From assurance to coproduction: a century of improving the quality of health-care service.

BACKGROUND: Over the last century, the invitation to improve health-care service quality has taken many different forms: questions, observations, methods, tools and actions have emerged and evolved to create relevant 'improvement work.' In this paper we present three phases of this work. The basic frameworks used in these phases have not supplanted each other, but they have been layered one upon the next over time. Each brought important new thinking, new change opportunities and a new set of limits. The important messages of each need to be carried together into the future, as must the sense of curiosity and possibility about the commonalities that has driven this evolution. METHODS: Literature, personal experience and other artifacts were reviewed to develop this description of how the focus on quality work has evolved (and continues to evolve) over the last century. RESULTS: We describe three phases. Quality 1.0 seeks to answer the question 'How might we establish thresholds for good healthcare services?' It described certain 'basic' standards that should be used to certify acceptable performance and capability. This led to the formation of formal processes for review, documentation and external audits and a system for public notice and recognition. Over time, the limits and risks of this approach also became more visible: a 'micro-accounting compliance' sometimes triumphed over what might be of even greater strategic importance in the development and operations of effective systems of disease prevention and management to improve outcomes for patients and families. Quality 2.0 asked 'How might we use enterprise-wide systems for disease management?' It added a focus on the processes and systems of production, reduction of unwanted variation, the intrinsic motivation to take pride in work, outcome measurement and collaborative work practices as ways to improve quality, modeled on experiences in other industries. Quality 3.0 asks 'How might we improve the value of the contribution that healthcare service makes to health?' It requires careful consideration of the meaning of 'service' and 'value', service-creating logic, and prompts us to consider both relationships and activities in the context of the coproduction of health-care services. CONCLUSION: Efforts to improve the quality and value of health-care services have evolved over the last century. With each success have come new challenges and questions, requiring the addition of new frames and approaches.

A starter's guide to learning and teaching how to coproduce healthcare services.

BACKGROUND: There has been insufficient attention paid to the role of learning in co-production-both how service users and professional service providers learn to co-produce effectively and how the lessons of co-production are captured at a service level. OBJECTIVE: We aimed to develop and test a curriculum to support healthcare professionals' interest in learning how to co-produce health and healthcare services with patients. METHODS: We developed a co-production curriculum that was tested iteratively in multiple in-person and virtual teaching sessions and short courses. We conducted a formative evaluation of the co-production curriculum and teaching tools to tailor the curriculum. RESULTS: Several theories underpin our approach to learning and teaching how to co-produce healthcare services. The co-production curriculum is grounded in systems theory and shares elements of educational theories, namely, the postmodern curriculum matrix, the actor network theory and situated learning in communities of practice. Learning participants valued the sense of community, the experiential learning environment, and the practical methods to support their exploration of co-production. CONCLUSION: This paper summarizes the educational theories that underpin our efforts to develop and implement the curriculum, reports on a formative assessment conducted with learners, and makes recommendations for creating an environment for learning how health professionals can co-produce health and healthcare with patients.

Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics.

BACKGROUND: Pressures are increasing for clinicians to provide high-quality, efficient care, leading to increased concerns about staff burnout. PURPOSE: This study asks whether staff well-being can be achieved in ways that are also beneficial for the patient's experience of care. It explores whether relational coordination can contribute to both staff well-being and patient satisfaction in outpatient surgical clinics where time constraints paired with high needs for information transfer increase both the need for and the challenge of achieving timely and accurate communication. METHODOLOGY/APPROACH: We studied relational coordination among surgeons, nurses, residents, administrators, technicians, and secretaries in 11 outpatient surgical clinics. Data were combined from a staff and a patient survey to conduct a cross-sectional study. Data were analyzed using ordinary least squares and random effects regression models. RESULTS: Relational coordination among all workgroups was significantly associated with staff outcomes, including job satisfaction, work engagement, and burnout. Relational coordination was also significantly associated with patients' satisfaction with staff and their overall visit, though the association between relational coordination and patients' satisfaction with their providers did not reach statistical significance. PRACTICE IMPLICATIONS: Even when patient-staff interactions are relatively brief, as in outpatient settings, high levels of relational coordination among interdependent workgroups contribute to positive outcomes for both staff and patients, and low levels tend to have the opposite effect. Clinical leaders can increase the expectation of positive outcomes for both staff and their patients by implementing interventions to strengthen relational coordination.

