Establishing and maintaining a remote vascular surgery aortic program: A single-center 5-year experience at the Veterans Affairs.

OBJECTIVE: We sought to detail the process of establishing a surgical aortic telehealth program and report the outcomes of a 5-year experience. METHODS: A telehealth program was established between two regional Veterans Affairs hospitals, one of which was without a comprehensive aortic surgical program, until such a program was established at the referring institution. A retrospective review was performed of all patients who underwent aortic surgery from 2014 to 2019. The operative data, demographics, perioperative complications, and follow-up data were reviewed. RESULTS: From 2014 to 2019, 109 patients underwent aortic surgery for occlusive and aneurysmal disease. Preoperative evaluation and postoperative follow-up were done remotely via telehealth. The median age of the patients was 68 years, 107 were men (98.2%), 28 (25.7%) underwent open aortic repair, and 81 (74.3%) underwent endovascular repair. Of the 109 patients, 101 (92.7%) had a median follow-up of 24.3 months, 5 (4.6%) were lost to follow-up or were noncompliant, 2 (1.8%) were noncompliant with their follow-up imaging studies but responded to telephone interviews, and 1 (0.9%) moved to another state. At the 30-day follow-up, eight patients (7.3%) required readmission. Four complications were managed locally, and four patients (3.6%) required transfer back to the operative hospital for additional care. CONCLUSIONS: Telehealth is a great tool to provide perioperative care and long-term follow-up for patients with aortic pathologies in remote locations. Most postoperative care and complications can be managed remotely, and patient compliance for long-term follow-up is high.

Bending the quality curve.

With this paper, we initiate the Supplement on Deepening our Understanding of Quality in Australia (DUQuA). DUQuA is an at-scale, cross-sectional research programme examining the quality activities in 32 large hospitals across Australia. It is based on, with suitable modifications and extensions, the Deepening our Understanding of Quality improvement in Europe (DUQuE) research programme, also published as a Supplement in this Journal, in 2014. First, we briefly discuss key data about Australia, the health of its population and its health system. Then, to provide context for the work, we discuss previous activities on the quality of care and improvement leading up to the DUQuA studies. Next, we present a selection of key interventional studies and policy and institutional initiatives to date. Finally, we conclude by outlining, in brief, the aims and scope of the articles that follow in the Supplement. This first article acts as a framing vehicle for the DUQuA studies as a whole. Aggregated, the series of papers collectively attempts an answer to the questions: what is the relationship between quality strategies, both hospital-wide and at department level? and what are the relationships between the way care is organised, and the actual quality of care as delivered? Papers in the Supplement deal with a multiplicity of issues including: how the DUQuA investigators made progress over time, what the results mean in context, the scales designed or modified along the way for measuring the quality of care, methodological considerations and provision of lessons learnt for the benefit of future researchers.

The "Waze" of Inequity Reduction Frameworks for Organizations: a Scoping Review.

BACKGROUND: Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks. OBJECTIVE: To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable. STUDY DESIGN: Fourteen inequity frameworks from scoping literature review 2000-2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time. PARTICIPANTS: We conducted member check interviews with framework authors to verify our assessments. KEY RESULTS: Frameworks stressed assessing the organization's outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks. CONCLUSIONS: Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions.

A framework for value-creating learning health systems.

BACKGROUND: Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs. METHODS: The framework was developed by an interdisciplinary team at the Institut national d'excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts. RESULTS: The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs' strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs. CONCLUSIONS: Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.

Research and instruction services for online advanced practice nursing programs: a survey of North American academic librarians.

