Using a multi-stakeholder co-design process to develop a health service organisation-wide patient reported outcome measure collection system.

PURPOSE: Limited examples exist of successful Patient Reported Outcome Measure (PROM) implementation across an entire healthcare organisation. The aim of this study was to use a multi-stakeholder co-design process to develop a PROM collection system, which will inform implementation of routine collection of PROMs across an entire healthcare organisation. METHODS: Co-design comprised semi-structured interviews with clinicians (n = 11) and workshops/surveys with consumers (n = 320). The interview guide with clinicians focused on their experience using PROMs, preferences for using PROMs, and facilitators/barriers to using PROMs. Co-design activities specific to consumers focused on: (1) how PROMs will be administered (mode), (2) when PROMs will be administered (timing), (3) who will assist with PROMs collection, and (4) how long a PROM will take to complete. Data were analysed using a manifest qualitative content analysis approach. RESULTS: Core elements identified during the co-design process included: PROMs collection should be consumer-led and administered by someone other than a clinician; collection at discharge from the healthcare organisation and at 3-6 months post discharge would be most suitable for supporting comprehensive assessment; PROMs should be administered using a variety of modes to accommodate the diversity of consumer preferences, with electronic as the default; and the time taken to complete PROMs should be no longer than 5-10 min. CONCLUSION: This study provides new information on the co-design of a healthcare organisation-wide PROM collection system. Implementing a clinician and patient informed strategy for PROMs collection, that meets their preferences across multiple domains, should address known barriers to routine collection.

Healthcare consumer acceptability of routine use of the EQ-5D-5L in clinical care: a cross-sectional survey.

PURPOSE: Patient reported outcome measures, such as the EQ-5D-5L, provide a measure of self-perceived health status or health-related quality of life. Understanding the consumer acceptability of a patient reported outcome measure can help to decide about its implementation across a healthcare organisation and possibly increase the likelihood of its use in clinical care. This study established the acceptability of the EQ-5D-5L from the perspective of clients receiving healthcare, and determined if acceptability varied by client sub-types. METHODS: A cross-sectional survey explored clients' experience of the EQ-5D-5L. Eligible clients were aged ≥ 18 years and completed the EQ-5D-5L on admission and discharge to one of two multi-disciplinary community health services. Likert scale items explored acceptability, and open-ended questions determined if the EQ-5D-5L reflects experience of illness. Associations between acceptability and client characteristics were established using χ2 test. Open-ended questions were analysed using content analysis. RESULTS: Most of the 304 clients (mean age 70 years, SD 16) agreed that the EQ-5D-5L: was easy to use/understand (n = 301, 99%) and useful (n = 289, 95%); improved communication with their therapist (n = 275, 90%); and made them feel more in control of their health (n = 276, 91%). Most clients also agreed that they wished to continue using the EQ-5D-5L (n = 285, 93%). Clients aged ≥ 60 years reported lower acceptability. Clients noted that the EQ-5D-5L did not capture experience of illness related to fatigue, balance/falls, cognition, and sleep. CONCLUSION: The EQ-5D-5L is acceptable for use in care but does not capture all aspects of health relevant to clients, and acceptability varies by subgroup.

Targeted care navigation to reduce hospital readmissions in 'at-risk' patients.

BACKGROUND: Care navigation is commonly used to reduce preventable hospitalisation. The use of Electronic Health Record-derived algorithms may enable better targeting of this intervention for greater impact. AIMS: To evaluate if community-based Targeted Care Navigation, supported by an Electronic Health Record-derived readmission risk algorithm, is associated with reduced rehospitalisation. METHODS: A propensity score matching cohort (5 comparison to 1 intervention cohort ratio) study was conducted in an 850-bed Victorian public metropolitan health service, Australia, from May to November 2017. Admitted acute care patients with a non-surgical condition, identified as at-risk of hospital readmission using an Electronic Health Record-derived readmission risk algorithm provide by the state health department, were eligible. Targeted Care Navigation involved telephone follow-up support provided for 30 days post-discharge by a registered nurse. The hazard ratio for hospital readmission was calculated at 30, 60 and 90 days post-discharge using multivariable Cox Proportional Hazards regression. RESULTS: Sixty-five recipients received care navigation and were matched to 262 people who did not receive care navigation. Excellent matching was achieved with standardised differences between groups being <0.1 for all 11 variables included in the propensity score, including the readmission risk score. The Targeted Care Navigation group had a significantly reduced hazard of readmission at 30 days (hazard ratio 0.34; 95% confidence interval: 0.12, 0.94) compared with the comparison group. The effect size was reduced at 60 and 90 days post-discharge. CONCLUSION: We provide preliminary evidence that Targeted Care Navigation supported by an Electronic Health Record-derived readmission risk algorithm may reduce 30-day hospital readmissions.

