma.
Hyun JK, Kimerling R, Cronkite RC, McCutcheon S, Frayne SM.
Women’s health issues : official publication of the Jacobs Institute of Women’s Health 2012 Mar;22(2):e209-15

This exploratory study investigated organizational factors associated with receipt of military sexual trauma (MST) screening during an early timeframe of the Veterans Health Administration’s (VHA) implementation of the universal MST screening policy. METHODS: The sample consisted of all VHA patients eligible for MST screening in fiscal year 2005 at 119 VHA facilities. Analyses were conducted separately by gender and by user status (i.e., new patients to the VHA health care system in FY 2005 and continuing users who had previously used the VHA health care system in the past year). Multivariate generalized estimating equations were used to assess the effects of facility-level characteristics and adjusted for person-level covariates. RESULTS: Facility-level mandatory universal MST screening policies were associated with increased odds of receiving MST screening among new female patients and both continuing and new male patients: Odds ratio (OR), 2.87 (95% confidence interval [CI], 1.39-5.89) for new female patients; OR, 8.15 (95% CI, 2.93-22.69) for continuing male patients; and OR, 4.48 (95% CI, 1.79-11.20) for new male patients. Facility-level audit and feedback practices was associated with increased odds of receiving MST screening among new patients: OR, 1.91 (95% CI, 1.26-2.91) for females and OR, 1.86 (95% CI, 1.22-2.84) for males. Although the facility-level effect for women’s health clinic (WHC) did not emerge as significant, patient-level effects indicated that among these facilities, women who used a WHC had greater odds of being screened for MST compared with women who had not used a WHC: OR, 1.79 (95% CI, 1.18-2.71) for continuing patients and OR, 2.20 (95% CI, 1.59-3.04) for new patients. CONCLUSION: This study showed that facility policies that promote universal MST screening, as well as audit and feedback practices at the facility, significantly improved the odds of patients receiving MST screening. Women veterans’ utilization of a WHC was associated with higher odds of receiving MST screening. This study provides empirical support for the use of policies and audit and feedback practices which the VHA has used since the implementation of the MST screening directive to encourage compliance with VHA’s MST screening policy and is likely associated with the present-day success in MST screening across all VHA facilities.

Improving health service delivery organisational performance in health systems: A taxonomy of strategy areas and conceptual framework for strategy selection
Pallas SW, Curry L, Bashyal C, Berman P, Bradley EH.
International Health 2012;4(1):20-29

Health systems strengthening (HSS) is a priority for global health funders, policy-makers and practitioners. Although many HSS efforts have focused on policy levers such as financing approaches, payment schemes or regulatory reforms, less attention has been directed to targeting the organisations that deliver health services such as hospitals, health centres and clinics. Evidence suggests that the impact of organisation-level interventions varies by context; however, we lack a general framework for integrating organisational context into performance improvement strategies for health service delivery organisations. Drawing on open systems theories from organisational behaviour and management as well as a review of 181 empirical studies of health service delivery organisations in low- and middle-income countries, we propose a taxonomy of seven strategy areas for improving organisational performance as well as a multistage conceptual framework for selecting among them. We propose that the choice of strategy for improving health service delivery organisational performance should be informed by: (i) the root cause of the organisation’s performance gap; (ii) the environmental conditions facing the organisation; and (iii) the implementation capability of the organisation. We also highlight conditions under which different strategy areas may be expected to be optimally effective. The approaches presented in this paper offer a way for health system decision-makers and researchers to systematically assess and incorporate organisational context in the process of developing strategies to improve the performance of health service delivery organisations and, ultimately, of health systems. © 2011 Royal Society of Tropical Medicine and Hygiene.

