Exploring the use of social network analysis methods in process improvement within healthcare organizations: a scoping review.

BACKGROUND: Communication breakdowns among healthcare providers have been identified as a significant cause of preventable adverse events, including harm to patients. A large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social networks to make meaningful improvements. Process Improvement in healthcare (systematic approach of identifying, analyzing, and enhancing workflows) is needed to improve quality and patient safety. This review aimed to characterize the use of SNA methods in Process Improvement within healthcare organizations. METHODS: Relevant studies were identified through a systematic search of seven databases from inception - October 2022. No limits were placed on study design or language. The reviewers independently charted data from eligible full-text studies using a standardized data abstraction form and resolved discrepancies by consensus. The abstracted information was synthesized quantitatively and narratively. RESULTS: Upon full-text review, 38 unique articles were included. Most studies were published between 2015 and 2021 (26, 68%). Studies focused primarily on physicians and nursing staff. The majority of identified studies were descriptive and cross-sectional, with 5 studies using longitudinal experimental study designs. SNA studies in healthcare focusing on process improvement spanned three themes: Organizational structure (e.g., hierarchical structures, professional boundaries, geographical dispersion, technology limitations that impact communication and collaboration), team performance (e.g., communication patterns and information flow among providers., and influential actors (e.g., key individuals or roles within healthcare teams who serve as central connectors or influencers in communication and decision-making processes). CONCLUSIONS: SNA methods can characterize Process Improvement through mapping, quantifying, and visualizing social relations, revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety.

The Rise of Patients Declining Rectal Cancer Surgery in the Era of Total Neoadjuvant Therapy.

BACKGROUND: The treatment landscape for rectal cancer is rapidly evolving, particularly with the increasing use of neoadjuvant therapies. Still, up to 50% of patients with stage II-III disease require surgical resection post-neoadjuvant therapy to achieve the best oncologic outcomes. Many patients, however, hope to avoid surgery. This study aimed to assess trends and factors associated with declining recommended oncologic resection after systemic therapy nationally and in our institution. PATIENTS AND METHODS: This is a retrospective analysis using the National Cancer Database from 2009 to 2021 and an institutional cohort at an academic center between 2009 and 2022 including adults with stage I-III rectal adenocarcinoma who underwent neoadjuvant therapy and were suitable for surgery. RESULTS: Of 96,997 patients nationally, the rate of declining surgery increased from 2.3% in 2009 to 6.3% in 2021, a trend mirrored in our institutional cohort of 365 patients (0% in 2009/2010 to approximately 6-12% in 2021/2022). Locally, patients who declined surgery had higher rates of tobacco use, temporary loss to follow-up during therapy, and a more robust, albeit incomplete, tumor response to neoadjuvant therapy compared with controls who underwent surgery. Despite a stoma being the most cited reason for declining surgery, 30.4% of patients who declined oncologic resection died with a stoma. CONCLUSIONS: Our findings underscore a notable trend of patients declining oncologic resections following neoadjuvant therapy for rectal cancer. By shedding light on the outcomes of patients who opt against surgery, we address a critical gap in the literature essential for informing patients about potential risks.

Implementation and Qualitative Analysis of Peer Support for New Pediatric Gastrostomy Tube Families.

INTRODUCTION: Gastrostomy tube (G-tube) insertion in children has frequent complications, including dislodgment and return to the system, which are associated with emotional burden for caregivers. To address these issues, we developed a peer support program for caregivers of children with new G-tubes and aimed to explore program feasibility and acceptability. METHODS: The G-tube Buddy Program is a peer support program that pairs an experienced G-tube caregiver with new G-tube caregivers. Between April 2022 and December 2022, seven mentors and 21 mentees participated in the program. Five mentors and ten mentees participated in semi-structured focus groups and interviews. Transcripts were analyzed using both inductive and deductive qualitative methods. RESULTS: We identified five prominent domains: peer support relationship dynamics; mentor and mentee-specific factors; determinants of program success; mentor and mentee perception of the program; and suggestions for program improvement. These domains encompassed main themes: support consisted primarily of assistance with daily life and social and emotional support; texting was usually the preferred communication method; mentee satisfaction is rooted in humanness, teaching, and generation of hope; mentors participated due to positive feelings regarding helping new caregivers with financial motivation being less important; and, participants perceived the program as a valuable source of support for new caregivers that complements and expands the reach of care they receive from clinical providers. CONCLUSIONS: A peer support model for families with new G-tubes appears feasible and acceptable from participant perspectives. Responses validate the program's potential to add value to the postoperative care of children with G-tubes and will guide program optimization.

