The assessment of general movements in term and late-preterm infants diagnosed with neonatal encephalopathy, as a predictive tool of cerebral palsy by 2 years of age-a scoping review.

BACKGROUND: The General Movements Assessment is a non-invasive and cost-effective tool with demonstrated reliability for identifying infants at risk for cerebral palsy. Early detection of cerebral palsy allows for the implementation of early intervention and is associated with better functional outcomes. No review to date has summarized the utility of the General Movements Assessment to predict cerebral palsy in term and late-preterm infants diagnosed with neonatal encephalopathy. METHODS: We conducted a scoping review involving infants born greater than or equal to 34 weeks gestational age to identify all available evidence and delineate research gaps. We extracted data on sensitivity, specificity, and positive and negative predictive values and described the strengths and limitations of the results. We searched five databases (MEDLINE, Embase, PsychINFO, Scopus, and CINAHL) and the General Movements Trust website. Two reviewers conducted all screening and data extraction independently. The articles were categorized according to key findings, and a critical appraisal was performed. RESULTS: Only three studies, a cohort and two case series, met all of the inclusion criteria. The total number of participants was 118. None of the final eligible studies included late-preterm neonates. All three studies reported on sensitivity, specificity, and positive predictive and negative predictive values. An abnormal General Movement Assessment at 3-5 months has a high specificity (84.6-98%) for cerebral palsy with a similarly high negative predictive value (84.6-98%) when it was normal. Absent fidgety movements, in particular, are highly specific (96%) for moderate to severe cerebral palsy and carry a high negative predictive value (98%) when normal. In the time period between term and 4-5 months post-term, any cramped synchronized movements had results of 100% sensitivity and variable results for specificity, positive predictive value, and negative predictive value. CONCLUSIONS: A normal General Movements Assessment at 3 months in a term high-risk infant is likely associated with a low risk for moderate/severe cerebral palsy. The finding of cramped synchronized General Movements is a strong predictor for the diagnosis of cerebral palsy by 2 years of age in the term population with neonatal encephalopathy. The deficit of high-quality research limits the applicability, and so the General Movements Assessment should not be used in isolation when assessing this population. SYSTEMATIC REVIEW REGISTRATION: Title registration with Joanna Briggs Institute. URL: http://joannabriggswebdev.org/research/registered_titles.aspx .

What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review.

Industrial improvement approaches such as Lean management are increasingly being adopted in health care. Synthesis is necessary to ensure these approaches are evidence based and requires operationalization of concepts to ensure all relevant studies are included. This article outlines the process utilized to develop an operational definition of Lean in health care. The literature search, screening, data extraction, and data synthesis processes followed the recommendations outlined by the Cochrane Collaboration. Development of the operational definition utilized the methods prescribed by Kinsman et al. and Wieland et al. This involved extracting characteristics of Lean, synthesizing similar components to establish an operational definition, applying this definition, and updating the definition to address shortcomings. We identified two defining characteristics of Lean health-care management: (1) Lean philosophy, consisting of Lean principles and continuous improvement, and (2) Lean activities, which include Lean assessment activities and Lean improvement activities. The resulting operational definition requires that an organization or subunit of an organization had integrated Lean philosophy into the organization's mandate, guidelines, or policies and utilized at least one Lean assessment activity or Lean improvement activity. This operational definition of Lean management in health care will act as an objective screening criterion for our systematic review. To our knowledge, this is the first evidence-based operational definition of Lean management in health care.

Effects of oncological care pathways in primary and secondary care on patient, professional, and health systems outcomes: protocol for a systematic review and meta-analysis.

