[Patient motivation and prehabilitation: assessment often overlooked]. / Motivation du patient et préhabilitation : l'évaluation souvent oubliée.

Prehabilitation, which is still in its infancy, is becoming an essential part of oncology treatment. Motivation assessment is crucial for adherence to these programs, which aim to optimize functional capacity before and during the intensive phases of treatment. To date, healthcare teams have had little experience of assessing motivation, which is a weakness in the care strategy. This is partly due to a lack of standardized models and a delay in caregivers changing their position in response to changes in patient' motivations. In this article, we invite to discuss the 'why' and 'how' of motivational assessment in patients undergoing prehabilitation.

Improving Medication Management for Inpatients with a Secondary Diagnosis of Parkinson Disease.

ABSTRACT: Patients who have Parkinson disease require individualized medication regimens to optimize care. A review of the medication management of patients admitted to a tertiary care hospital with a secondary diagnosis of Parkinson disease found significant departures from the patients' home regimen. Medication regimens are often altered by health care teams unfamiliar with Parkinson disease-specific care in order to conform to standard hospital medication orders and administration times, potentially resulting in increased patient falls, delirium, and mortality.A nurse-led multidisciplinary team consisting of pharmacy, nursing, informatics, neurology, and quality personnel implemented a quality improvement (QI) project between July 2020 and July 2022 to identify patients with Parkinson disease, including those with a secondary diagnosis and those undergoing deep brain stimulation, and customize medication management in order to reduce length of stay, mortality, falls, falls with harm, and 30-day readmissions. The QI project team also evaluated patient satisfaction with medication management.Among patients with a secondary diagnosis of Parkinson disease, the proportion who had medication histories conducted by a pharmacy staff member increased from a baseline of 53% to more than 75% per month. For all patients with Parkinson disease, those whose medication history was taken by a pharmacy staff member had orders matching their home regimen 89% of the time, whereas those who did not had orders matching the home regimen only 40% of the time. Among patients with a secondary diagnosis of Parkinson disease, the length-of-stay index decreased from a baseline of 1 to 0.94 and observed-to-expected mortality decreased from 1.03 to 0.78. The proportion of patients experiencing a fall decreased from an average of 5% to 4.08% per quarter, while the proportion of patients experiencing a fall with harm decreased from an average of 1% to 0.75% per quarter. The rate of 30-day readmissions decreased from 10.81% to 4.53% per quarter. Patient satisfaction scores were 1.95 points higher for patients who had medication histories taken by pharmacy than for those who did not (5 versus 3.05).

Framework for an interprofessional experience addressing health and disability for health professional students.

BACKGROUND AND PURPOSE: A Health and Disabilities Interprofessional Education (IPE) course was implemented to join three healthcare disciplines together to collaboratively plan, implement, and reflect on professional roles and responsibilities. The goal and purpose of this course was to create an advancement of interprofessional education and practice within health science professions early in their students' programs utilizing innovative teaching methods working directly with individuals with disabilities. EDUCATIONAL ACTIVITY AND SETTING: 72 students were assigned to interprofessional teams of 10-11 people. Through asynchronous and synchronous learning activities, student teams worked together to plan and conduct community-based client interviews. FINDINGS: Quantitative and qualitative evaluation methods were used to explore the impact of interprofessional experiential learning experiences. Qualitative data showed a greater awareness and understanding of the different roles and responsibilities in interprofessional teams as well as a greater appreciation for the value of interacting with persons with disabilities (PWD) during their training. Quantitative data showed a significant change in students' understanding of their roles and responsibilities as a member of an interprofessional team, their confidence with working with PWD in a future healthcare capacity, as well as their understanding of how the social determinants of health may influence the healthcare experience of a PWD. SUMMARY: Interprofessional education and experiential learning opportunities are good ways to facilitate "real" patient care experiences and team roles and responsibilities. This enables healthcare students to practice communication, build relationships, and understand the lived experience of their patients.

Overcoming Barriers to Collaborative Team Practice: A System Approach.