A landscape assessment of the use of patient reported outcome measures in research, quality improvement and clinical care across a healthcare organisation.

BACKGROUND: Patient reported outcome measures (PROMs) can be used by healthcare organisations to inform improvements in service delivery. However, routine collection of PROMs is difficult to achieve across an entire healthcare organisation. An understanding of the use of PROMs within an organisation can provide valuable insights on the purpose, scope and practical considerations of PROMs collection, which can inform implementation of PROMs. METHODS: We used multiple research methods to assess the use of PROMs in research projects, data registries and clinical care across a healthcare organisation from January 2014 to April 2021. The methods included an audit of ethics applications approved by the organisation's human research ethics committee and registries which the health organisation had contributed data to; a literature review of peer-reviewed journal articles reporting on research projects conducted at the organisation; and a survey of health professionals use of PROMs in research projects, data registries and clinical care. The scope of PROMs was determined by classifying PROMs as either 'specific' to a particular disease and/or condition, or as a 'generic' measure with further classification based on the health domains they measured, using the World Health Organization International Classification Framework. Practical considerations included mode and timing of PROMs administration. Data were described using frequency and proportion. RESULTS: PROMs were used by 22% of research projects (n = 144/666), 68% of data registries (n = 13/19), and 76% of clinical specialties in their clinical care (n = 16/21). Disease specific PROMs were most commonly used: 83% of research projects (n = 130/144), 69% of clinical registries (n = 9/13), and 75% of clinical specialties (n = 12/16). Greater than 80% of research projects, clinical registries and clinical specialties measured health domains relating to both body impairments and participation in daily life activities. The most commonly used generic PROM was the EQ-5D (research projects n = 56/144, 39%; data registries n = 5/13, 38%; clinical specialties n = 4/16, 25%). PROMs used in clinical care were mostly paper-based (n = 47/55, 85%). CONCLUSIONS: We have elicited information on the use of PROMs to inform a health organisation wide implementation strategy. Future work will determine clinician and patient acceptability of the EQ-5D, and co-design a system for the collection of PROMs.

Prospective application of theoretical implementation frameworks to improve health care in hospitals - a systematic review.

BACKGROUND: Health Service implementation projects are often guided by theoretical implementation frameworks. Little is known about the effectiveness of these frameworks to facilitate change in processes of care and patient outcomes within the inpatient setting. The aim of this review was to assess the effectiveness of the application of theoretical implementation frameworks in inpatient healthcare settings to change processes of care and associated patient outcomes. METHOD: We conducted a search in CINAHL, MEDLINE, EMBASE, PsycINFO, EMCARE and Cochrane Library databases from 1st January 1995 to 15th June 2021. Two reviewers independently applied inclusion and exclusion criteria to potentially eligible studies. Eligible studies: implemented evidence-based care into an in-patient setting using a theoretical implementation framework applied prospectively; used a prospective study design; presented process of care or patient outcomes; and were published in English. We extracted theoretical implementation frameworks and study design against the Workgroup for Intervention Development and Evaluation Research (WIDER) Checklist and implementation strategies mapped to the Cochrane Effective Practice and Organisation of Care (EPOC) taxonomy. We summarised all interventions using the Template for Intervention Description and Replication (TIDieR) checklist. We appraised study quality using the Item bank on risk of bias and precision of observational studies and the revised Cochrane risk of bias tool for cluster randomised trials. We extracted process of care and patient outcomes and described descriptively. We conducted meta-analysis for process of care and patient outcomes with reference to framework category. RESULTS: Twenty-five studies met the inclusion criteria. Twenty-one used a pre-post (no comparison), two a pre-post with a comparison, and two a cluster randomised trial design. Eleven theoretical implementation frameworks were prospectively applied: six process models; five determinant frameworks; and one classic theory. Four studies used two theoretical implementation frameworks. No authors reported their justification for selecting a particular framework and implementation strategies were generally poorly described. No consensus was reached for a preferred framework or subset of frameworks based on meta-analysis results. CONCLUSIONS: Rather than the ongoing development of new implementation frameworks, a more consistent approach to framework selection and strengthening of existing approaches is recommended to further develop the implementation evidence base. TRIAL REGISTRATION: CRD42019119429.

