Contextual factors and mechanisms in the implementation of Value Stream Mapping in breast cancer centres - A multiple case study.

INTRODUCTION: Lean, especially Value Stream Mapping is increasingly used in hospitals to optimize processes. This method, which originated in the automotive industry, enables all staff involved in the process to make it more customer-friendly. Despite the widely reported success of Lean projects, they have failed in some cases. This study investigated the contextual factors and mechanisms that contribute to a successful implementation of Value Stream Mapping. METHODS: Value Stream Mapping was applied to the discharge process in four breast cancer centers. A mixed-method approach was used in two steps. First, to verify the successful implementation, defined as time optimization, time measurement was conducted at three points in time and analyzed using an ANOVA. Second, an analysis of contextual factors was combined with a qualitative content analysis of mechanisms based on normalization process theory, using routine data, meeting protocols, field notes, and interview transcripts as data source. RESULTS: At one of the four breast cancer centers, lead- and waiting time were significantly reduced; at the others, these reductions did not occur. Failure/success cannot be explained by the size of the hospital, the number of cases or staffing levels. The variable project team composition is evident, especially leadership involvement. DISCUSSION: A comparative analysis was conducted to identify the factors that led to success. These factors were: participation of all leaders relevant to the process, in the case of the discharge process including medical and nursing leaders; dissemination of the changes from the project team to colleagues including its sense and possibility to discuss it; joint reflection of the implementation process in regular work team meetings. CONCLUSIONS: These results confirm the important role of leadership in implementation projects. Leadership support enabled the mechanisms found. The used combination of theoretical approaches from management research and implementation science determined the interpretation and should be applied more often in implementation science.

[Implementation of an Open Door Policy on Two Acute Care Units]. / Implementierung eines Konzepts der offenen Türen auf zwei psychiatrischen Akutstationen an zwei Kliniken.

BACKGROUND: Since the amendments to the Baden-Württemberg Psychiatric Assistance Act, psychiatric patients who are treated involuntarily can be admitted to open wards. As a result, a comprehensive research project was carried out to implement an open-door policy. This work evaluates the attitudes of patients and therapeutic teams. METHODS: Over the course of a year, 8 focus groups with 6 to 11 participants were conducted with patients and staff before and at the end of the intervention phase and analyzed qualitatively. RESULTS: The concept of open doors was received positively. The staff raised safety concerns whereas on the patient side the door status seemed to be of limited relevance regarding the experience of autonomy or stigmatization. DISCUSSION: The elaboration of conflict issues allows a further development of specific concepts towards the implementation of open doors on psychiatric acute wards.

On-the-Go Adaptation of Implementation Approaches and Strategies in Health: Emerging Perspectives and Research Opportunities.

In many cases, implementation approaches (composed of one or more strategies) may need to change over time to work optimally. We use a literature review to inform a mechanistic analysis of such on-the-go adaptations. We suggest that such adaptations of implementation strategies consist of three necessary steps. The first component is the initial effect of the implementation approach on intended implementation, service delivery, or clinical outcomes. Second, these initial effects must in turn be used to modify, alter, intensify, or otherwise change the implementation approach. Third, the modified approach itself has effects. Conceiving of adaptation as all three steps implies that a full understanding of adaptation involves (a) a sense of initial effects, (b) conceptualizing and documenting content and rationale for changes in approach (e.g., alteration, intensification), and (c) the effects of the changed approach (including how the latter effects depend on initial effects). Conceptualizing these steps can help researchers ask questions about adaptation (e.g., thresholds for change, dosing, potentiation, sequencing) to advance our understanding of implementation strategies.

Implementing multidisciplinary tumor boards in oncology: a narrative review.

The healthcare industry compares unfavorably with other ultra-safe industries such as aviation and nuclear power plants, which address complexity by reducing the vulnerability of a single person and promoting teams and strong systems. A multidisciplinary tumor board (MTB) is an evidence-based organizational approach to implementing a more effective concept in oncology practice. Studies addressing the correlation between MTBs and cancer outcomes show promising results, and other potential benefits are also addressed. The objectives of this article are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs effectiveness and address challenges to the implementation and maintenance of MTBs. In this commentary-type narrative review, the authors present their opinions and, whenever possible, substantiate recommendations by citing supportive literature.

Lay abstract Compared with other ultra-safe industries such as aviation and nuclear power plants, the healthcare industry operates with lower safety standards. Multidisciplinary tumor boards (MTBs) are regular meetings of various specialist doctors and other health professionals involved in cancer care to discuss cases of patients with cancer. MTBs are considered valuable tools to promote the quality of care in oncology by reducing the vulnerability of a single person and promoting teams and strong systems. Studies have shown that MTBs correlate with better treatment results, and other potential benefits are also addressed. The objectives of this paper are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs and address challenges to the implementation and maintenance of MTBs. The authors substantiate their views with literature citations where possible.