Understanding the perceived benefits, barriers, and cues to action for lung cancer screening among Latinos: A qualitative study.

Introduction: Rates of lung cancer screening among Latinos remain low. The purpose of the study was to understand the perceived benefits, barriers, and cues to action for lung cancer screening among Latinos. Methods: Participants (N=20) were recruited using community-based recruitment strategies. Eligibility criteria included: 1) self-identified as Hispanic/Latino, 2) spoke English and/or Spanish, and 3) met the USA Preventive Services Task Force eligibility criteria for lung cancer screening. Interviews were conducted in Spanish and English, audio recorded, and transcribed verbatim. Using the health belief model, a qualitative theoretical analysis was used to analyze the interviews. Results: Participants' mean age was 58.3 years old (SD=5.8), half of the participants were female, 55% had completed high school or lower educational level, and 55% reported speaking more Spanish than English. All participants were currently smoking. Fourteen participants (70%) were unaware of lung cancer screening, and eighteen (90%) did not know they were eligible for lung cancer screening. Regarding lung cancer screening, participants reported multiple perceived benefits (e.g., smoking cessation, early detection of lung cancer, increased survivorship) and barriers (e.g., fear of outcomes, cost, lung cancer screening not being recommended by their clinician). Lastly, multiple cues to actions for lung cancer screening were identified (e.g., family as a cue to action for getting screened). Conclusions: Most Latinos who were eligible for lung cancer screening were unaware of it and, when informed, they reported multiple perceived benefits, barriers, and cues to action. These factors provide concrete operational strategies to address lung cancer screening among Latinos.

Building a communication and support network among quality improvement teams in nursing homes: a longitudinal study of the SCOPE trial.

BACKGROUND: We applied a longitudinal network analysis approach to assess the formation of knowledge sharing and collaboration networks among care aide-led quality improvement (QI) teams in Canadian nursing homes participating in the Safer Care for Older Persons (in residential) Environments (SCOPE) trial which aimed to support unregulated front-line staff to lead unit-based quality improvement (QI) teams in nursing homes. We hypothesized that SCOPE's communicative and participatory nature would provide opportunities for peer support, knowledge sharing, and collaboration building among teams. METHODS: Fourteen QI teams in Alberta (AB) and seventeen QI teams in British Columbia (BC) participated in the study. Communications across nursing homes occurred through a series of 4 collaborative Learning Congresses (training sessions) over a 1-year period. The senior leaders of QI teams participated in two online network surveys about the communication/collaboration between teams in their province, 1 month after the first, and 6 months later, after the fourth Learning Congress. We developed communication and collaboration network maps pertaining to three time points: before SCOPE, at 2 months, and at 9 months. RESULTS: Over time, teams made significantly more new connections and strengthened existing ones, within and across regions. Geographic proximity and co-membership in organizational chains were important predictors of connectivity before and during SCOPE. Teams whose members were well connected at baseline disproportionately improved connectivity over time. On the other hand, teams that did not have prior opportunities to connect appeared to use SCOPE to build new ties. CONCLUSIONS: Our findings suggest the importance of network-altering activities to the formation of collaboration networks among QI teams across nursing homes. Active strategies could be used to better connect less connected teams and facilitate collaboration among geographically proximate teams. These findings may inform the development of interventions to leverage existing networks and provide new networking opportunities to develop and sustain organizational improvements.