BACKGROUND: The high impact of a cancer diagnosis on patients and their families and the increasing costs of cancer treatment call for optimal and efficient oncological care. To improve the quality of care and to minimize healthcare costs and its economic burden, many healthcare organizations introduce care pathways to improve efficiency across the continuum of cancer care. However, there is limited research on the effects of cancer care pathways in different settings. METHODS: The aim of this systematic review and meta-analysis described in this protocol is to synthesize existing literature on the effects of oncological care pathways. We will conduct a systematic search strategy to identify all relevant literature in several biomedical databases, including Cochrane library, MEDLINE, Embase, and CINAHL. We will follow the methodology of Cochrane Effective Practice and Organisation of Care (EPOC), and we will include randomized trials, non-randomized trials, controlled before-after studies, and interrupted time series studies. In addition, we will include full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses), cost analyses, and comparative resource utilization studies, if available. Two reviewers will independently screen all studies and evaluate those included for risk of bias. From these studies, we will extract data regarding patient, professional, and health systems outcomes. Our systematic review will follow the PRISMA set of items for reporting in systematic reviews and meta-analyses. DISCUSSION: Following the protocol outlined in this article, we aim to identify, assess, and synthesize all available evidence in order to provide an evidence base on the effects of oncological care pathways as reported in the literature. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017057592 .

Patient family advisors' perspectives on engagement in health-care quality improvement initiatives: Power and partnership.

BACKGROUND: Engagement of the public in defining and shaping the organization and delivery of health care is increasingly viewed as integral to improving quality and promoting transparent decision making. Meaningful engagement of the public in health-care reform is predicated on shifting entrenched power imbalances between health-care systems and those it claims to serve. OBJECTIVES: To describe the expressions, forms and spaces of power from the perspectives of persons who participated as Patient/Family Advisors (PFAs) in Rapid Process Improvement Workshops (RPIWs) within Saskatchewan, Canada. METHODS: Using a qualitative, interpretive approach, in-depth interviews were conducted with a purposive sample of 18 PFAs who had participated in at least one RPIW over the past year. Deductive thematic analysis was informed by Gaventa's model of power. RESULTS: Motivations for serving as a PFA included a sense of obligation to contribute to the improvement of a public system, recognition of their rights as citizens within a publicly funded system and an opportunity to openly express their concerns where previous encounters had been very negative. The invited spaces of the RPIWs were created by policymakers to accord visible power to PFAs. Participation resulted in PFAs gaining new insights into the structure and operations of the system, affirmation of their right to advocate and recognition of the potential to claim spaces of power as consumers. Advisement on specific health-care initiatives using the vehicle of PFAs shaped and promoted new forms and spaces of power, representing one step in a very long road to full engagement of consumers in health care.

Use of videoconferencing for physical therapy in people with musculoskeletal conditions: A systematic review.

Background Physical therapists are key players in the management of musculoskeletal conditions, which are common in rural and remote communities. There are few physical therapists in rural regions compared to potential need, so care is either not provided or must be sought in urban centers, requiring travel and time away from work and family to access services. Telerehabilitation strategies, such as real-time videoconferencing, are emerging as possible solutions to address shortages in rural physical therapy services. Objectives This review will: (1) determine the validity and the reliability of secure videoconferencing for physical therapy management of musculoskeletal conditions; (2) determine the health, system, and process outcomes when using secure videoconferencing for physical therapy management of musculoskeletal conditions. Methods A protocol-driven systematic review of four databases was carried out by two independent reviewers. Study criteria included English language articles from January 2003 to December 2016, on physical therapy management using secure videoconferencing, pertaining to adults 18-80 years with chronic musculoskeletal disorders. Randomized controlled trials, pre-experimental studies, and case-control studies were included. Quality analysis was performed utilizing standardized tools specific for the study designs. Results and conclusions Validity and reliability studies were identified as having high risk of bias. Intervention studies were of moderate quality, and found positive impact on health outcomes and satisfaction. Two studies evaluated costs, with evidence of cost savings in one study. More robust research is required to evaluate long-term effects of telerehabilitation for physical therapy management of musculoskeletal disorders, including cost-benefit analyses.