Utilization of lean project management principles and health informatics to reduce operating room delays in a vascular surgery practice.

OBJECTIVES: Perioperative inefficiency can increase cost. We describe a process improvement initiative that addressed preoperative delays on an academic vascular surgery service. METHODS: First case vascular surgeries from July 2019-January 2020 were retrospectively reviewed for delays, defined as late arrival to the operating room (OR). A stakeholder group spearheaded by a surgeon-informaticist analyzed this process and implemented a novel electronic medical records (EMR) preoperative tool with improved preoperative workflow and role delegation; results were reviewed for 3 months after implementation. RESULTS: 57% of cases had first case on-time starts with average delay of 19 min. Inappropriate preoperative orders were identified as a dominant delay source (average delay = 38 min). Three months post-implementation, 53% of first cases had on-time starts with average delay of 11 min (P < 0.05). No delays were due to missing orders. CONCLUSIONS: Inconsistent preoperative workflows led to inappropriate orders and delays, increasing cost and decreasing quality. A novel EMR tool subsequently reduced delays with projected savings of $1,200/case. Workflow standardization utilizing informatics can increase efficiency, raising the value of surgical care.

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation.

OBJECTIVES: To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes. DESIGN: Multicentre, parallel, cluster randomised controlled trial. SETTING: Long term care homes in the UK, registered to care for older people or those with dementia. PARTICIPANTS: 1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care. INTERVENTIONS: Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care. MAIN OUTCOME MEASURES: Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation. RESULTS: Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval -£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (-0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively. CONCLUSIONS: The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency. TRIAL REGISTRATION: ISRCTN34353836.

Bacteriophage Therapy for Difficult-to-Treat Infections: The Implementation of a Multidisciplinary Phage Task Force (The PHAGEFORCE Study Protocol).

In times where only a few novel antibiotics are to be expected, antimicrobial resistance remains an expanding global health threat. In case of chronic infections caused by therapy-resistant pathogens, physicians have limited therapeutic options, which are often associated with detrimental consequences for the patient. This has resulted in a renewed interest in alternative strategies, such as bacteriophage (phage) therapy. However, there are still important hurdles that currently impede the more widespread implementation of phage therapy in clinical practice. First, the limited number of good-quality case series and clinical trials have failed to show the optimal application protocol in terms of route of administration, frequency of administration, treatment duration and phage titer. Second, there is limited information on the systemic effects of phage therapy. Finally, in the past, phage therapy has been applied intuitively in terms of the selection of phages and their combination as parts of phage cocktails. This has led to an enormous heterogeneity in previously published studies, resulting in a lack of reliable safety and efficacy data for phage therapy. We hereby present a study protocol that addresses these scientific hurdles using a multidisciplinary approach, bringing together the experience of clinical, pharmaceutical and molecular microbiology experts.

The future of newborn screening for lysosomal disorders.

The goal of newborn screening is to enhance the outcome of individuals with serious, treatable disorders through early, pre-symptomatic detection. The lysosomal storage disorders (LSDs) comprise a group of more than 50 diseases with a combined frequency of approximately 1:7000. With the availability of existing and new enzyme replacement therapies, small molecule treatments and gene therapies, there is increasing interest in screening newborns for LSDs with the goal of reducing disease-related morbidity and mortality through early detection. Novel screening methods are being developed, including efforts to enhance accuracy of screening using an array of multi-tiered, genomic, statistical, and bioinformatic approaches. While NBS data for Gaucher disease, Fabry disease, Krabbe disease, MPS I, and Pompe disease has demonstrated the feasibility of widespread screening, it has also highlighted some of the complexities of screening for LSDs. These include the identification of infants with later-onset, untreatable, and uncertain phenotypes, raising interesting ethical concerns that should be addressed as part of the NBS implementation process. Taken together, these efforts will provide critical, detailed data to help guide objective, ethically sensitive decision-making about NBS for LSDs.

The impact of rotavirus vaccination in the prevalence of gastroenteritis and comorbidities among children after suboptimal rotavirus vaccines implementation in Taiwan: A population-based study.