Social Network Analysis in Undergraduate and Postgraduate Medical Education: A Scoping Review.

PURPOSE: Social network analysis (SNA) is a theoretical framework and analytical approach used to study relationships among individuals and groups. While SNA has been employed by many disciplines to understand social structures and dynamics of interpersonal relationships, little is known about its use in medical education. Mapping and synthesizing the scope of SNA in undergraduate and postgraduate medical education can inform educational practice and research. METHOD: This scoping review was based on searches conducted in Medline, Embase, Scopus, and ERIC in December 2020 and updated in March 2022. After removal of duplicates, the search strategy yielded 5,284 records, of which 153 met initial inclusion criteria. Team members conducted full-text reviews, extracted relevant data, and conducted descriptive and thematic analyses to determine how SNA has been used as a theoretical and analytical approach in undergraduate and postgraduate medical education. RESULTS: Thirty studies, from 11 countries, were retained. Most studies focused on undergraduate medical students, primarily in online environments, and explored students' friendships, information sharing, and advice seeking through SNA. Few studies included residents and attending staff. Findings suggested that SNA can be a helpful tool for monitoring students' interactions in online courses and clinical clerkships. SNA can also be used to examine the impact of social networks on achievement, the influence of social support and informal learning outside the classroom, and the role of homophily in learning. In clinical settings, SNA can help explore team dynamics and knowledge exchange among medical trainees. CONCLUSIONS: While SNA has been underutilized in undergraduate and postgraduate medical education, findings indicate that SNA can help uncover the structure and impact of social networks in the classroom and the clinical setting. SNA can also be used to help design educational experiences, monitor learning, and evaluate pedagogical interventions. Future directions for SNA research in medical education are described.

Social Dynamics of Advice-Seeking: A Network Analysis of Two Residency Programs.

Phenomenon: Residents interact with their peers and supervisors to ask for advice in response to complicated situations occurring during patient care. To provide a deeper understanding of workplace learning, this study explores the structure and dynamics of advice-seeking networks in two residency programs. Approach: We conducted a survey-based social network study. To develop the survey, we conducted focus group discussions and identified three main categories of advice: factual knowledge, clinical reasoning, and procedural skills. We invited a total of 49 emergency medicine and psychiatry residents who had completed at least six months of their training, to nominate their supervisors and peer residents, as their sources of advice, from a roster. Participants identified the number of occasions during the previous month that they turned to each person to seek advice regarding the three broad categories. We calculated the density, centrality, and reciprocity measures for each advice category at each department. Findings: The response rates were 100% (n = 21) and 85.7% (n = 24) in the emergency medicine and psychiatry departments, respectively. The advice network of emergency medicine residents was denser, less hierarchical, and less reciprocated compared to the psychiatry residents' network. In both departments, PGY-1s were the top advice-seekers, who turned to PGY-2s, PGY-3s, and supervisors for advice. The "procedural skills" network had the lowest density in both departments. There was less overlap in the sources of advice for different advice types in the psychiatry department, implying more selectivity of sources. Insights: Complex social structures and dynamics among residents vary by discipline and level of seniority. Program directors can develop tailored educational interventions informed by their departments' specific network patterns to promote a timely and effective advice-seeking culture which in turn, could lead to optimally informed patient care.

Mindful practice with medical interpreters.