Access to and effectiveness of clinical supervision for allied health workers: A cross-sectional survey.

INTRODUCTION: Clinical supervision supports patient care and health worker wellbeing. However, access to effective clinical supervision is not equitable. We aimed to explore the access and effectiveness of clinical supervision in allied health workers. METHODS: A cross-sectional survey design using the Manchester Clinical Supervision Scale (MCSS-26), including open-ended survey responses, to collect data on effectiveness. Multivariable regression was conducted to determine how MCSS-26 scores differed across discipline, work location and setting. Open-ended responses were analysed using content analysis. RESULTS: 1113 workers completed the survey, with 319 (28%) reporting they did not receive supervision; this group were more likely to hold management positions, work in a medical imaging discipline and practice in a regional or rural location. For those who received supervision, MCSS-26 scores significantly differed between disciplines and work settings; psychologists and those practising in private practice settings (i.e. fee-for-service) reported the highest levels of effectiveness. Suggested strategies to enhance effectiveness included the use of alternate supervision models, dedicated time for supervision, and training. CONCLUSION: Targeted subgroups for improving access include senior staff, medical imaging professionals, and those working across regional and rural settings. Where supervision was least effective, strategies to address behaviours with organisational support may be required.

Patient-reported outcome measures to evaluate postoperative quality of life in patients undergoing elective abdominal surgery: a systematic review.

PURPOSE: To appraise the measurement properties of generic patient-reported outcome measures (PROMs) measuring postoperative quality of life in adults undergoing elective abdominal surgery. METHODS: We conducted a systematic review of PROMs administered after elective abdominal surgery. We systematically searched Ovid MEDLINE, Embase, the Cumulative Index to Nursing & Allied Health Literature database, and the Cochrane Library from earliest available dates to July 24, 2021, using relevant search terms. Articles were included if they reported assessment of measurement properties of a generic PROM/s measuring postoperative quality of life in adults who had undergone elective abdominal surgery. We used the Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN) Risk of Bias checklist to assess methodological quality. We synthesized the data and used the COSMIN criteria for good measurement properties and the Grading of Recommendations, Assessment, Development and Evaluations criteria to rate the certainty of evidence. RESULTS: Of 12,121 identified articles, nine articles assessing five PROMs (SF-6D, EQ-5D, SF-36, SF-12, PROMIS-10) met inclusion criteria. Measurement properties assessed included internal consistency (n = 2), construct validity (n = 5), and responsiveness (n = 8). Two PROMs had high quality evidence for a single measurement property each. The SF-6D demonstrated high quality evidence for responsiveness and the EQ-5D had high quality evidence for construct validity. CONCLUSION: There is insufficient evidence to support the choice of a specific generic PROM to evaluate quality of life following elective abdominal surgery. Clinicians and researchers should be aware of the current limitations in knowledge of the measurement properties of available PROMs.

Community Reintegration After Rehabilitation for Hip Fracture: A Systematic Review and Meta-analysis.