ABSTRACT: In Taiwan, rotavirus vaccination was implemented in 2006 in the private sector. The population-based impact of rotavirus vaccination on gastroenteritis and comorbidities of children remains under-investigated.We analyzed the annual prevalence of rotavirus-related disease, including gastroenteritis, convulsions, epilepsy, type I diabetes mellitus, intussusception, and biliary atresia among children under 5 years of age. Data were collected from Taiwan's National Health Insurance Research Database, a nationwide population-based database. A 16-year retrospective cohort study was conducted between 2000 and 2015.Among children <5 years of age, the prevalence of gastroenteritis decreased after 2012 (44,259.69 per 100 thousands) and remained lower through 2015 (39,931.11per 100 thousands, P < .001). The prevalence of convulsions rose steadily and significantly from 2007 (775.90 per 100 thousands) to 2015 (962.17 per 100 thousands, P < .001). The prevalence of epilepsy decreased significantly until reaching a nadir in 2013 (from 501.56 to 293.53 per 100 thousands, P < .001). The prevalence of biliary atresia tended upward, and surged suddenly in 2007 with a peak in 2013 (18.74 per 100 thousands). Among infants (<1 year of age) from 2000 to 2015, the prevalence of gastroenteritis declined steadily, and more rapidly after 2007 (22,513 to 17,285 per 100 thousands).In Taiwan, after introducing rotavirus vaccination, gastroenteritis in young children decreased, especially in infancy. However, gastroenteritis is still common in children, given other emerging pathogens. Our results highlight the impact of rotavirus vaccines on children's health in Taiwan and provide indications for future preventive medicine and healthcare strategies in children.

Applying the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to Safe Surgery 2020 Implementation in Tanzania's Lake Zone.

BACKGROUND: Access to safe, high-quality surgical care in sub-Saharan Africa is a critical gap. Interventions to improve surgical quality have been developed, but research on their implementation is still at a nascent stage. We retrospectively applied the Exploration, Preparation, Implementation, Sustainment framework to characterize the implementation of Safe Surgery 2020, a multicomponent intervention to improve surgical quality. METHODS: We used a longitudinal, qualitative research design to examine Safe Surgery 2020 in 10 health facilities in Tanzania's Lake Zone. We used documentation analysis with confirmatory key informant interviews (n = 6) to describe the exploration and preparation phases. We conducted interviews with health facility leaders and surgical team members at 1, 6, and 12 months (n = 101) post initiation to characterize the implementation phase. Data were analyzed using the constant comparison method. RESULTS: In the exploration phase, research, expert consultation, and scoping activities revealed the need for a multicomponent intervention to improve surgical quality. In the preparation phase, onsite visits identified priorities and barriers to implementation to adapt the intervention components and curriculum. In the active implementation phase, 4 themes related to the inner organizational context-vision for safe surgery, existing surgical practices, leadership support, and resilience-and 3 themes related to the intervention-innovation-value fit, holistic approach, and buy-in-facilitated or hindered implementation. Interviewees perceived improvements in teamwork and communication and intra- and inter-facility learning, and their need to deliver safe surgery evolved during the implementation period. CONCLUSIONS: Examining implementation through the exploration, preparation, implementation, and sustainment phases offers insights into the implementation of interventions to improve surgical quality and promote sustainability.

Using NSQIP Data to Reduce Institutional Postoperative Pneumonia Rates in Non-ICU Patients: A Plan-Do-Study-Act Approach.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a program designed to measure and improve surgical care quality. In 2015, the study institution formed a multidisciplinary team to address the poor adult postoperative pneumonia performance (worst decile). STUDY DESIGN: The study institution is a 450+ bed tertiary care center that performs 12,000+ surgical procedures annually. From January 2016 to December 2019, the institution abstracted surgical cases and assigned postoperative pneumonia as a complication per the NSQIP operations manual. Using a plan-do-study-act approach, a multidisciplinary postoperative pneumonia prevention team implemented initiatives regarding incentive spirometry education, anesthetic optimization, early mobility, and oral care. The team measured the initiatives' success by analyzing semiannual reports (SAR) provided by the ACS NSQIP and regional adjusted percentile rankings provided by the Georgia Surgical Quality Collaborative (GSQC). RESULTS: The 2015 SAR postoperative pneumonia rate was 4.20% (odds ratio [OR] 3.86, confidence interval [CI] 2.92-5.11). After project initiation, the postoperative pneumonia rates decreased for all NSQIP cases, from 2.51% (OR 2.67, CI 1.89-3.77) in 2016 to 2.08% (OR 2.61, CI 1.82-3.74) in 2017, to 0.85% (OR 1.10, CI 0.69-1.75) in 2018, and then increased slightly to 1.14% (OR 1.27, CI 0.84-1.92) in 2019. The institution's adjusted percentile regional rank of participating regional ACS NSQIP hospitals' postoperative pneumonia rate improved from 14/14 (July 2015-June 2016) to 6/14 (July 2018-June 2019). CONCLUSIONS: The multidisciplinary postoperative pneumonia prevention team successfully decreased the postoperative pneumonia rate, therefore improving surgical patients' outcomes. Furthermore, this quality improvement project also saved valuable revenue for the hospital.