Assessing trauma-informed care readiness in behavioral health: An organizational case study
Farro SA, Clark C, Hopkins Eyles C.
Journal of Dual Diagnosis 2011;7(4):228-241

Objective: In this organizational case study the authors pilot a new protocol for evaluating and developing trauma-informed care in behavioral health settings. Methods: A mixed methods design was used to collect data with three instruments: the Adverse Childhood Experiences, the Consumer Perceptions of Care, and the Community Readiness Model key informant interview. Adults (N = 138) in a behavioral health residential treatment program provided a consumer perspective on trauma and integrated services. Providing the staff perspective, key informant interviews of staff (N = 7) were conducted and the overall protocol’s utility was assessed. Results: Results indicate the protocol is an efficient, strength-based, and culturally sensitive assessment approach that provided valuable data about the agency’s prevalence of consumer trauma, level of integrated trauma-informed services, and readiness to advance a trauma-informed organizational culture. The piloted protocol also fostered understanding of trauma-informed care principles among staff and improved awareness of how to enhance the level of trauma-informed services at their agency. Conclusions: In addition to providing assessment data, the protocol helped agency staff and leadership to fully engage and mobilize toward change. Further application of this tool and future research are discussed. © 2011 Copyright Taylor and Francis Group, LLC.

Research Methodology
AHRQ: Validity and Inter-rater Reliability Testing of Quality Assessment Instruments
March 2012

Background: Numerous tools exist to assess methodological quality, or risk of bias in systematic reviews; however, few have undergone extensive reliability or validity testing. Objectives: (1) assess the reliability of the Cochrane Risk of Bias (ROB) tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies between individual raters, and between consensus agreements of individual raters for the ROB tool; (2) assess the validity of the Cochrane ROB tool and NOS by examining the association between study quality and treatment effect size (ES); (3) examine the impact of study-level factors on reliability and validity. Methods: Two reviewers independently assessed risk of bias for 154 RCTs. For a subset of 30 RCTs, two reviewers from each of four Evidence-based Practice Centers assessed risk of bias and reached consensus. Inter-rater agreement was assessed using kappa statistics. We assessed the association between ES and risk of bias using meta-regression. We examined the impact of study-level factors on the association between risk of bias and ES using subgroup analyses. Two reviewers independently applied the NOS to 131 cohort studies from 8 meta-analyses. Inter-rater agreement was calculated using kappa statistics. Within each meta-analysis, we generated a ratio of pooled estimates for each quality domain. The ratios were combined to give an overall estimate of differences in effect estimates with inverse-variance weighting and a random effects model. Results: Inter-rater reliability between two reviewers was considered fair for most domains (κ ranging from 0.24 to 0.37), except for sequence generation (κ=0.79, substantial). Inter-rater reliability of consensus assessments across four reviewer pairs was moderate for sequence generation (κ=0.60), fair for allocation concealment and “other sources of bias” (κ=0.37, 0.27), and slight for the remaining domains (κ ranging from 0.05 to 0.09). Inter-rater variability was influenced by study-level factors including nature of outcome, nature of intervention, study design, trial hypothesis, and funding source. Inter-rater variability resulted more often from different interpretation of the tool rather than different information identified in the study reports. No statistically significant differences were found in ES when comparing studies categorized as high, unclear or low risk of bias. Inter-rater reliability of the NOS varied from substantial for length of followup to poor for selection of non-exposed cohort and demonstration that the outcome was not present at outset of study. We found no association between individual NOS items or overall NOS score and effect estimates. Conclusion: More specific guidance is needed to apply risk of bias/quality tools. Study-level factors that were shown to influence agreement provide direction for detailed guidance. Low agreement across pairs of reviewers has implications for incorporation of risk of bias into results and grading the strength of evidence. Variable agreement for the NOS, and lack of evidence that it discriminates studies that may provide biased results, underscores the need for more detailed guidance to apply the tool in systematic reviews.