All healthcare systems are challenged to provide sufficient access to appropriate care for the individuals and communities they serve. Among the commonly discussed interventions in an era of clinical shortages is the establishment of team-based care, where team members can practice at the top of their license. This solution ensures that talent and ability are amplified. However, this vision has been thwarted by several barriers. Recognizing that complex causes prevent team-based care, CommonSpirit Health leadership has embarked on a multifaceted implementation of tactics to mitigate the barriers. The strategy addresses issues ranging from regulations, laws, and payment practices to a lack of knowledge and understanding between professions. A combination of solutions, rather than discrete tactics, holds the key to the system's strategy. The complement of actions put in place at CommonSpirit Health has included new executive roles, dyad leadership models, shared multidisciplinary education, targeted advocacy, best practice playbooks, and the flexibility to individualize local models as part of the journey to a more effective and efficient model of care.

Improving morbidity and mortality in hip fragility fractures.

PURPOSE OF REVIEW: Hip fragility fractures (HFF) carry high morbidity and mortality for patients and will increase in frequency and in proportion to the average patient age. Provision of effective, timely care for these patients can decrease their morbidity and mortality and reduce the large burden they place on the healthcare system. RECENT FINDINGS: There are associative relationships between prefracture frailty, postoperative delirium and increased morbidity and mortality. The use of a multidisciplinary approach to HFF care has shown improved outcomes in care with focus on modifiable factors including admission to specialty care floor, use of peripheral nerve blocks preoperatively and Anesthesia and Physical Therapy involvement in the care team. Peripheral nerve blocks including pericapsular nerve group (PENG) blocks have shown benefit in lowering morbidity and mortality. SUMMARY: HFF are associated with >40% chance of continued pain and inability to return to prefracture functional status at 1 year as well as >30% mortality at 2 years. In this opinion piece, we will discuss how a multidisciplinary approach that includes Anesthesia as well as utilization of peripheral nerve blocks can help to lessen postoperative issues and improve recovery.

What is the power of a genomic multidisciplinary team approach? A systematic review of implementation and sustainability.

Due to the increasing complexity of genomic data interpretation, and need for close collaboration with clinical, laboratory, and research expertise, genomics often requires a multidisciplinary team (MDT) approach. This systematic review aims to establish the evidence for effectiveness of the genomic multidisciplinary team, and the implementation components of this model that can inform precision care. MEDLINE, Embase and PsycINFO databases were searched in 2022 and 2023. We included qualitative and quantitative studies of the genomic MDT, including observational and cohort studies, for diagnosis and management, and implementation outcomes of effectiveness, adoption, efficiency, safety, and acceptability. A narrative synthesis was mapped against the Genomic Medicine Integrative Research framework. 1530 studies were screened, and 17 papers met selection criteria. All studies pointed towards the effectiveness of the genomic MDT approach, with 10-78% diagnostic yield depending on clinical context, and an increased yield of 6-25% attributed to the MDT. The genomic MDT was found to be highly efficient in interpretation of variants of uncertain significance, timeliness for a rapid result, made a significant impact on management, and was acceptable for adoption by a wide variety of subspecialists. Only one study utilized an implementation science based approach. The genomic MDT approach appears to be highly effective and efficient, facilitating higher diagnostic rates and improved patient management. However, key gaps remain in health systems readiness for this collaborative model, and there is a lack of implementation science based research especially addressing the cost, sustainability, scale up, and equity of access.

School health-care team members' reflections of their promotion of sexual and reproductive health and rights (SRHR): Important but neglected.

OBJECTIVE: Young people are prioritized regarding the promotion and safeguarding of sexual and reproductive health and rights - SRHR. In Sweden, the school is seen as an important arena with members of the school health-care or SHC team as vital actors in this work. This study explored SRHR-related work in SHC teams in Sweden. METHODS: Within an explorative qualitative design, structured interviews were conducted with 33 nurses, counsellors, SHC unit managers and headmasters. Reflexive thematic analysis was applied, and two main themes found. RESULTS: SHC team members see SRHR as an urgent topic, but address it only 'when necessary', not systematically - and they experience a shortage of guidance and cooperation regarding SRHR-related work. Even in a country with agreement on the importance of SRHR for all and on providing holistic comprehensive sex education in schools, young people are left to chance - i.e., to the SRHR competence in the professionals they meet. CONCLUSION: SHC team members in Sweden see SRHR as an urgent topic but do not address it systematically. Moreover, they experience a shortage of guidance for their work. To avoid any professional stress of conscience and for equitable school health care regarding SRHR to be realized, research-informed policy needs to underline systematic, comparable and proactive practice.