OBJECTIVE: To investigate the effect of rehabilitation on the physical, social, and psychological dimensions of community reintegration after hip fracture. DATA SOURCES: Electronic databases Embase, EMCare, MEDLINE, PsycINFO, Cumulative Index to Nursing and Allied Health, and SPORTDiscus were searched from the earliest date available to second June 2021. STUDY SELECTION: Searching identified 1844 potentially relevant articles. Twenty randomized controlled trials evaluating physical retraining, cognitive retraining, and model of care interventions on physical, social and psychological aspects of community reintegration for 3075 adults after hip fracture were included. DATA EXTRACTION: Data were extracted using predetermined templates for participant characteristics, intervention type and setting, and outcomes related to community reintegration. Methodological quality was assessed using the Physiotherapy Evidence Database scale, and the Grading of Recommendations, Assessment, Development, and Evaluations approach was applied to each meta-analysis. DATA SYNTHESIS: Post intervention data were pooled to calculate risk ratios (RRs), mean differences, standardized mean differences, and 95% confidence intervals (CIs) using inverse variance methods and a random-effects model. Compared with usual care or no rehabilitation, there was moderate-quality evidence to suggest that physical retraining interventions improved outdoor mobility (RR, 1.45; 95% CI, 1.09-1.91; I2=0%) and moderate-quality evidence to suggest that physical retraining improved Nottingham Extended Activities of Daily Living Scale scores (physical and social reintegration) by a mean 3.5 units (95% CI, 0.99-6.01; I2=0%). Meta-analyses showed no significant effect for cognitive retraining and model of care interventions on any dimension of community reintegration. CONCLUSIONS: Preliminary evidence suggests that physical rehabilitation after hip fracture improves physical and social aspects of community reintegration. The effect of psychological and home-based interventions on community reintegration is currently unclear. Further research is needed to determine the effect of rehabilitation on community reintegration, using interventions and measures that encompass all dimensions of community reintegration.

Delegation of patient related tasks to allied health assistants: a time motion study.

BACKGROUND: Allied health assistants (AHAs) are support staff who complete patient and non-patient related tasks under the delegation of an allied health professional. Delegating patient related tasks to AHAs can benefit patients and allied health professionals. However, it is unclear whether the AHA workforce is utilised optimally in the provision of patient care. The purpose of this study was to determine the proportion of time AHAs spend on patient related tasks during their working day and any differences across level of AHA experience, clinical setting, and profession delegating the task. METHODS: A time motion study was conducted using a self-report, task predominance work sampling method. AHAs were recruited from four publicly-funded health organisations in Victoria, Australia. AHAs worked with dietitians, occupational therapists, physiotherapists, podiatrists, social workers, speech pathologists, psychologists, and exercise physiologists. The primary outcome was quantity of time spent by AHAs on individual task-categories. Tasks were grouped into two main categories: patient or non-patient related activities. Data were collected from July 2020 to May 2021 using an activity capture proforma specifically designed for this study. Logistic mixed-models were used to investigate the extent to which level of experience, setting, and delegating profession were associated with time spent on patient related tasks. RESULTS: Data from 51 AHAs showed that AHAs spent more time on patient related tasks (293 min/day, 64%) than non-patient related tasks (167 min/day, 36%). Time spent in community settings had lower odds of being delegated to patient related tasks than time in the acute hospital setting (OR 0.44, 95%CI 0.28 to 0.69, P < 0.001). Time delegated by exercise physiologists and dietitians was more likely to involve patient related tasks than time delegated by physiotherapists (exercise physiology: OR 3.77, 95% 1.90 to 7.70, P < 0.001; dietetics: OR 2.60, 95%CI 1.40 to 1.90, P = 0.003). Time delegated by other professions (e.g. podiatry, psychology) had lower odds of involving patient related tasks than physiotherapy (OR 0.37, 95%CI 0.16 to 0.85, P = 0.02). CONCLUSION: AHAs may be underutilised in community settings, and by podiatrists and psychologists. These areas may be targeted to understand appropriateness of task delegation to optimise AHAs' role in providing patient care.

The effect of delegation of therapy to allied health assistants on patient and organisational outcomes: a systematic review and meta-analysis.