An Integrative Review of Organizational Factors Influencing Successful Large-Scale Changes in Healthcare.

OBJECTIVE: The aim of this study was to review organizational factors influencing successful large-scale change (LSC) in healthcare. BACKGROUND: LSC is necessary to achieve sustained and meaningful healthcare improvement. However, organizational readiness needs to be considered to promote successful LSC. METHODS: Four databases were searched for articles published between 2009 and 2018. Thematic analysis was used to identify enabling or hindering factors to LSC. RESULTS: Seven organizational factors were consistently described as facilitators of or barriers to successful LSC in healthcare: infrastructure support, organizational culture, leadership, change management approach, roles and responsibilities, networks, and measurement and feedback. CONCLUSION: The factors that emerged from this review are consistent with concepts of implementation but broadened and highlight learning organizations in successful LSC. The results of this review informed the development of a reflective tool on LSC for nurse leaders.

Scaling-Up Stage 4 Pediatric Obesity Clinics: Identifying Barriers and Future Directions Using Implementation Science.

Nearly one-fifth of the pediatric population in the United States has obesity. Comprehensive behavioral interventions, with at least 26 contact hours, are the recommended treatment for pediatric obesity; however, there are various barriers to implementing treatment. This Perspective applies the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to address barriers to implementing multidisciplinary pediatric weight management clinics and identify potential solutions and areas for additional research. Lack of insurance coverage and reimbursement, high operating costs, and limited access to stage 4 care clinics with sufficient capacity were among the main barriers identified. Clinicians, researchers, and patient advocates are encouraged to facilitate conversations with insurance companies and hospital and clinic administrators, increase telehealth adoption, request training to improve competency and self-efficacy discussing and implementing obesity care, and advocate for more stage 4 clinics.

Qualitative interviews and supporting evidence to identify the positive impacts of multidisciplinary vascular access teams.

BACKGROUND: Vascular access by means of intravenous catheters is essential for the safe, effective and cost-efficient delivery of intravenous fluids, antibiotics, nutrition and chemotherapy, but the use of these devices is not without complications. PURPOSE: A faculty of multidisciplinary European vascular access team (VAT) Leads/Members and experts sought to reframe how the implementation of a VAT could have positive impacts on patients and hospitals. METHODS: Interview data from a Faculty of nine VAT Leads/Members and experts from six European countries on the impact of multidisciplinary VATs in modern healthcare were assessed. A literature search was conducted that included Medline®-cited peer-reviewed articles published in the past 10 years in order to identify impact data and post-implementation of a multidisciplinary VAT that support the benefits to patient safety and satisfaction and to hospital efficiencies reported in the interview program. RESULTS: While VATs vary in structure and function, clarity of purpose and supportive training and education are key. Barriers to the implementation of VATs show commonality across countries, such as lack of investment, insufficient training and lack of awareness. Proven markers of VAT success include rapid referrals, improved patient outcomes and improved organizational efficiency. Standardization of outcomes data capture, processing and reporting are key to monitoring performance against baseline. Awareness of the cost of complications arising from inappropriate choice and placement, and poor care and maintenance, of the vascular access device must be raised. CONCLUSIONS: The implementation of VATs can positively impact patient safety and satisfaction, improve organizational efficiencies and cost-effectiveness, and could create new opportunities for in- and outpatient services, beneficial to both patients and institutions.

What will it take to end AIDS in Asia and the Pacific region by 2030?

The 2016 global commitments towards ending the AIDS epidemic by 2030 require the Asia-Pacific region to reach the Fast-Track targets by 2020. Despite early successes, the region is well short of meeting these targets. The overall stalled progress in the HIV response has been further undermined by rising new infections among young key populations and the unprecedented COVID-19 pandemic. This paper examines the HIV situation, assesses the gaps, and analyses what it would take the region to end AIDS by 2030. Political will and commitments for ending AIDS must be reaffirmed and reinforced. Focused regional strategic direction that answers the specific regional context and guides countries to respond to their specific needs must be put in place. The region must harness the power of innovative tools and technology in both prevention and treatment. Community activism and meaningful community engagement across the spectrum of HIV response must be ensured. Punitive laws, stigma, and discrimination that deter key populations and people living with HIV from accessing health services must be effectively tackled. The people-centred public health approach must be fully integrated into national universal health coverage while ensuring domestic resources are available for community-led service delivery. The region must utilise its full potential and draw upon lessons that have been learnt to address common challenges of the HIV and COVID-19 pandemics and achieve the goal of ending AIDS by 2030, in fulfillment of the United Nations' Sustainable Development Goals.