Patient safety culture assessment before and after safety huddle implementation.

OBJECTIVE: To identify whether safety huddle implementation enabled a change in patient safety culture. METHOD: Quasi-experimental research that assessed patient safety culture before and after safety huddle implementation. RESULTS.: The study revealed that 53.98% completed the two safety culture assessments, with 60.1% adherence from the nursing team, with a statistically significant difference in the second assessment regarding perception of patient safety and adverse events notified (p < 0.00). Regarding good practice indicators, a statistically significant difference (p < 0.00) was observed in item 43 and improvement in almost all dimensions in the second safety culture assessment. The huddles totaled 105 days, with 100% adherence from the nursing team. Regarding checklist items, all presented satisfactory responses (above 50%). CONCLUSION: Safety huddles proved to be an effective tool for communication between healthcare professionals and managers, demonstrating positive impacts on good practice indicators and most safety culture dimensions.

A patient-centered evaluation of a novel medical student-based patient navigation program.

OBJECTIVES: Understand the patient experience of a pilot medical student-based patient navigator (PN) program. (2) Assess areas of improvement for further development as a model for expansion. METHODS: This was a cross-sectional study assessing patients' subjective experience of medical student navigators for rheumatological conditions. Current student navigators contacted enrolled patients by phone with both structured and free-response questions. RESULTS: 44 of 71 patients completed the questionnaire. 84% reported a satisfaction of ≥ 4 on a 5 point Likert scale. > 80% of patients felt that the program helped them better care for their health, feel more understood by their medical team, and feel cared for by their healthcare team. Medical student navigators were able to assist with most patient requests. CONCLUSIONS: Patients enrolled in our medical student PN program expressed high levels of satisfaction and felt better able to access health resources with the help of a navigator. PRACTICE IMPLICATIONS: Employing medical students as PNs may serve as a mutually beneficial intervention providing early clinical exposure to students while furthering patient access to care. Other institutions may benefit from similarly structured interventions.

Family Medicine Team Perspectives on Screening for Health-Related Social Needs.

INTRODUCTION: Social drivers of health (SDH) strongly influence health outcomes and disparities. Although systemic level change is vital to address the disparities driven by SDH, it is also crucial that health care organizations develop the ability to care for patients in a manner that accounts for social factors and their influence on patient health. Although primary care is a natural fit for health-related social needs (HRSN) screening and intervention, significant barriers can impede primary care's effectiveness in this area. METHODS: We conducted 3 focus groups with family medicine clinicians, clinical staff, and social care workers in an academic medical center using a semistructured discussion guide to explore current practices, perceived benefits, barriers, and potential opportunities and approaches for integrating routine HRSN screening in primary care. RESULTS: 3 primary themes emerged from the focus groups. They included 1) the barriers to routine screening in primary care, including time, workload, emotional burden, patient factors, and team members' fear of inadequacy of resources or their own ability; 2) the importance and benefit of HRSN screening, including the opportunity to improve patient care through increased care team awareness of the patient's context, interventions to address HRSN, and improved relationships between the care team and the patient; and 3) recommendations for implementing routine screening in primary care, including opportunities to optimize workflow and technology, the importance of an electronic medical record (EMR)-integrated resource database, and the centrality of teamwork. DISCUSSION: Family medicine health care teams embrace the importance of HRSN screening and the potential for positive impact. However, there are vital barriers and considerations to address for HRSN screening to be effectively integrated into primary care visits.

Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery?