BACKGROUND: Allied health assistants (AHAs) are support staff who complete clinical and non-clinical tasks under the supervision and delegation of an allied health professional. The effect of allied health professional delegation of clinical tasks to AHAs on patient and healthcare organisational outcomes is unknown. The purpose of this systematic review was to investigate the effect of allied health professional delegation of therapy to AHAs on patient and organisational outcomes. METHODS: A systematic review and meta-analysis was conducted. Databases MEDLINE (Ovid), Embase (Ovid), Informit (all databases), Emcare (Ovid), PsycINFO (Ovid), Cumulative Index to Nursing and Allied Health Literature [CINAHL] (EbscoHost) and the Cochrane Database of Systematic Reviews were searched from earliest date available. Additional studies were identified by searching reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. The quality of the study was rated using internal validity items from the Downs and Black checklist. Risk ratios (RR) and mean differences (MD) were calculated for patient and organisational outcomes. Meta-analyses were conducted using the inverse variance method and random-effects model. RESULTS: Twenty-two studies met the inclusion criteria. Results of meta-analysis provided low quality evidence that AHA supervised exercise in addition to usual care improved the likelihood of patients discharging home (RR 1.28, 95%CI 1.03 to 1.59, I2 = 60%) and reduced length of stay (MD 0.28 days, 95%CI 0.03 to 0.54, I2 = 0%) in an acute hospital setting. There was preliminary evidence from one high quality randomised controlled trial that AHA provision of nutritional supplements and assistance with feeding reduced the risk of patient mortality after hip fracture (RR 0.41, 95%CI 0.16 to 1.00). In a small number of studies (n = 6) there was no significant difference in patient and organisational outcomes when AHA therapy was substituted for therapy delivered by an allied health professional. CONCLUSION: We found preliminary evidence to suggest that the use of AHAs to provide additional therapy may be effective for improving some patient and organisational outcomes. REVIEW REGISTRATION: CRD42019127449.

Sustainable waiting time reductions after introducing the STAT model for access and triage: 12-month follow up of a stepped wedge cluster randomised controlled trial.

BACKGROUND: Timely access is a challenge for providers of outpatient and community-based health services, as seen by the often lengthy waiting lists to manage demand. The Specific Timely Appointments for Triage (STAT) model, an alternative approach for managing access and triage, reduced waiting time by 34% in a stepped wedge cluster randomised controlled trial involving 8 services and more than 3000 participants. Follow up periods ranged from 3 to 10 months across the participating services in accordance with the stepped wedge design. This study aimed to determine whether outcomes were sustained for a full 12 months after implementation of the STAT model at each site. METHODS: Routinely collected service data were obtained for a total of 12 months following implementation of the STAT model at each of the 8 services that participated in a stepped wedge cluster randomised controlled trial. The primary outcome was time to first appointment. Secondary outcomes included non-attendance rates, time to second appointment and service use over 12 weeks. Outcomes were compared to pre-intervention data from the original trial, modelled using generalised linear mixed effects models accounting for clustering of sites. RESULTS: A 29% reduction in waiting time could be attributed to STAT over 12 months, compared to 34% in the original trial. A reduction in variability in waiting time was sustained. There were no significant changes in time to second appointment or in the number of missed appointments in the extended follow up period. CONCLUSIONS: STAT is an effective strategy for reducing waiting time in community-based outpatient services. At 12 months, small reductions in the overall effect are apparent, but reductions in variability are sustained, suggesting that people who previously waited the longest benefit most from the STAT model. TRIAL REGISTRATION: This is a 12-month follow up of a stepped wedge cluster randomised controlled trial that was registered with the Australia and New Zealand Clinical Trials Registry ( ACTRN12615001016527 ).

Effective clinical supervision of allied health professionals: a mixed methods study.

BACKGROUND: Clinical supervision is recommended for allied health professionals for the purpose of supporting them in their professional role, continued professional development and ensuring patient safety and high quality care. The aim of this mixed methods study was to explore allied health professionals' perceptions about the aspects of clinical supervision that can facilitate effective clinical supervision. METHODS: Individual semi-structured interviews were conducted on a purposive sample of 38 allied health professionals working in a metropolitan public hospital. Qualitative analysis was completed using an interpretive description approach. To enable triangulation of qualitative data, a quantitative descriptive survey of clinical supervision effectiveness was also conducted using the Manchester Clinical Supervision Scale (MCSS-26). RESULTS: Three main themes emerged from qualitative analysis: Allied health professionals reported that clinical supervision was most effective when their professional development was the focus of clinical supervision; the supervisor possessed the skills and attributes required to facilitate a constructive supervisory relationship; and the organisation provided an environment that facilitated this relationship together with their own professional development. Three subthemes also emerged within each of the main themes: the importance of the supervisory relationship; prioritisation of clinical supervision relative to other professional duties; and flexibility of supervision models, processes and approaches to clinical supervision. The mean MCSS-26 score was 79.2 (95%CI 73.7 to 84.3) with scores ranging from 44 to 100. MCSS-26 results converged with the qualitative findings with participants reporting an overall positive experience with clinical supervision. CONCLUSIONS: The factors identified by allied health professionals that influenced the effectiveness of their clinical supervision were mostly consistent among the professions. However, allied health professionals reported using models of clinical supervision that best suited their profession's role and learning style. This highlighted the need for flexible approaches to allied health clinical supervision that should be reflected in clinical supervision policies and guidelines. Many of the identified factors that influence the effectiveness of clinical supervision of allied health professionals can be influenced by health organisations.