Telephone follow-up to a mail survey: when to offer an interview compared to a reminder call.
Ziegenfuss JY, Burmeister KR, Harris A, Holubar SD, Beebe TJ.
BMC medical research methodology 2012 Mar 20;12(1):32

BACKGROUND: Using a different mode of contact on the final follow-up to survey non-respondents is an identified strategy to increase response rates. This study was designed to determine if a reminder phone call or a phone interview as a final mode of contact to a mailed survey works better to increase response rates and which strategy is more cost effective. METHODS: A randomized study was embedded within a survey study of individuals treated with ulcerative colitis conducted in March 2009 in Olmsted County, Minnesota. After two mail contacts, non-respondents were randomly assigned to either a reminder telephone call or a telephone interview. Average cost per completed interview and response rates were compared between the two experimental conditions. RESULTS: The response rate in the reminder group and the interview did not differ where we considered both a completed survey and a signed form a complete (24% vs. 29%, p=0.08). However, if such a signed form was not required, there was a substantial advantage to completing the interview over the phone (24% vs. 43%, p<0.0001). The reminder group on average cost $27.00 per completed survey, while the interview group on average cost $53.00 per completed survey when a signed form was required and $36.00 per complete when a signed form was not required. CONCLUSIONS: The additional cost of completing an interview is worth it when an additional signed form is not required of the respondent. However, when such a signed form is required, offering an interview instead of a reminder phone call as a follow up to non-respondents does not increase response rates enough to outweigh the additional costs.

Ongoing monitoring of data clustering in multicenter studies.
Guthrie LB, Oken E, Sterne JA, Gillman MW, Patel R, Vilchuck K, et al.
BMC medical research methodology 2012 Mar 13;12(1):29

Multicenter study designs have several advantages, but the possibility of non-random measurement error resulting from procedural differences between the centers is a special concern. While it is possible to address and correct for some measurement error through statistical analysis, proactive data monitoring is essential to ensure high-quality data collection. METHODS: In this article, we describe quality assurance efforts aimed at reducing the effect of measurement error in a recent follow-up of a large cluster-randomized controlled trial through periodic evaluation of intraclass correlation coefficients (ICCs) for continuous measurements. An ICC of 0 indicates the variance in the data is not due to variation between the centers, and thus the data are not clustered by center. RESULTS: Through our review of early data downloads, we identified several outcomes (including sitting height, waist circumference, and systolic blood pressure) with higher than expected ICC values. Further investigation revealed variations in the procedures used by pediatricians to measure these outcomes. We addressed these procedural inconsistencies through written clarification of the protocol and refresher training workshops with the pediatricians. Further data monitoring at subsequent downloads showed that these efforts had a beneficial effect on data quality (sitting height ICC decreased from 0.92 to 0.03, waist circumference from 0.10 to 0.07, and systolic blood pressure from 0.16 to 0.12). CONCLUSIONS: We describe a simple but formal mechanism for identifying ongoing problems during data collection. The calculation of the ICC can easily be programmed and the mechanism has wide applicability, not just to cluster randomized controlled trials but to any study with multiple centers or with multiple observers.

Health Care in Canada
Bundles: An opportunity to align incentives for continuing care in Canada?
Sutherland JM, Hellsten E, Yu K.
Health policy (Amsterdam, Netherlands) 2012 Mar 2

Over the past three decades, diagnosis related groups (DRG) have revolutionized hospital funding by successfully focusing hospitals attention on the ‘production’ process. However, using DRG for funding acute hospitals does little to create incentives outside of the hospital, or coordinate health care across providers and settings. With many health care quality and efficiency issues stemming from failures at the ‘seams’ in the system, there is increasing interest in creating new ‘bundles’ of care which includes acute and post-acute care services that align economic incentives for care coordination. Analysis of Ontario (Canada) datasets demonstrates that linking existing sources of clinical, administrative and cost data to create ‘bundles’ is technically feasible. However, key implementation challenges need to be addressed, such as administrative and contractual arrangements across multiple provider organizations, pricing and relations with physicians. Nonetheless, this analysis of Ontario data demonstrates that bundles provide an alternative policy option to DRG’s in Canada’s move toward activity-based funding. © 2012 Elsevier Ireland Ltd. All rights reserved.