Introduction: Medical interpreters experience emotional burdens from the complex demands at work. Because communication access is a social determinant of health, protecting and promoting the health of medical interpreters is critical for ensuring equitable access to care for language-minority patients. The purpose of this study was to pilot a condensed 8-h program based on Mindful Practice® in Medicine addressing the contributors to distress and psychosocial stressors faced by medical sign and spoken language interpreters. Methods: Using a single-arm embedded QUAN(qual) mixed-methods pilot study design, weekly in-person 1-h sessions for 8 weeks involved formal and informal contemplative practice, didactic delivery of the week's theme (mindfulness, noticing, teamwork, suffering, professionalism, uncertainty, compassion, and resilience), and mindful inquiry exercises (narrative medicine, appreciative interviews, and insight dialog). Quantitative well-being outcomes (mean±SEM) were gathered via survey at pre-, post-, and 1-month post-intervention time points, compared with available norms, and evaluated for differences within subjects. Voluntary feedback about the workshop series was solicited post-intervention via a free text survey item and individual exit interviews. A thematic framework was established by way of qualitative description. Results: Seventeen medical interpreters (46.2 ± 3.1 years old; 16 women/1 man; 8 White/9 Hispanic or Latino) participated. Overall scores for teamwork (p ≤ 0.027), coping (p ≤ 0.006), and resilience (p ≤ 0.045) increased from pre- to post-intervention and pre- to 1-month post-intervention. Non-judging as a mindfulness component increased from pre- to post-intervention (p = 0.014). Compassion satisfaction (p = 0.021) and burnout (p = 0.030) as components of professional quality of life demonstrated slightly delayed effects, improving from pre- to 1-month post-intervention. Themes such as workshop schedule, group size, group composition, interactivity, topics to be added or removed, and culture are related to the overarching topic areas of intervention logistics and content. Integration of the findings accentuated the positive impact of the intervention. Discussion: The results of this research demonstrate that mindful practice can serve as an effective resource for medical interpreters when coping with work-related stressors. Future iterations of the mindful practice intervention will further aspire to address linguistic and cultural diversity in the study population for broader representation and subsequent generalization.

Putting the Mix in Mixed Methods Research.

Research and quality improvement in pediatric hospital medicine often benefit from using mixed methods research (MMR) approaches. MMR requires the intentional collection, analysis, and mixing, or integration, of both quantitative and qualitative data to build on their complementary strengths to answer complex research questions. In this methodology paper, we define MMR, describe its characteristics, the importance of integration, and outline the core designs of explanatory sequential, exploratory sequential, and convergent MMR by illustrating practical examples from pediatric hospital medicine.

Utilizing the Un-Meeting model to advance innovative translational and team science.

Advances in translational science require innovative solutions, and engagement of productive transdisciplinary teams play a critical role. While various forms of scientific meetings have long provided venues for sharing scientific findings and generating new collaborations, many conferences lack opportunities for active discussions. We describe the use of an Un-Meeting to foster innovative translational science teams through engaged discussions across multidisciplinary groups addressing a shared theme. The Un-Meeting was delivered by the University of Rochester Center for Leading Innovation and Collaboration, the national coordinating center for the National Institutes of Health Clinical and Translational Science Awards (CTSA) program. This pilot CTSA program Un-Meeting focused on engaging translational scientists, policy-makers, community members, advocates, and public health professionals to address the opioid crisis. The participant-driven format leveraged lightning talks, attendee-led idea generation, and extensive breakout discussions to foster multidisciplinary networking. Results indicated participation by a broad set of attendees and a high level of networking during the meeting. These results, coupled with the growth of the Un-Meeting across the CTSA Consortium, provide practices and models to potentially advance team and translational science. While future work will further assess the impact of Un-Meetings, this format presents a promising approach to enhance translational science.

Mapping the distribution of health equity research and practice across a university: a network analysis.

Introduction: Health equity research spans various disciplines, crossing formal organizational and departmental barriers and forming invisible communities. This study aimed to map the nomination network of scholars at the University of Rochester Medical Center who were active in racial and ethnic health equity research, education, and social/administrative activities, to identify the predictors of peer recognition. Methods: We conducted a snowball survey of faculty members with experience and/or interest in racial and ethnic health equity, nominating peers with relevant expertise. Results: Data from a total of 121 individuals (64% doing research on extent and outcomes of racial/ethnic disparities and racism, 48% research on interventions, 55% education, and 50% social/administrative activities) were gathered in six rounds of survey. The overlap between expertise categories was small with coincidence observed between education and social/administrative activities (kappa: 0.27; p < 0.001). Respondents were more likely to nominate someone if both were involved in research (OR: 3.1), if both were involved in education (OR: 1.7), and if both were affiliated with the same department (OR: 3.7). Being involved in health equity research significantly predicted the centrality of an individual in the nomination network, and the most central actors were involved in multiple expertise categories. Conclusions: Compared with equity researchers, those involved in racial equity social/administrative activities were less likely to be recognized by peers as equity experts.

