Process mapping in healthcare: a systematic review.

INTRODUCTION: Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare. METHODS: We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach. RESULTS: The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions. CONCLUSION: The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM. TRIAL REGISTRATION: Prospero ID: CRD42017082140.

The nurse's role in patient nutrition and hydration.

Abstract Evans L, Best C (2015) Meeting patients' nutrition and hydration needs. The Nursing and Midwifery Council's new code was introduced in March 2015. For the first time, nutrition and hydration are mentioned specifically within the code. This article explores why this has become necessary and how nursing responsibility for the nutritional care of the patient has changed over the past 150 years. It also looks in more depth at how the nutritional care can meet the standards of the code.

Accurate assessment patient weigh.

Measuring patient weight is considered a routine assessment that is frequently delegated to unregistered staff. Yet patient weight is a fundamental part of nutrition assessment and may be used to calculate drug dosages and assess fluid balance. It is vital that staff carrying out this measurement are trained and have access to appropriate equipment that is regularly calibrated.

Management of specific and excessive posturing behavior in a hyacinth macaw (Anodorhynchus hyacinthinus) by using applied behavior analysis.

Applied behavior analysis was used in a female hyacinth macaw (Anodorhynchus hyacinthinus) to reduce specific, excessive mating-type posturing that had become disruptive due to increased frequency, duration, and intensity. A functional assessment and intervention design worksheet was used to evaluate behavior-environment relations and to develop an individualized behavior-change plan. The functional assessment indicated that human attention was maintaining the behavior. The intervention, differential reinforcement of incompatible behavior, was implemented to increase attention for standing upright and to remove attention for posturing. Within 1 month, posturing decreased to acceptable levels and was replaced with an upright posture. Problem behaviors that appear "reproductive" may be responsive to behavior management alone. Applied behavior analysis and a functional assessment and intervention design are ideal tools to address problem behavior in avian patients.

Implementing guidelines on physical health in the acute mental health setting: a quality improvement approach.

BACKGROUND: In the UK, life expectancy for people living with a serious mental illness, such as schizophrenia and bipolar disorder, is reduced by 15-20 years compared with the general population. In recent years, evidence based guidelines/policies designed to improve their physical health have been published, yet a gap remains between recommendations and practice. This case study describes how guidelines to support physical health were implemented using a quality improvement approach. CASE PRESENTATION: A quasi-experimental study explored systems and processes for assessing the physical health of patients admitted to an acute mental health unit. The multi-disciplinary team of healthcare professionals, service users and experts in quality improvement methods developed solutions to improve the assessment of physical health, drawing on existing guidelines/policies as well as professional and lived experience. Three key interventions were developed: a comprehensive physical health assessment; a patient-held physical health booklet; and education and training for staff and patients. Interventions were co-designed by front-line healthcare staff and service users with iterative development and implementation through Plan-Do-Study-Act cycles. Real-time weekly data were reported on five measures over a 15-month implementation period (318 patients) and compared to a 10-month baseline period (247 patients) to gauge the success of the implementation of the physical health assessment. Improvements were seen in the numbers of patients receiving a physical health assessment: 81.3% (201/247) vs 96.9% (308/318), recording of body mass index: 21.55% (53/247) vs 58.6% (204/318) and systolic blood pressure: 22.35% (55/247) vs 75.9% (239/318) but a reduction in the recording of smoking status: 80.1% (198/247) vs 70.9% (225/318). However, 31.7% (118/318) patients had a cardiovascular risk-score documented in the implementation phase, compared to none in the baseline. CONCLUSION: This study demonstrates the use of a quality improvement approach to support teams to implement guidelines on physical health in the acute mental health setting. Reflections of the team have identified the need for resources, training, support and leadership to support changes to the way care is delivered. Furthermore, collaborations between service users and frontline clinical staff can co-design interventions to support improvements and raise awareness of the physical health needs of this population.

Time to share. Interview by Adele Waters.

The RCN's Nutrition now campaign, supported by Nursing Standard, is giving nurses the resources to stop patients becoming dehydrated and malnourished.

Case study: design and implementation of training for scientists deploying to Ebola diagnostic field laboratories in Sierra Leone: October 2014 to February 2016.