INTRODUCTION: The increasing popularity of distance education has led many advanced practice nursing (APN) programs to shift to either online or hybrid models. To meet the needs of these students, some nursing librarians are using technology for virtual research and instruction. This study was designed to assess the extent to which librarians in North America are providing virtual research and instruction services for APN students. METHODS: An institutional review board-approved, ten-question survey was developed to determine how librarians are providing services for APN students. It was announced in October 2017 through several health sciences librarian email discussion lists. The survey ran for four weeks. Data were analyzed using Qualtrics and Excel. RESULTS: Eighty complete responses were received. The majority of respondents (66%) indicated that their universities' APN programs were conducted in a hybrid format. Sixty-seven percent also indicated that they provide library instruction in person. Most librarians indicated that they have provided research assistance through some virtual method (phone or email, at 90% and 97%, respectively), and some have used online chat (42%) and video chat (35%). A strong majority of librarians (96%) indicated that they felt comfortable using technology to provide research assistance and instruction. CONCLUSION: Opportunities exist to leverage technology to provide virtual research assistance and instruction. Greater promotion of these alternative methods can supplement traditional in-person services to provide greater flexibility for graduate nursing students' busy schedules. Some outreach may be necessary to highlight the advantages of virtual services, and further research is needed to identify other barriers and potential solutions.

Simplification and optimization of transcatheter aortic valve implantation - fast-track course without compromising safety and efficacy.

Transcatheter aortic valve implantation (TAVI) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis. Ageing of the Western and Asian population and expansion of indications for TAVI will lead to a substantial increase in the number of TAVI procedures performed worldwide within the next decades. In line with the maturation of TAVI over the past few years, there has also been a significant simplification and optimisation of the TAVI procedure. A minimalist TAVI procedure and fast-track TAVI course have been shown to have distinct advantages over the more traditional TAVI approach. The aim of this manuscript is to discuss strategies of TAVI simplification and optimization, with special focus on fast-track TAVI, without compromising safety and efficacy.

Safe working in a 7-day service. Experience of hip fracture care as documented by the UK National Hip Fracture Database.

Objective: to describe differences in care and 30-day mortality of patients admitted with hip fracture on weekends (Saturday-Sunday) compared to weekdays (Monday-Friday), and their relationship to the organisation of care. Methods: data came from the National Hip Fracture Database (NHFD) linked to ONS mortality data on 52,599 patients presenting to 162 units in England between 1 January and 31 December 2014. This was combined with information on geriatrician staffing and major trauma centre (MTC) status. 30-day mortality and care were compared for patients admitted at weekends and weekdays; separately for patients treated in units grouped by the mean level of input by geriatricians, weekend geriatrician clinical cover and MTC status. Differences were adjusted for variation in patients' characteristics. Results: there was no evidence of differences in 30-day mortality between patients admitted at weekends compared to weekdays (7.2 vs 7.5%, P = 0.3) before or after adjusting for patient characteristics in either MTCs or general hospitals. The proportion receiving a preoperative geriatrician assessment was lower at weekends (42.8 vs 60.7%, P < 0.001). 30-day mortality was lower in units with higher levels of geriatrician input, but there was no weekend mortality effect associated with lower levels of input or absence of weekend cover. Conclusion: there was no evidence of a weekend mortality effect among patients treated for hip fracture in the English NHS. It appears that clinical teams provide comparably safe and effective care throughout the week. However, greater geriatrician involvement in teams was associated with overall lower mortality.

State-based Review of Maternal Deaths: The Ohio Experience.

Ohio established a Pregnancy-Associated Mortality Review system in 2010 to ensure that all maternal deaths are identified and preventive actions developed. The need for detailed and reliable information to supplement vital statistics data has led to the development of state-based and urban-based maternal death reviews. Although processes vary from state to state, in general, an expert panel is convened to review individual cases and make recommendations for systems change. This article describes the development and operation of Ohio's state-based maternal death review including interventions developed and actions taken based on review data.

Reducing Maternal Mortality and Severe Maternal Morbidity Through State-based Quality Improvement Initiatives.

State Perinatal Quality Collaboratives (PQCs) represent a major advance for scaling up quality improvement efforts for reducing maternal mortality and severe maternal morbidity. The critical roles of partners, rapid-cycle low-burden data systems, and linkage to maternal mortality review committees are reviewed. The choice of measures is also explored. California's experience with its PQC, data center, quality improvement efforts, and promising results for reduction of maternal mortality and morbidity from hemorrhage are presented. Early data from other states is also shared.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

The Centers for Disease Control and Prevention's Hospital Sepsis Program Core Elements.