ICES-MNO Reports on Chronic Diseases: Diabetes, Cancer, Cardiovascular Disease & Respiratory Disease
ICES & MNO, March 2012

The Métis Nation of Ontario (MNO) Healing and Wellness Branch’s Chronic Disease Surveillance Project (CDSP) is a groundbreaking health surveillance initiative focused on gathering Métis specific data on health and health care. Part of this project includes population based studies to determine the rate of chronic disease in Métis people in Ontario as well as outcomes from healthcare. These studies are achieved in partnership with the Institute for Clinical Evaluative Sciences (ICES). The findings will be useful in allowing the MNO to determine the health priorities of Métis people in Ontario as well as to develop and deliver health programs tailored to their specific needs.

CIHI: Wait Times in Canada – A Summary, 2012
2012

In 2004, Canada’s first ministers agreed to reduce wait times in five priority areas: cancer treatment, cardiac care, diagnostic imaging, joint replacement and sight restoration. They also agreed to work towards meeting evidence-based benchmarks–or targets–for medically acceptable waits, which were established in late 2005 for some priority procedures. CIHI was mandated to collect wait times information and monitor provincial progress in meeting benchmarks. Wait Times in Canada–A Summary, 2012 is CIHI’s seventh annual report in this series and is accompanied by a new graphic display of wait time data across Canada.

Aging
Maximizing caring relationships between nursing assistants and patients: care partners.
Prestia A, Dyess S.
The Journal of nursing administration 2012 Mar;42(3):144-147

Certified nursing assistants (CNAs) are an integral part of the care team in most hospitals. The chief nursing officer at a community hospital in Florida developed a program of communication, education, and accountability to highlight the role of the CNA as a team member. This easy-to-implement initiative resulted in increased understanding about the CNA role in delivering high-quality patient care and increases in patient satisfaction with responsiveness of staff to call lights.

Fidelity and moderating factors in complex interventions: A case study of a continuum of care program for frail elderly people in health and social care.
Hasson H, Blomberg S, Duner A.
Implementation science : IS 2012 Mar 22;7(1):23

Prior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people. METHODS: The intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity. RESULTS: A total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity. DISCUSSION: The Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time. Trial registration ClinicalTrials.gov, NCT01260493.

Hospital Transfers of Nursing Home Residents with Advanced Dementia.
Givens JL, Selby K, Goldfeld KS, Mitchell SL.
Journal of the American Geriatrics Society 2012 Mar 16

OBJECTIVES: To describe diagnoses and factors associated with hospital transfer in nursing home (NH) residents with advanced dementia.
DESIGN: Prospective cohort study. SETTING: Twenty-two Boston, Massachusetts-area NHs. PARTICIPANTS: Three hundred twenty-three NH residents with advanced dementia. MEASUREMENTS: Data were collected quarterly for up to 18 months. Data regarding transfers were collected with regard to hospitalization or emergency department (ED) visit, diagnosis, and duration of inpatient admission. Information on the occurrence of any acute medical event (pneumonia, febrile episode, or other acute illness) in the prior 90 days was obtained quarterly. Logistic regression conducted at the level of the acute medical event identified characteristics associated with hospital transfer. RESULTS: The entire cohort experienced 74 hospitalizations and 60 ED visits. Suspected infections were the most common reason for hospitalization (44, 59%), most frequently attributable to a respiratory source (30, 41%). Feeding tube-related complications accounted for 47% of ED visits. In adjusted analysis conducted on acute medical events, younger resident age, event type (pneumonia or other event vs febrile episode), chronic obstructive pulmonary disease, and the lack of a do-not-hospitalize (DNH) order (adjusted odds ratio = 5.22, 95% confidence interval = 2.31-11.79) were associated with hospital transfer. CONCLUSION: The majority of hospitalizations of NH residents with advanced dementia were due to infections and thus were potentially avoidable, because infections are often treatable in the NH. Feeding tube-related complications accounted for almost half of all ED visits, representing a common but underrecognized burden of this intervention. Advance care planning in the form of a DNH order was the only identified modifiable factor associated with avoiding hospitalization. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

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