As part of the UK response to the 2013-2016 Ebola virus disease (EVD) epidemic in West Africa, Public Health England (PHE) were tasked with establishing three field Ebola virus (EBOV) diagnostic laboratories in Sierra Leone by the UK Department for International Development (DFID). These provided diagnostic support to the Ebola Treatment Centre (ETC) facilities located in Kerry Town, Makeni and Port Loko. The Novel and Dangerous Pathogens (NADP) Training group at PHE, Porton Down, designed and implemented a pre-deployment Ebola diagnostic laboratory training programme for UK volunteer scientists being deployed to the PHE EVD laboratories. Here, we describe the training, workflow and capabilities of these field laboratories for use in response to disease epidemics and in epidemiological surveillance. We discuss the training outcomes, the laboratory outputs, lessons learned and the legacy value of the support provided. We hope this information will assist in the recruitment and training of staff for future responses and in the design and implementation of rapid deployment diagnostic field laboratories for future outbreaks of high consequence pathogens.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.

Managing malnutrition in patients with dementia.

As dementia progresses, an individual may experience increasing difficulties in eating and drinking safely. Evidence suggests that admission to hospital may exacerbate these problems. This article aims to familiarise readers with some of the issues associated with providing good nutritional care for a patient with dementia in hospital. Strategies to address the maintenance of oral intake are suggested. The article also explores the use of artificial nutrition in dementia, with examples to clarify when its use may be helpful.

Improving access to primary mental health services: are link workers the answer?

Background The incidences of common mental disorders such as anxiety, depression and low-level post-traumatic stress are associated with deprivation. Since 2007, the Improving Access to Psychological Therapy (IAPT) programme in Ealing has made it easier for primary care practitioners to refer patients with common mental disorders for treatment. However, fewer patients of a black and minority ethnic (BME) background were referred than expected. Setting Southall, Ealing, is a diverse ethnic community; over 70% of the population is classified as having a BME background. Aim To evaluate the effect of locating mental health link workers in general practitioners' (GP) surgeries on referral of BME patients to IAPT services. Methods In 2009, an initiative in Southall helped practitioners and managers that served geographic areas to work with many different agencies to improve whole systems of care. One strand of this work led to mental health link workers being placed in 6 of the 23 GP practices. They provided psychological therapy and raised awareness of common mental disorders in BME groups and what mental health services can do to improve these. Referrals to the service were monitored and assessed using statistical process control. Results The mean referral rate of BME patients for GP practices without a link worker was 0.35 per week per 10 000 patients and was unchanged throughout the period of the study. The referral rates for the six practices with a link worker increased from 0.65 to 1.37 referrals per week per 10 000 patients. Conclusions Link workers located in GP practices, as part of a collaborative network of healthcare, show promise as one way to improve the care of patients with anxiety and depression from BME communities.

Improving patient and project outcomes using interorganisational innovation, collaboration and co-design.

Background Common mental disorders (CMDs) are a leading cause of disability. The Department of Health has launched a large-scale initiative to improve access to evidence-based psychological treatments, such as cognitive behavioural therapy (CBT), through the Improving Access to Psychological Therapy (IAPT) programme. Access to IAPT services by black and minority ethnic (BME) communities is lower than for other groups. Setting The London Borough of Ealing in west London; a diverse borough with areas of high BME population and relatively high deprivation. Aim To compare the outcomes of two linked quality improvement (QI) projects undertaken by Ealing Mental Health and Wellbeing Service (MHWBS), both with the same aim of increasing access to talking therapies for BME communities. Methods Application of QI methodologies supported by the NIHR CLAHRC for northwest London in two different settings in Ealing. One, the 'Southall project', was set within a wider initiative for collaborative improvements and shared learning (the Southall Initiative for Integrated Care) in an ethnically diverse area of Ealing; it was undertaken between April 2010 and September 2011. The second, 'the Ealing project', operated in the two other Ealing localities that did not have the advantage of a broader initiative for collaborative improvements; it was undertaken between April 2011 and September 2012. Results Comparison of the monthly referral rates of BME patients (standardised per 10 000 general practitioner (GP)-registered patients) show that the Southall project was more effective in increasing referrals from BME communities than the Ealing project. Conclusion Broad local participation and ownership in the project design of the Southall project may explain why it was more effective in achieving its aims than the Ealing project which lacked these ownership-creating mechanisms.

How Ealing Health Networks can contribute to efficient and quality healthcare.

We describe how the formation of Health Networks in Ealing leads to improved outcomes for patients by the coordination of the care they receive by health and social care professionals.

Taking diabetes services out of hospital into the community.

We describe four stages of an initiative to co-create a shared care system to treat patients with diabetes out of hospital and in the community.

How Ealing Health Networks can contribute to efficient and quality healthcare.

We describe how the formation of Health Networks in Ealing leads to improved outcomes for patients by the coordination of the care they receive by health and social care professionals.

Taking diabetes services out of hospital into the community.

We describe four stages of an initiative to co-create a shared care system to treat patients with diabetes out of hospital and in the community.