This Viewpoint discusses Hospital Sepsis Program Core Elements, a set of guidance provided by the Centers for Disease Control and Prevention to help hospitals develop multiprofessional programs that monitor and optimize management and outcomes of sepsis.

Implementing iRound: A Computer-Based Auditing Tool.

Many hospitals use rounding or auditing as a tool to help identify gaps and needs in quality and process performance. Some hospitals are also using rounding to help improve patient experience. It is known that purposeful rounding helps improve Hospital Consumer Assessment of Healthcare Providers and Systems scores by helping manage patient expectations, provide service recovery, and recognize quality caregivers. Rounding works when a standard method is used across the facility, where data are comparable and trustworthy. This facility had a pen-and-paper process in place that made data reporting difficult, created a silo culture between departments, and most audits and rounds were completed differently on each unit. It was recognized that this facility needed to standardize the rounding and auditing process. The tool created by the Advisory Board called iRound was chosen as the tool this facility would use for patient experience rounds as well as process and quality rounding. The success of the iRound tool in this facility depended on several factors that started many months before implementation to current everyday usage.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. / Standarddatensatz für die Evaluation bei Selektivverträgen bei Ulcus cruris : Nationaler Konsensus.

BACKGROUND: Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES: Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS: Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS: For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS: The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

Measuring healthcare productivity - from unit to system level.

Purpose - Healthcare productivity is a growing issue in most Western countries where healthcare expenditure is rapidly increasing. Therefore, accurate productivity metrics are essential to avoid sub-optimization within a healthcare system. The purpose of this paper is to focus on healthcare production system productivity measurement. Design/methodology/approach - Traditionally, healthcare productivity has been studied and measured independently at the unit, organization and system level. Suggesting that productivity measurement should be done in different levels, while simultaneously linking productivity measurement to incentives, this study presents the challenges of productivity measurement at the different levels. The study introduces different methods to measure productivity in healthcare. In addition, it provides background information on the methods used to measure productivity and the parameters used in these methods. A pilot investigation of productivity measurement is used to illustrate the challenges of measurement, to test the developed measures and to prove the practical information for managers. Findings - The study introduces different approaches and methods to measure productivity in healthcare. Practical implications - A pilot investigation of productivity measurement is used to illustrate the challenges of measurement, to test the developed measures and to prove the practical benefits for managers. Originality/value - The authors focus on the measurement of the whole healthcare production system and try to avoid sub-optimization. Additionally considering an individual patient approach, productivity measurement is examined at the unit level, the organizational level and the system level.

Measuring patient satisfaction in complex continuing care/rehabilitation care.

Purpose - The purpose of this paper is to develop a psychometrically validated survey to assess satisfaction in complex continuing care (CCC)/rehabilitation patients. Design/methodology/approach - A paper or computer-based survey was administered to 252 CCC/rehabilitation patients (i.e. post-acute hospital care setting for people who require ongoing care before returning home) across two hospitals in Toronto, Ontario, Canada. Findings - Using factor analysis, five domains were identified with loadings above 0.4 for all but one item. Behavioral intention and information/communication showed the lowest patient satisfaction, while patient centredness the highest. Each domain correlated positively and significantly predicted overall satisfaction, with quality and safety showing the strongest predictive power and the healing environment the weakest. Gender made a significant contribution to predicting overall satisfaction, but age did not. Research limitations/implications - Results provide evidence of the survey's psychometric properties. Owing to a small sample, supplemental testing with a larger patient group is required to confirm the five-factor structure and to assess test-retest reliability. Originality/value - Improving the health system requires integrating patient perspectives. The patient experience, however, will vary depending on the population being served. This is the first psychometrically validated survey specific to a smaller specialty patient group receiving care at a CCC/rehabilitation facility in Canada.

The Experience of Patients Engaged in Co-designing Care Processes.