BACKGROUND: International guidelines recommend preoperative multidisciplinary team (MDT) assessment for high-risk surgical patients. Preoperative MDT meetings can help to improve surgical care, but there is little evidence on whether they improve patient outcomes. METHODS: This paper aims to share our experience of MDT meetings for high-risk surgical patients to underline their added value to the current standard of care. An observational study of a retrospective cohort of preoperative high-risk MDT meetings of a tertiary referral hospital between January 2015 and December 2020. For 249 patients the outcomes preoperative data, MDT decisions, and patient outcomes were collected from electronic health records. MAIN RESULTS: A total of 249 patients were discussed at high-risk MDT meetings. Most of the patients (97%) were assessed as having an American Society of Anesthesiology score ≥ 3, and 219 (88%) had a European Society of Cardiology and European Society of Anaesthesiology risk score of intermediate or high. After MDT assessment, 154 (62%) were directly approved for surgery, and 39 (16%) were considered ineligible for surgery. The remaining 56 (23%) patients underwent additional assessments before reconsideration at a high-risk MDT meeting. The main reason for patients being discussed at the high-risk MDT meeting was to assess the risk-benefit ratio of surgery. Ultimately, 184 (74%) patients underwent surgery. Of the operated patients, 122 (66%) did not have a major complication in the postoperative period, and 149 patients (81%) were alive after one year. CONCLUSIONS: This cohort study shows the vulnerability and complexity of high-risk patients but also shows that the use of an MDT assessment contributes too improved peri- and postoperative treatment strategies in high-risk patients. Most patients underwent surgery after careful risk assessment and, if deemed necessary, preoperative and perioperative treatment optimization to reduce their risk.

A Combined Assessment Tool of Teamwork, Communication, and Workload in Hospital Procedural Units.

Teamwork, communication, and workload issues continue to contribute to patient safety events. The authors developed a diagnostic mixed methods toolkit combining a behavior observation tool, semistructured interview guide, and surveys to proactively identify relevant gaps. Applied across 14 units at three hospitals, this toolkit yielded 344 findings with 156 associated recommendations and took, on average, four days of observation. On a scale from 1 (not at all helpful) to 6 (substantially helpful), leaders indicated that the assessment and its recommendations were very helpful (median 5, interquartile range 5-6, 34 survey respondents, 47.9% individual-level response rate, 85.7% unit-level response rate). Integrating this tool into a broader safety strategy can help inform organizational improvement efforts.

Engaging resident physicians in the design, implementation, and assessment of bedside interdisciplinary rounds.

Bedside interdisciplinary rounds (IDR) improve teamwork, communication, and collaborative culture in inpatient settings. Implementation of bedside IDR in academic settings depends on engagement from resident physicians; however, little is known about their knowledge and preferences related to bedside IDR. The goal of this program was to identify medical resident perceptions about bedside IDR and to engage resident physicians in the design, implementation, and assessment of bedside IDR in an academic setting. This is a pre-post mixed methods survey assessing resident physicians' perceptions surrounding a stakeholder-informed bedside IDR quality improvement project. Resident physicians in the University of Colorado Internal Medicine Residency Program (n = 77 pre-implementation survey responses from 179 eligible participants - response rate 43%) were recruited via e-mail to participate in surveys assessing perceptions surrounding the inclusion of interprofessional team members, timing, and preferred structure of bedside IDR. A bedside IDR structure was created based on input from resident and attending physicians, patients, nurses, care coordinators, pharmacists, social workers, and rehabilitation specialists. This rounding structure was implemented on acute care wards in June 2019 at a large academic regional VA hospital in Aurora, CO. Resident physicians were surveyed post implementation (n = 58 post-implementation responses from 141 eligible participants - response rate 41%) about interprofessional input, timing, and satisfaction with bedside IDR. The pre-implementation survey revealed several important resident needs during bedside IDR. Post-implementation survey results revealed high overall satisfaction with bedside IDR among residents, improved perceived efficiency of rounds, preserved quality of education, and value added by interprofessional input. Results also suggested areas for future improvement including timeliness of rounds and enhanced systems-based teaching. This project successfully engaged residents as stakeholders in system-level interprofessional change by incorporating their values and preferences into a bedside IDR framework.

[Interdisciplinary multimodal assessment : Interprofessional interaction in team meetings and final talks]. / Interdisziplinäres Multimodales Assessment : Interprofessionelle Interaktion in Teamsitzung und Abschlussgespräch.