Experiences of Sign Language Interpreters and Perspectives of Interpreting Administrators During the COVID-19 Pandemic: A Qualitative Description.

OBJECTIVE: Interpreting during the COVID-19 pandemic caused stress and adverse mental health among sign language interpreters. The objective of this study was to summarize the pandemic-related work experiences of sign language interpreters and interpreting administrators upon transitioning from on-site to remote work. METHODS: From March through August 2021, we conducted focus groups with 22 sign language interpreters in 5 settings, 1 focus group for each setting: staff, educational, community/freelance, video remote interpreting, and video relay services. We also conducted 5 individual interviews with interpreting administrators or individuals in positions of administrative leadership in each represented setting. The 22 interpreters had a mean (SD) age of 43.4 (9.8) years, 18 were female, 17 were White, all identified as hearing, and all worked a mean (SD) of 30.6 (11.6) hours per week in remote interpreting. We asked participants about the positive and negative consequences of transitioning from on-site to remote at-home interpreting. We established a thematic framework by way of qualitative description for data analysis. RESULTS: We found considerable overlap across positive and negative consequences identified by interpreters and interpreting administrators. Positive consequences of transitioning from on-site to remote-at-home interpreting were realized across 5 overarching topic areas: organizational support, new opportunities, well-being, connections/relationships, and scheduling. Negative consequences emerged across 4 overarching topic areas: technology, financial aspects, availability of the interpreter workforce, and concerns about the occupational health of interpreters. CONCLUSIONS: The positive and negative consequences shared by interpreters and interpreting administrators provide foundational knowledge upon which to create recommendations for the anticipated sustainment of some remote interpreting practice in a manner that protects and promotes occupational health.

Developing a typology of network alteration strategies for implementation: a scoping review and iterative synthesis.

BACKGROUND: Social networks transmit knowledge, influence, and resources. These relationships among patients, professionals, and organizations can shape how innovations are disseminated, adopted, implemented, and sustained. Network alteration interventions-interventions that change or rewire social networks-have the potential to be used as implementation strategies. Yet, the types, mechanisms, and effectiveness of these interventions for implementation are unclear. This scoping review and iterative synthesis identified and described network alteration strategies that could be tested for implementation. METHODS: We used forward and backward citation tracking of influential articles on network interventions, bibliometric searches, and hand searches of peer-reviewed social network journals. At least two team members screened article titles/abstracts to identify studies that met inclusion criteria: empirical studies of an intervention, the intervention was designed to alter some element of a social network, and changes in social network metrics were measured at two or more time points. During full-text reviews, information about the network interventions, actors, ties, and main findings was extracted. Reporting was informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). To develop our typology, we synthesized these results using an iterative team-based and consensus-building process. RESULTS: Fifty-three articles met the inclusion criteria. The interventions described were conducted in healthcare systems or behavioral health systems (34%), communities (26.4%), and schools (22.6%). The majority included records describing interventions designed to alter social support, information-sharing, or friendship networks (65%) among individual actors (84.9%), or to increase ties. Eight strategies emerged. Three strategies targeted the general context: (1) change the environment, (2) create groups, and (3) change the composition. Four strategies targeted individual actors: change (4) motivations, (5) skills for networking, (6) knowledge of one's social network, and (7) prominence/roles. One strategy (8) targeted specific ties within the network (targeting a particular pair-wise relationship or changing the nature of an existing tie). CONCLUSION: The network alteration strategies in this typology provide further operational specificity for how implementation strategies target relationships. Advancing these strategies will require greater theoretical specification, the development of strategies that target professionals and organizations, and studies that examine the impact on implementation outcomes.