This article presents the experiences of patients engaged in co-designing care under a program entitled, "Transforming Care at the Bedside," based at an academic health sciences center. This descriptive, qualitative study collected data through individual interviews. Participants included patients from 5 units in an academic health sciences center in Quebec, Canada. A total of 6 individual interviews were conducted in November 2014, 15 months after the Transforming Care at the Bedside work began in September 2013. Content analysis was used to analyze the qualitative data. Being listened to and informed gave patients an opportunity to better understand patient needs and the complexity of care in the unit and in the organization. The experience enabled patients to better translate the patient experience for the team's benefit and influence the team's perspective and decisions. Through this experience, several patients felt motivated and empowered and that they afforded consideration through this experience. This study highlights the importance of creating opportunities for patients and health care providers to share their unique experiences and expertise to better understand each other's reality. In this context, they developed a more comprehensive understanding of the issues and worked together to implement realistic changes on behalf of the patients.

Performance Measurement for People with Multimorbidity and Complex Health Needs.

This paper reviews approaches to performance measurement in health systems with particular attention to people with multimorbidity and complex health needs. Performance measurement should be informative and used by multiple stakeholders in order to align performance improvement efforts. System performance measures must allow for macro-system and meso-organization and provider-level reporting, and they should be relevant and important to stakeholders at each level, as well as to patients and all potential care recipients. Measures that assess health outcomes and individuals' experiences with providers, including care planning and coordination of care across providers, are essential to assess value for people with multimorbidity and complex health needs. I suggest that performance measurement for this population should be motivated by the Complexity Framework and organized by the Triple Aim. Based on the care needs and appropriate goals for the health system for this population, applicable measures and suggestions for implementing and using performance measurement systems are identified. Particularly in the case of people with multimorbidity and complex health needs, performance measures must move beyond measures specific to individual encounters to track care for people over time and space. Measures must be rooted in individuals' own needs and goals for care. New systems are required to enable collection and reporting of these measures.

Evaluation of collected outcome measures in axial spondyloarthritis in daily-care rheumatology settings: the experience of the RHEVER network.

OBJECTIVES: Nowadays, the recommended measures for optimal monitoring of axial Spondyloarthritis (ax-SpA) disease activity are either BASDAI and CRP, or ASDAS-CRP. However, there could be a gap between recommendations and daily practice. We aimed to determine the measures collected by rheumatologists in an ax-SpA follow-up visit, and to determine the impact of a meeting (where rheumatologists reached a consensus on the measures to be collected) on the collection of such measures. METHODS: A consensual meeting of a local network of 32 rheumatologists proposed, four months later, to report at least the BASDAI score in the medical file of every ax-SpA patient at every follow-up visit. An independent investigator reviewed the medical files of 10 consecutive patients per rheumatologist, seen twice during the year (e.g. before and after the meeting). The most frequently collected measures were assessed, and then, the frequency of collection before and after the meeting was compared. RESULTS: A total of 456 medical files from 228 patients were reviewed. Treatment (>60%), CRP (51.3%) and total BASDAI (28.5%) were the most reported measures in medical files. Before/After the meeting, the frequencies of collected measures in medical files were 28.5%/51.7%, 51.3%/52.2%, 16.7%/31.6% and 0.9%/6.1% for BASDAI, CRP, BASDAI + CRP and ASDAS, respectively reaching a statistically significance for BASDAI, ASDAS and BASDAI+CRP (p<0.05). CONCLUSIONS: This study revealed a low rate of systematic report of the recommended outcome measures in ax-SpA. However, it suggests that a consensual meeting involving practicing rheumatologists might be relevant to improve the implementation of such recommendations.

The second national audit of intermediate care.

Intermediate care services have developed internationally to expedite discharge from hospital and to provide an alternative to an emergency hospital admission. Inconsistencies in the evidence base and under-developed governance structures led to concerns about the care quality, outcomes and provision of intermediate care in the NHS. The National Audit of Intermediate Care was therefore established by an interdisciplinary group. The second national audit reported in 2013 and included crisis response teams, home-based and bed-based services in approximately a half of the NHS. The main findings were evidence of weak local strategic planning, considerable under-provision, delays in accessing the services and lack of mental health involvement in care. There was a very high level of positive patient experience reported across all types of intermediate care, though reported involvement with care decisions was less satisfactory.

Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.