BACKGROUND: In PAIN2020 (Innovation Fund, 01NVF17049), an outpatient interdisciplinary multimodal assessment (IMA) was introduced early in the course of the disease. The central quality feature is the close interdisciplinary collaboration of pain medicine, physiotherapy and psychology, which requires a complex organizational and coordination process, especially in team meetings and final discussions. OBJECTIVES: The (different) views of the professional groups involved are brought together in the team process as a common consensus. The process of shaping the interaction of the professional groups among each other in the team meeting and final discussion as well as with the patients is examined (qualitatively) and discussed. METHODS: In PAIN2020, a workshop on IMA was held to jointly reflect on the insights and experiences gained in the process so far through monitoring with staff or teams of the PAIN2020 centers. In one of three work phases, interprofessionally composed groups gathered statements from participants on the design of the interaction in team meeting and final discussion in three rotating rounds within the framework of a World Café. RESULTS: It was possible to identify conducive and obstructive factors for the design of interdisciplinary collaboration in team meetings and final discussions, which were brought together in a superordinate framework model. DISCUSSION: The provision of the new care service as an interdisciplinary task in a team goes beyond existing structural and process parameters in the definition of framework conditions in interdisciplinary multimodal pain therapy and should therefore also take personal competencies and professional competencies into account. Therefore, new dimensions arise for the implementation of the IMA, which should be discussed in the future.

Does Interdisciplinary Care Team Care Management Improve Health Quality and Demonstrate Cost-Effectiveness?

This study evaluated the impact of an interdisciplinary care teams (IDCT) care management program on cost and quality outcomes using a novel algorithm to identify 400 high-risk patients out of 48,235 Medicare Advantage (MA) beneficiaries. Of the 400, 252 were enrolled in the IDCT care management intervention program, while the remaining 148 were not enrolled. A second comparison group consisted of 660 who were referred to the IDCT program but not selected by the algorithm. The program's effectiveness was evaluated 1-year postintervention. Analyses found that health care costs for members enrolled in the IDCT program were reduced by US$1,121.76 and US$1,625.61 per member per month, respectively, relative to those not enrolled and those enrolled by referral. The cost reduction from the program generated a net savings of US$1.9MM, covering the program's cost. Findings suggest IDCTs can cost-effectively manage populations of high-risk patients with better selection and fostering greater interdependence.

The Design of the Electronic Health Record in Type 1 Diabetes Centers: Implications for Metrics and Data Availability for a Quality Collaborative.

BACKGROUND: Systematic and comprehensive data acquisition from the electronic health record (EHR) is critical to the quality of data used to improve patient care. We described EHR tools, workflows, and data elements that contribute to core quality metrics in the Type 1 Diabetes Exchange Quality Improvement Collaborative (T1DX-QI). METHOD: We conducted interviews with quality improvement (QI) representatives at 13 T1DX-QI centers about their EHR tools, clinic workflows, and data elements. RESULTS: All centers had access to structured data tools, nine had access to patient questionnaires and two had integration with a device platform. There was significant variability in EHR tools, workflows, and data elements, thus the number of available metrics per center ranged from four to 17 at each site. Thirteen centers had information about glycemic outcomes and diabetes technology use. Seven centers had measurements of additional self-management behaviors. Centers captured patient-reported outcomes including social determinants of health (n = 9), depression (n = 11), transition to adult care (n = 7), and diabetes distress (n = 3). Various stakeholders captured data including health care professionals, educators, medical assistants, and QI coordinators. Centers that had a paired staffing model in clinic encounters distributed the burden of data capture across the health care team and was associated with a higher number of available data elements. CONCLUSIONS: The lack of standardization in EHR tools, workflows, and data elements captured resulted in variability in available metrics across centers. Further work is needed to support measurement and subsequent improvement in quality of care for individuals with type 1 diabetes.

The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation.