Staff perspectives of a model of access and triage for reducing waiting time in ambulatory services: a qualitative study.

BACKGROUND: Specific Timely Appointments for Triage (STAT) is an intervention designed to reduce waiting time in community outpatient health services, shown to be effective in a large stepped wedge cluster randomised controlled trial. STAT combines initial strategies to reduce existing wait lists with creation of a specific number of protected appointments for new patients based on demand. It offers an alternative to the more traditional methods of demand management for these services using waiting lists with triage systems. This study aimed to explore perceptions of clinicians and administrative staff involved in implementing the model. METHOD: Semi-structured interviews with 20 staff members who experienced the change to STAT were conducted by an independent interviewer. All eight sites involved in the original trial and all professional disciplines were represented in the sample. Data were coded and analysed thematically. RESULTS: Participants agreed that shorter waiting time for patients was the main advantage of the STAT model, and that ongoing management of caseloads was challenging. However, there was variation in the overall weight placed on these factors, and therefore the participants' preference for the new or previous model of care. Perceptions of whether the advantages outweighed the disadvantages were influenced by five sub-themes: staff perception of how much waiting matters to the patient, prior exposure to the management of waiting list, caseload complexity, approach and attitude to the implementation of STAT and organisational factors. CONCLUSIONS: The STAT model has clear benefits but also presents challenges for staff members. The findings of this study suggest that careful preparation and management of change and active planning for known fluctuations in supply and demand are likely to help to mitigate sources of stress and improve the likelihood of successful implementation of the STAT model for improving waiting times for patients referred to community outpatient services.

A model of access combining triage with initial management reduced waiting time for community outpatient services: a stepped wedge cluster randomised controlled trial.

BACKGROUND: Long waiting times are associated with public community outpatient health services. This trial aimed to determine if a new model of care based on evidence-based strategies that improved patient flow in two small pilot trials could be used to reduce waiting time across a variety of services. The key principle of the Specific Timely Appointments for Triage (STAT) model is that patients are booked directly into protected assessment appointments and triage is combined with initial management as an alternative to a waiting list and triage system. METHODS: A stepped wedge cluster randomised controlled trial was conducted between October 2015 and March 2017, involving 3116 patients at eight sites across a major Australian metropolitan health network. RESULTS: The intervention reduced waiting time to first appointment by 33.8% (IRR = 0.663, 95% CI 0.516 to 0.852, P = 0.001). Median waiting time decreased from a median of 42 days (IQR 19 to 86) in the control period to a median of 24 days (IQR 13 to 48) in the intervention period. A substantial reduction in variability was also noted. The model did not impact on most secondary outcomes, including time to second appointment, likelihood of discharge by 12 weeks and number of appointments provided, but was associated with a small increase in the rate of missed appointments. CONCLUSIONS: Broad-scale implementation of a model of access and triage that combined triage with initial management and actively managed the relationship between supply and demand achieved substantial reductions in waiting time without adversely impacting on other aspects of care. The reductions in waiting time are likely to have been driven, primarily, by substantial reductions for those patients previously considered low priority. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001016527 registration date: 29/09/2015.

Reducing wait time from referral to first visit for community outpatient services may contribute to better health outcomes: a systematic review.