Addressing COVID-19 vaccine hesitancy in rural communities: A case study in engaging trusted messengers to pivot and plan.

The pandemic declaration of COVID-19 in 2020 presented unique challenges, lessons, and opportunities for public health practice in the United States. Despite clear evidence of COVID-19 vaccine effectiveness, vaccine uptake and vaccine confidence remained low in many regions. Vaccine holdouts, or those who are vaccine hesitant, have been an increasingly difficult population to reach. Several factors influence vaccine hesitancy and behavior in rural areas, including health care access challenges, misinformation, political loyalties, and concerns regarding the perceived lack of trustworthy evidence and knowledge of long-term effects. In March 2021, the Finger Lakes Rural Immunization Initiative (FLRII) engaged stakeholders to address vaccine hesitancy in a nine-county region of rural New York known as the Finger Lakes. Driven by data collected from community partners, physicians, and local health departments regarding their biggest barriers and greatest needs, the FLRII team created an interactive program for trusted messengers (TMs) including a stakeholder panel, called the Trusted Messenger Forum (TMF). The TMF met every 2 weeks from August 2021- August 2022 to engage local TMs and disseminate up-to-date knowledge in real time. During forum sessions, TMs shared detailed accounts of their experiences combating vaccine hesitancy in their communities and supported one another in their efforts through positive interaction and reaffirming conversations. Collaborations between community stakeholders can form a scaffolding to support a rapid response to a variety of public health problems and result in impactful change. For researchers implementing community-based research projects, modeling stakeholder panels after trusted messenger forums can be effective for diversifying the scope of the project and reacting to emergent problems in real-time.

Loneliness in the presence of others: A mixed-method study of social networks of caregivers of patients with severe mental disorders.

BACKGROUND: One in four families has at least one member with a mental disorder and families are the main caregivers in most patients in low and middle-income countries. Caregivers experience disruption in their routine lives, increased responsibilities, increased need for support, and changes in their network. The role of personal support networks in the health and burden of the caregivers is complex and depends on the context, cultural and socioeconomical variables. In this study, we aimed to investigate the personal support network of caregivers of patients with severe mental illness in Iran. METHODS: By using a mixed-methods design, we focused on the structure and composition of caregiver networks, as well as self-perceived caregiver support. RESULTS: We found that the support network of caregivers was mostly composed of immediate family members whom themselves were selectively chosen as a result of the multidimensional process of interaction between stigma, availability, and the perceived needs of caregivers. The participants mentioned economic and instrumental supports more frequently than emotional support, probably reflecting their unmet basic needs. Advocacy for providing formal systemic supports to caregivers, as well as interventions that expand caregivers personal support network is recommended. CONCLUSIONS: Most participants of the study were relatively isolated and had a small network of support, mostly composed of immediate family members. Stigma was a serious source of family distress for caregivers and a limiting factor in social relationships.

The role of social networks in prognostic understanding of older adults with advanced cancer.

OBJECTIVES: Explore how older patients utilize their social networks to inform prognostic understanding. METHODS: In a pilot study of adults (≥65 years old) with advanced cancer, 16 patients completed surveys, social network maps, and semi-structured interviews exploring with whom they preferred to communicate about their illness. Interviews were analyzed using open-coding, and codes were categorized into emergent themes. Social network maps and themes were analyzed via mixed-methods social network analysis (MMSNA). Three case examples with diverse network characteristics and communication patterns were selected for further analysis. RESULTS: Three overarching themes (i.e., prognostic understanding, social support, and therapeutic alliance) revealed that patients' prognostic understanding was strongly influenced by the quality of the social support patients perceived from members of their social networks. Patients demonstrated prognostic understanding when they reported close relationships and open communication with their network members. Case examples revealed some ways that patients sought information and had better sense of their prognosis when they had supportive social networks. CONCLUSION: Findings illustrate how understanding social networks may provide information on how older adults with cancer seek, share, and process prognostic information.