INTRODUCTION: One in three patients is affected by diagnosis-related communication failures. Only a few valid and reliable instruments that measure teamwork and communication exist, and none of those focus on improving diagnosis. The authors developed, refined, and psychometrically evaluated the TeamSTEPPSⓇ for Improving Diagnosis Team Assessment Tool (TAT), which assesses diagnostic teamwork and communication in five critical teamwork domains and can be used to identify strengths and opportunities for improvement and monitor performance. METHODS: The TAT was administered as a cross-sectional survey to 360 health professionals across nine diverse US health systems. Content and construct validity were evaluated through pilot implementation and subject matter expert review. Reliability and internal consistency were assessed with Cronbach's alpha. To understand sources of variation in TAT scores and assess the tool's consistency across diverse health care organizations, generalizability theory (G-theory) was used. Best practices in screening for careless responding identified participants with random or nonvarying responses. RESULTS: Analyses indicated strong support for the tool. Content validity findings indicated that the TAT encompassed relevant diagnostic improvement teamwork and communication content. Construct validity, evaluated through pilot implementations, demonstrated the tool's effectiveness in assessing teamwork categories. Reliability analyses confirmed the TAT's internal consistency, with an overall Cronbach's alpha of 0.97. Each dimension of the TAT exhibited good reliability coefficients, ranging from 0.83 to 0.95. G-theory analysis showed that variations in TAT scores were primarily attributed to respondents (28.0%) and scale dimensions (59.6%); both are desirable facets of variation. Further, examination of careless respondents ensured the accuracy and quality of the results, enhancing the TAT's credibility as a valuable diagnostic improvement tool. CONCLUSION: Psychometric evaluation demonstrated that the TAT is a reliable and valid instrument for assessing teamwork and communication among and across diagnostic teams. The TAT adds a novel, evidence-based, psychometrically sound measurement tool to help advance diagnostic teamwork and communication to improve patient care and outcomes.

Rural versus urban outcomes following transcatheter aortic valve implantation: The importance of the heart team.

BACKGROUND: Rural patients face known healthcare disparities and worse cardiovascular outcomes compared to urban residents due to inequitable access and delayed care. Few studies have assessed rural-urban differences in outcomes following Transcatheter Aortic Valve Implantation (TAVI). We compared short-term post-TAVI outcomes between rural and urban patients. METHODS: We performed a retrospective analysis of n = 413 patients who underwent TAVI at our large academic medical center, between 2011 and 2020 (rural/urban patients = 93/320. Rural/urban males = 53/173). Primary outcomes were all-cause mortality and cardiovascular mortality. Secondary outcomes included stroke/transient ischemic attack, myocardial infarction, atrial fibrillation, acute kidney injury, bleeding, vascular complications, and length of stay. RESULTS: The mean age in years was 77 [IQR 70-82] for rural patients and 78 [IQR 72-84] for urban patients. Baseline characteristics were similar between groups, except for a greater frequency of active smokers and diabetics as well as a greater body mass index in the rural group. There were no statistically significant differences in all-cause or cardiovascular mortality between the groups. There was also no statistically significant difference in secondary outcomes. CONCLUSION: Rural and urban patients had no statistically significant difference in all-cause mortality or cardiovascular mortality following TAVI. Given its minimally invasive nature and quality-centric, multidisciplinary care provided by the TAVI Heart Teams, TAVI may be the preferred modality for the treatment of severe aortic stenosis in rural populations.

Describing the evidence linking interprofessional education interventions to improving the delivery of safe and effective patient care: a scoping review.

Empirical evidence indicates that collaborative interprofessional practice leads to positive health outcomes. Further, there is an abundance of evidence examining student and/or faculty perceptions of learning or satisfaction about the interprofessional education (IPE) learning experience. However, there is a dearth of research linking IPE interventions to patient outcomes. The objective of this scoping review was to describe and summarize the evidence linking IPE interventions to the delivery of effective patient care. A three-step search strategy was utilized for this review with articles that met the following criteria: publications dated 2015-2020 using qualitative, quantitative or mixed methods; the inclusion of healthcare professionals, students, or practitioners who had experienced IPE or training that included at least two collaborators within coursework or other professional education; and at least one of ten Centers for Medicare & Medicaid Services quality measures (length of stay, medication errors, medical errors, patient satisfaction scores, medication adherence, patient and caregiver education, hospice usage, mortality, infection rates, and readmission rates). Overall, n=94 articles were identified, providing overwhelming evidence supporting a positive relationship between IPE interventions and several key quality health measures including length of stay, medical errors, patient satisfaction, patient or caregiver education, and mortality. Findings from this scoping review suggest a critical need for the development, implementation, and evaluation of IPE interventions to improve patient outcomes.