An economic analysis of a system wide Lean approach: cost estimations for the implementation of Lean in the Saskatchewan healthcare system for 2012-2014.

BACKGROUND: The costs of investing in health care reform initiatives to improve quality and safety have been underreported and are often underestimated. This paper reports direct and indirect cost estimates for the initial phase of the province-wide implementation of Lean activities in Saskatchewan, Canada. METHODS: In order to obtain detailed information about each type of Lean event, as well as the total number of corresponding Lean events, we used the Provincial Kaizen Promotion Office (PKPO) Kaizen database. While the indirect cost of Lean implementation has been estimated using the corresponding wage rate for the event participants, the direct cost has been estimated using the fees paid to the consultant and other relevant expenses. RESULTS: The total cost for implementation of Lean over two years (2012-2014), including consultants and new hires, ranged from $44 million CAD to $49.6 million CAD, depending upon the assumptions used. Consultant costs accounted for close to 50% of the total. The estimated cost of Lean events alone ranged from $16 million CAD to $19.5 million CAD, with Rapid Process Improvement Workshops requiring the highest input of resources. CONCLUSIONS: Recognizing the substantial financial and human investments required to undertake reforms designed to improve quality and contain cost, policy makers must carefully consider whether and how these efforts result in the desired transformations. Evaluation of the outcomes of these investments must be part of the accountability framework, even prior to implementation.

Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol).

BACKGROUND: Lean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer's needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited. METHODS: This is a protocol for a systematic review, following the Cochrane Effective Practice and Organisation of Care (EPOC) methodology. The review aims to document, catalogue and synthesize the existing literature on the effects of lean implementation in health care settings especially the potential effects on professional practice and health care outcomes. We have developed a Medline keyword search strategy, and this focused strategy will be translated into other databases. All search strategies will be provided in the review. The method proposed by the Cochrane EPOC group regarding randomized study designs, non-randomised controlled trials controlled before and after studies and interrupted time series will be followed. In addition, we will also include cohort, case-control studies, and relevant non-comparative publications such as case reports. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the reported types of implementation in the primary studies. We will present the results of studies in a tabular form. DISCUSSION: Overall, the systematic review aims to identify, assess and synthesize the evidence to underpin the implementation of lean activities in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and implementation methodologies reported in health care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42014008853.

"The largest Lean transformation in the world": the implementation and evaluation of lean in Saskatchewan healthcare.

The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial.

BACKGROUND: The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. DESIGN/METHODS: We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. DISCUSSION: This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01815710.

The effects of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review and meta-analysis.

This paper is a summary version of the previously published Cochrane review. It may increase the reach of the topic to health researchers and practitioners and encourage further discussion. The systematic review aims to summarize the evidence and assess the effect of clinical pathways on professional practice, patient outcomes, length of hospital stay, and hospital costs. The authors searched the Database of Abstracts of Reviews of Effectiveness, the Effective Practice and Organisation of Care Register, the Cochrane Central Register of Controlled Trials and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED, and Global Health. Twenty-seven studies considering a total of 11,398 participants were included for analysis. The main results were a reduction in in-hospital complications (odds ratio 0.58: 95% CI [0.36, 0.94] and improved documentation (odds ratio 11.95: 95% CI [4.72, 30.30]) associated with clinical pathways. Considerable variation in study design and settings prevented statistical pooling of results for length of stay (LOS) and hospital costs. The authors concluded that clinical pathways are associated with reduced in-hospital complications and improved documentation.

Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs.