Encounter decision aids to facilitate shared decision-making with women experiencing heavy menstrual bleeding or symptomatic uterine fibroids: A before-after study.

OBJECTIVE: Is the level of shared decision-making (SDM) higher after introduction of a SDM package (including encounter decision aids on treatment options for heavy menstrual bleeding and training for clinicians) than before?. METHODS: This before-after study, performed in OB-GYN practice, compared consultations before and after introduction of a SDM package. The target sample size was 25 patients per group. Women seeking treatment for heavy menstrual bleeding were eligible. After their appointments, patients filled out a three-item patient-reported SDM measure. Treatment discussions were audio-recorded and rated for SDM using Observer OPTION5. Consultation transcripts in the 'after' group were checked for adherence to the steps required for intended use of decision aids. RESULTS: 16 gynaecologists participated. 25 patients participated before introduction of the decision aids and 28 after. The proportion of women reporting optimal SDM was higher after introduction (75 %) than before (50 %;p < 0.001). The mean observer-rated level of SDM was also significantly higher after than before (MD = 12.50,95 % CI 5.53-19.47). CONCLUSION: The level of SDM was higher after the introduction of the package than before. PRACTICE IMPLICATIONS: This study was conducted in a real-life setting in three clinics, both large academic and small rural, offering opportunities for implementation in different type of organizations.

COproduction VALUE creation in healthcare service (CO-VALUE): an international multicentre protocol to describe the application of a model of value creation for use in systems of coproduced healthcare services and to evaluate the initial feasibility, utility and acceptability of associated system-level value creation assessment approaches.

INTRODUCTION: Coproduction introduces a fundamental shift in how healthcare service is conceptualised. The mechanistic idea of healthcare being a 'product' generated by the healthcare system and delivered to patients is replaced by that of a service co-created by the healthcare system and the users of healthcare services. Fjeldstad et al offer an approach for conceptualising value creation in complex service contexts that we believe is applicable to coproduction of healthcare service. We have adapted Fjeldstad's value creation model based on a detailed case study of a renal haemodialysis service in Jonkoping, Sweden, which demonstrates coproduction characteristics and key elements of Fjeldstad's model. METHODS AND ANALYSIS: We propose a five-part coproduction value creation model for healthcare service: (1) value chain, characterised by a standardised set of processes that serve a commonly occurring need; (2) value shop, which offers a customised response for unique cases; (3) a facilitated value network, which involves groups of individuals struggling with similar challenges; (4) interconnection between shop, chain and network elements and (5) leadership. We will seek to articulate and assess the value creation model through the work of a community of practice comprised of a diverse international workgroup with representation from executive, financial and clinical leaders as well as other key stakeholders from multiple health systems. We then will conduct pilot studies of a qualitative self-assessment process in participating health systems, and ultimately develop and test quantitative measures for assessing coproduction value creation. ETHICS AND DISSEMINATION: This study has been approved by the Dartmouth-Hitchcock Health Institutional Review Board (D-HH IRB) as a minimal risk research study. Findings and scholarship will be disseminated broadly through continuous engagement with health system stakeholders, national and international academic presentations and publications and an internet-based electronic platform for publicly accessible study information.

Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services?

In 2016, Batalden et al proposed a coproduction model for health care services. Starting from the argument that health care services should demonstrate service-dominant rather than goods-dominant logic, they argued that health care outcomes are the result of the intricate interaction of the provider and patient in concert with the system, community, and, ultimately, society. The key notion is that the patient is as much an expert in determining outcomes as the provider, but with different expertise. Patients come to the table with expertise in their lived experiences and the context of their lives.The authors posit that education, like health care services, should follow a service-dominant logic. Like the relationship between patients and providers, the relationship between learner and teacher requires the integrated expertise of each nested in the context of their system, community, and society to optimize outcomes. The authors then argue that health professions learners cannot be educated in a traditional, paternalistic model of education and then expected to practice in a manner that prioritizes coproductive partnerships with colleagues, patients, and families. They stress the necessity of adapting the health care services coproduction model to health professions education. Instead of asking whether the coproduction model is possible in the current system, they argue that the current system is not sustainable and not producing the desired kind of clinicians.A current example from a longitudinal integrated clerkship highlights some possibilities with coproduced education. Finally, the authors offer some practical ways to begin changing from the traditional model. They thus provide a conceptual framework and ideas for practical implementation to move the educational model closer to the coproduction health care services model that many strive for and, through that alignment, to set the stage for improved health outcomes for all.

Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff.

BACKGROUND: There is limited evidence on how to implement shared decision-making (SDM) interventions in routine practice. We conducted a qualitative study, embedded within a 2 × 2 factorial cluster randomized controlled trial, to assess the acceptability and feasibility of two interventions for facilitating SDM about contraceptive methods in primary care and family planning clinics. The two SDM interventions comprised a patient-targeted intervention (video and prompt card) and a provider-targeted intervention (encounter decision aids and training). METHODS: Participants were clinical and administrative staff aged 18 years or older who worked in one of the 12 clinics in the intervention arm, had email access, and consented to being audio-recorded. Semi-structured telephone interviews were conducted upon completion of the trial. Audio recordings were transcribed verbatim. Data collection and thematic analysis were informed by the 14 domains of the Theoretical Domains Framework, which are relevant to the successful implementation of provider behaviour change interventions. RESULTS: Interviews (n = 29) indicated that the interventions were not systematically implemented in the majority of clinics. Participants felt the interventions were aligned with their role and they had confidence in their skills to use the decision aids. However, the novelty of the interventions, especially a need to modify workflows and change behavior to use them with patients, were implementation challenges. The interventions were not deeply embedded in clinic routines and their use was threatened by lack of understanding of their purpose and effect, and staff absence or turnover. Participants from clinics that had an enthusiastic study champion or team-based organizational culture found these social supports had a positive role in implementing the interventions. CONCLUSIONS: Variation in capabilities and motivation among clinical and administrative staff, coupled with inconsistent use of the interventions in routine workflow contributed to suboptimal implementation of the interventions. Future trials may benefit by using implementation strategies that embed SDM in the organizational culture of clinical settings.

Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol.

BACKGROUND: Uterine fibroids are non-cancerous overgrowths of the smooth muscle in the uterus. As they grow, some cause problems such as heavy menstrual bleeding, pelvic pain, discomfort during sexual intercourse, and rarely pregnancy complications or difficulty becoming pregnant. Multiple treatment options are available. The lack of comparative evidence demonstrating superiority of any one treatment means that choosing the best option is sensitive to individual preferences. Women with fibroids wish to consider treatment trade-offs. Tools known as patient decision aids (PDAs) are effective in increasing patient engagement in the decision-making process. However, the implementation of PDAs in routine care remains challenging. Our aim is to use a multi-component implementation strategy to implement the uterine fibroids Option Grid™ PDAs at five organizational settings in the USA. METHODS: We will conduct a randomized stepped-wedge implementation study where five sites will be randomized to implement the uterine fibroid Option Grid PDA in practice at different time points. Implementation will be guided by the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT). There will be a 6-month pre-implementation phase, a 2-month initiation phase where participating clinicians will receive training and be introduced to the Option Grid PDAs (available in text, picture, or online formats), and a 6-month active implementation phase where clinicians will be expected to use the PDAs with patients who are assigned female sex at birth, are at least 18 years of age, speak fluent English or Spanish, and have new or recurrent symptoms of uterine fibroids. We will exclude postmenopausal patients. Our primary outcome measure is the number of eligible patients who receive the Option Grid PDAs. We will use logistic and linear regression analyses to compare binary and continuous quantitative outcome measures (including survey scores and Option Grid use) between the pre- and active implementation phases while adjusting for patient and clinician characteristics. DISCUSSION: This study may help identify the factors that impact the implementation and sustained use of a PDA in clinic workflow from various stakeholder perspectives while helping patients with uterine fibroids make treatment decisions that align with their preferences. TRIAL REGISTRATION: Clinicaltrials.gov , NCT03985449. Registered 13 July 2019, https://clinicaltrials.gov/ct2/show/NCT03985449.

Residency education, preventive medicine, and population health care improvement: the Dartmouth-Hitchcock Leadership Preventive Medicine approach.