BACKGROUND: Many people wait long periods for community outpatient services. However little is known about the impact of waiting from referral to first visit on patient outcomes. The aim of this systematic review is to investigate whether waiting for community outpatient services is associated with adverse effects on patient outcomes. METHODS: Medline, Embase, Psych Info and CINAHL databases were searched, combining the key concepts of waiting for healthcare and patient outcomes. Studies were included if they reported data comparing health outcomes for patients with different waiting times for the same period. Three reviewers applied inclusion and exclusion criteria to identified studies and assessed quality using the McMaster Critical Review Forms. Levels of evidence were assessed using National Health and Medical Research Council guidelines. Included studies were analysed using a descriptive synthesis, and summarised according to levels of evidence and clinical significance for key outcomes. RESULTS: Fourteen studies that included 69,606 adult patients were selected. Selected studies included patients referred for treatment for musculoskeletal disorders (n = 28,722) or to cardiac rehabilitation (n = 40,884). There was low-level evidence that reduced wait time is associated with moderate improvement in workplace participation for patients seeking care for musculoskeletal conditions; and moderate improvement in exercise tolerance for patients referred to cardiac rehabilitation. There was inconsistent evidence that improvements in quality of life, patient satisfaction and psychological symptoms may be associated with shorter wait times. Pain, function and physical activity outcomes were not associated with wait time. CONCLUSIONS: This review found low-level evidence suggesting an association between early access to community outpatient services and improvement of some patient outcomes. Specifically, shorter wait times from referral to first visit for musculoskeletal pain services may improve patient work participation. Shorter wait times for cardiac rehabilitation may improve patient exercise capacity. The effects of a short wait time for other patient conditions and patient outcomes, including quality of life, psychological symptoms and patient experience, are inconclusive. The modest benefits in health outcomes observed in reducing wait time for community outpatient services suggest that other possible benefits such as increasing patient flow should be explored. TRIAL REGISTRATION: PROSPERO registration no: CRD42016047003.

Are wait lists inevitable in subacute ambulatory and community health services? A qualitative analysis.

Objectives Wait lists are common in ambulatory and community-based services. The aim of the present study was to explore managers' perceptions of factors that contribute to wait times. Methods A qualitative study was conducted using semi-structured interviews with managers and team leaders of ambulatory and community health services within a large health network. Interviews were transcribed and coded, and the codes were then grouped into themes and subthemes. Results Representatives from 26 services participated in the project. Four major themes were identified. Three themes related to reasons and factors contributing to increased wait time for services (inefficient intake and scheduling processes; service disruptions due to human resource issues; and high service demand). A fourth theme related to staff attitudes towards wait times and acceptance and acknowledgement of wait lists. Conclusions Service providers perceive high demand to be a key driver of wait times, but a range of other factors also contributes and may represent opportunities for improving access to care. These other factors include improving process efficiencies, greater consistency of service delivery through more efficient management of human resources and shifting to more consumer-centred approaches in measuring wait times in order to drive improvements in patient flow. What is known about the topic? Wait times are common in out-patient and ambulatory services. These services experience high demand, which is likely to continue to grow as health service delivery shifts from hospital to community settings. What does this paper add? Although demand is an important driver of wait times, there are other modifiable factors that also contribute, including process inefficiencies and service disruption related to human resource issues. An underlying staff attitude of acceptance of wait times appears to be an additional barrier to improving access. What are the implications for practitioners? The findings of the present study suggest that there are opportunities for improving access to ambulatory and community health services through more efficient use of existing resources. However, a more consumer-focused approach regarding acceptability of wait times is needed to help drive change.

Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review.

BACKGROUND: To ensure quality of care delivery clinical supervision has been implemented in health services. While clinical supervision of health professionals has been shown to improve patient safety, its effect on other dimensions of quality of care is unknown. The purpose of this systematic review is to determine whether clinical supervision of health professionals improves effectiveness of care and patient experience. METHODS: Databases MEDLINE, PsychINFO, CINAHL, EMBASE and AMED were searched from earliest date available. Additional studies were identified by searching of reference lists and citation tracking. Two reviewers independently applied inclusion and exclusion criteria. The quality of each study was rated using the Medical Education Research Study Quality Instrument. Data were extracted on effectiveness of care (process of care and patient health outcomes) and patient experience. RESULTS: Seventeen studies across multiple health professions (medical (n = 4), nursing (n = 7), allied health (n = 2) and combination of nursing, medical and/or allied health (n = 4)) met the inclusion criteria. The clinical heterogeneity of the included studies precluded meta-analysis. Twelve of 14 studies investigating 38,483 episodes of care found that clinical supervision improved the process of care. This effect was most predominant in cardiopulmonary resuscitation and African health settings. Three of six studies investigating 1756 patients found that clinical supervision improved patient health outcomes, namely neurological recovery post cardiopulmonary resuscitation (n = 1) and psychological symptom severity (n = 2). None of three studies investigating 1856 patients found that clinical supervision had an effect on patient experience. CONCLUSIONS: Clinical supervision of health professionals is associated with effectiveness of care. The review found significant improvement in the process of care that may improve compliance with processes that are associated with enhanced patient health outcomes. While few studies found a direct effect on patient health outcomes, when provided to mental health professionals clinical supervision may be associated with a reduction in psychological symptoms of patients diagnosed with a mental illness. There was no association found between clinical supervision and the patient experience. REVIEW REGISTRATION: CRD42015029643 .