BACKGROUND: Clinical pathways are structured multidisciplinary care plans used by health services to detail essential steps in the care of patients with a specific clinical problem. They aim to link evidence to practice and optimise clinical outcomes whilst maximising clinical efficiency. OBJECTIVES: To assess the effect of clinical pathways on professional practice, patient outcomes, length of stay and hospital costs. SEARCH STRATEGY: We searched the Database of Abstracts of Reviews of Effectiveness (DARE), the Effective Practice and Organisation of Care (EPOC) Register, the Cochrane Central Register of Controlled Trials (CENTRAL) and bibliographic databases including MEDLINE, EMBASE, CINAHL, NHS EED and Global Health. We also searched the reference lists of relevant articles and contacted relevant professional organisations. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time series studies comparing stand alone clinical pathways with usual care as well as clinical pathways as part of a multifaceted intervention with usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently screened all titles to assess eligibility and methodological quality. Studies were grouped into those comparing clinical pathways with usual care and those comparing clinical pathways as part of a multifaceted intervention with usual care. MAIN RESULTS: Twenty-seven studies involving 11,398 participants met the eligibility and study quality criteria for inclusion. Twenty studies compared stand alone clinical pathways with usual care. These studies indicated a reduction in in-hospital complications (odds ratio (OR) 0.58; 95% confidence interval (CI) 0.36 to 0.94) and improved documentation (OR 13.65: 95%CI 5.38 to 34.64). There was no evidence of differences in readmission to hospital or in-hospital mortality. Length of stay was the most commonly employed outcome measure with most studies reporting significant reductions. A decrease in hospital costs/ charges was also observed, ranging from WMD +261 US$ favouring usual care to WMD -4919 US$ favouring clinical pathways (in US$ dollar standardized to the year 2000). Considerable heterogeneity prevented meta-analysis of length of stay and hospital cost results. An assessment of whether lower hospital costs contributed to cost shifting to another health sector was not undertaken.Seven studies compared clinical pathways as part of a multifaceted intervention with usual care. No evidence of differences were found between intervention and control groups. AUTHORS' CONCLUSIONS: Clinical pathways are associated with reduced in-hospital complications and improved documentation without negatively impacting on length of stay and hospital costs.

A systematic review and meta-analysis of the effects of clinical pathways on length of stay, hospital costs and patient outcomes.

BACKGROUND: To perform a systematic review about the effect of using clinical pathways on length of stay (LOS), hospital costs and patient outcomes. To provide a framework for local healthcare organisations considering the effectiveness of clinical pathways as a patient management strategy. METHODS: As participants, we considered hospitalized children and adults of every age and indication whose treatment involved the management strategy "clinical pathways". We include only randomised controlled trials (RCT) and controlled clinical trials (CCT), not restricted by language or country of publication. Single measures of continuous and dichotomous study outcomes were extracted from each study. Separate analyses were done in order to compare effects of clinical pathways on length of stay (LOS), hospital costs and patient outcomes. A random effects meta-analysis was performed with untransformed and log transformed outcomes. RESULTS: In total 17 trials met inclusion criteria, representing 4,070 patients. The quality of the included studies was moderate and studies reporting economic data can be described by a very limited scope of evaluation. In general, the majority of studies reporting economic data (LOS and hospital costs) showed a positive impact. Out of 16 reporting effects on LOS, 12 found significant shortening. Furthermore, in a subgroup-analysis, clinical pathways for invasive procedures showed a stronger LOS reduction (weighted mean difference (WMD) -2.5 days versus -0.8 days)).There was no evidence of differences in readmission to hospitals or in-hospital complications. The overall Odds Ratio (OR) for re-admission was 1.1 (95% CI: 0.57 to 2.08) and for in-hospital complications, the overall OR was 0.7 (95% CI: 0.49 to 1.0). Six studies examined costs, and four showed significantly lower costs for the pathway group. However, heterogeneity between studies reporting on LOS and cost effects was substantial. CONCLUSION: As a result of the relatively small number of studies meeting inclusion criteria, this evidence base is not conclusive enough to provide a replicable framework for all pathway strategies. Considering the clinical areas for implementation, clinical pathways seem to be effective especially for invasive care. When implementing clinical pathways, the decision makers need to consider the benefits and costs under different circumstances (e.g. market forces).