In 2003, Dartmouth-Hitchcock Medical Center (DHMC) inaugurated its Leadership Preventive Medicine residency (DHLPMR), which combines two years of leadership preventive medicine (LPM) training with another DHMC residency. The aim of DHLPMR is to attract and develop physicians who seek to become capable of leading change and improvement of the systems where people and health care meet. The capabilities learned by residents are (1) leadership -- including design and redesign -- of small systems in health care, (2) measurement of illness burden in individuals and populations, (3) measurement of the outcomes of health service interventions, (4) leadership of change for improvement of quality, value, and safety of health care of individuals and populations, and (5) reflection on personal professional practice enabling personal and professional development. The DHLPMR program includes completion of an MPH degree at The Dartmouth Institute for Health Policy and Clinical Practice (formerly the Center for Evaluative Clinical Sciences) and a practicum during which the resident leads change to improve health care for a defined population of patients. Residents also complete a longitudinal public health experience in a governmental public health agency. A coach in the resident's home clinical department helps the resident develop his or her practicum proposal, which must then be approved by a practicum review board (PRB). Twelve residents have graduated as of July 2007. Residents have combined anesthesia, family medicine, internal medicine, infectious disease, pain medicine, pathology, psychiatry, pulmonary and critical care medicine, surgery, gastroenterology, geriatric psychiatry, obstetrics-gynecology, and pediatrics with preventive medicine.

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

INTRODUCTION: Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. METHODS AND ANALYSIS: We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. ETHICS AND DISSEMINATION: We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02759939.

Co-Creating Quality in Health Care Through Learning and Dissemination.

For most of the 20th century the predominant focus of medical education across the professional continuum was the dissemination and acquisition of medical knowledge and procedural skills. Today it is now clear that new areas of focus, such as interprofessional teamwork, care coordination, quality improvement, system science, health information technology, patient safety, assessment of clinical practice, and effective use of clinical decision supports are essential to 21st century medical practice. These areas of need helped to spawn an intense interest in competency-based models of professional education at the turn of this century. However, many of today's practicing health professionals were never educated in these newer competencies during their own training. Co-production and co-creation of learning among interprofessional health care professionals across the continuum can help close the gap in acquiring needed competencies for health care today and tomorrow. Co-learning may be a particularly effective strategy to help organizations achieve the triple aim of better population health, better health care, and lower costs. Structured frameworks, such as the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, provide guidance in the design, planning, and dissemination of interventions designed to improve care through co-production and co-learning strategies.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

Publicly reporting comprehensive quality and cost data: a health care system's transparency initiative.

BACKGROUND: Transparency in health care, including the public reporting of health care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measures, and (3) use public reporting to foster process of care and outcome improvement initiatives. An overview is provided of the first 22 months of a transparency initiative at Dartmouth-Hitchcock Medical Center (DHMC). LAUNCHING THE TRANSPARENCY INITIATIVE: An interdisciplinary operations group works with the various clinical programs--both providers and patients--to identify what quality and cost measures are most desired by patients and what measures are the focus of the clinical program's internal measurement and reporting processes. The measures are presented on the DHMC Web site, with access to additional resources, such as clinical decision aids. DISCUSSION: A variety of factors are important to the transparency initiative--senior leaders' perceptions, risk management issues, resources required for the design and maintenance of the initiative, and developing both methodological protocols and technical systems.

Exploring and embracing complexity in a distance-learning curriculum for physicians.

The recent pressures on clinical medicine such as the attention to medical error and the challenges of interdisciplinary care have also exerted pressure on health professions education. Educators must now gauge how to redesign education systems to adapt quickly to these disruptions. Sometimes disruptions can be self-inflicted, such as the VA National Quality Scholars Fellowship's decision to use interactive video (IV) as its primary medium for delivering the curriculum to its six sites around the nation. The authors describe how this disruption to their education system helped to fashion a learning environment that is adaptable. Along the journey from a classroom-based curriculum to an IV-based curriculum, the authors and others involved in the program learned the basic tenets of IV sessions, redefined the roles of the teachers and learners, and discovered an IV environment that functions as a complex adaptive learning system. This distance-learning curriculum can be a model for other health professions education, since it starts with simple rules, changes from within, has a tolerance for unpredictability, and continually moves forward and transforms itself despite tension.

Improving the effectiveness of physician participation in local quality improvement efforts.

The authors present five success factors for medical students, residents, and fellows to consider when engaged in quality improvement projects: (1) add value, not work; (2) start small and build; (3) move quickly; (4) adapt, innovate, and collaborate; (5) produce understandable results. Using examples from the Veterans Affairs National Quality Scholars Fellowship Program, they describe how these factors were used successfully. While not the only steps to take, these critical success factors proved helpful in defining the problem to be addressed, engaging leadership, and anticipating the resolution of conflict.