Does clinical supervision of health professionals improve patient safety? A systematic review and meta-analysis.

PURPOSE: To determine whether clinical supervision (CS) of health professionals improves patient safety. DATA SOURCES: Databases MEDLINE, PsychINFO, CINAHL, EMBASE and AMED were searched from earliest date available. Additional studies were identified by searching of reference lists and citation tracking. STUDY SELECTION: Two reviewers independently applied inclusion and exclusion criteria. Thirty-two studies across three health professions [medicine (n = 29), nursing (n = 2) and paramedicine (n = 1)] were selected. DATA EXTRACTION: The quality of each study was rated using the Medical Education Research Study Quality Instrument. Risk ratios (RR) were calculated for patient safety outcomes of mortality, complications, adverse events, reoperation following initial surgery, conversion to more invasive surgery and readmission to hospital. RESULTS OF DATA SYNTHESIS: Results of meta-analyses provided low-quality evidence that supervision of medical professionals reduced the risk of mortality (RR 0.76, 95% CI 0.60-0.95, I(2) = 76%) and supervision of medical professionals and paramedics reduced the risk of complications (RR 0.69, 95% CI 0.53-0.89, I(2) = 76%). Due to a high level of statistical heterogeneity, sub-group analyses were performed. Sub-group analyses provided moderate-quality evidence that direct supervision of surgery significantly reduced the risk of mortality (RR 0.68, 95% CI 0.50-0.93, I(2) = 33%) and direct supervision of medical professionals conducting non-surgical invasive procedures significantly reduced the risk of complications (RR 0.33, 95% CI 0.24-0.46, I(2) = 0%). CONCLUSIONS: CS was associated with safer surgery and other invasive procedures for medical practitioners. There was a lack of evidence about the relationship between CS and safer patient care for non-medical health professionals.

Effectiveness of clinical supervision of physiotherapists: a survey.

OBJECTIVES: Limited literature exists on the practice of clinical supervision (CS) of professional physiotherapists despite current Australian safety and quality health standards stating that CS is to be provided to all physiotherapists. The aim of the present study was to evaluate the effectiveness of CS of physiotherapists working in an Australian public health service. METHODS: CS was measured using the allied health-specific 26-item modified Manchester Clinical Supervision Scale (MCSS-26). Subscales of the MCSS-26 were summed for three domain scores (normative, restorative and formative) and a total score was calculated, which was compared with the reported threshold score of 73 for effective supervision. Sixty registered physiotherapists (response rate 92%), working for a large metropolitan public health service, with six different site locations, completed the survey. RESULTS: The mean (± s.d.) total MCSS-26 score was 71.0 ± 14.3 (95% confidence interval (CI) 67.4-74.6). Hospital site was the only variable that had a significant effect on total MCSS-26 score (P=0.005); there was no effect for supervisor or supervisee experience, or hospital setting (acute vs subacute). Physiotherapists scored a significantly lower mean percentage MCSS-26 score on the normative domain compared with the restorative domain (mean difference 7.8%; 95% CI 2.9-12.7; P=0.002) and the formative domain (mean difference 9.6%; 95% CI 6.3-13.0; P<0.001). Of the two subscales that form the normative domain, 'finding time' had a significantly lower mean percentage MCSS-26 score than 'importance/value of CS' (mean difference 35.4%; 95% CI 31.3-39.4; P<0.001). CONCLUSIONS: Within this publicly funded physiotherapy department there was uncertainty about the effectiveness of CS, with more than half the physiotherapists rating their supervision as less than effective, suggesting there is opportunity for improvement in the practice of physiotherapy CS. Physiotherapists scored lowest in the normative domain, indicating that they found it difficult to find time for CS.