Collaborative Integration of Community Health Workers in Hospitals and Health Centers to Reduce Pediatric Asthma Disparities: A Quality Improvement Program Evaluation.

To address pediatric asthma disparities on the South Side of Chicago, a community health worker (CHW) home visiting intervention was implemented collaboratively by academic institutions and community based health centers. This evaluation assessed the effectiveness of this longitudinal quality improvement CHW intervention in reducing asthma morbidity and healthcare utilization. All patients aged 2-18 who met the high-risk clinical criteria in outpatient settings or those who visited the ED due to asthma were offered the program. A within-subject study design analyzed asthma morbidity and healthcare utilization at baseline and follow-up. Multivariable mixed-effects regression models, adjusted for baseline demographic and asthma characteristics, were used to assess changes over time. Among 123 patients, the average age was 8.8 (4.4) years, and 89.3% were non-Hispanic black. Significant reductions were observed in the average daytime symptoms days (baseline 4.1 days and follow-up 1.6 days), night-time symptoms days (3.0 days and 1.2 days), and days requiring rescue medication (4.1 days and 1.6 days) in the past two weeks (all p < 0.001). The average number of emergency department visits decreased from 0.92 one year before to 0.44 one year after program participation, a 52% reduction (p < 0.001). No significant difference was found in hospital admissions. These results support the use of a collaborative approach to implement the CHW home visiting program as part of standard care for pediatric asthma patients in urban settings. This approach has the potential to reduce asthma disparities and underscores the valuable role of CHWs within the clinical care team.

Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature.

PURPOSE: Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians. METHODS: We conducted a critical interpretive synthesis. We searched 7 databases for papers published in English from database inception until October 2017 for primary research of any design that addressed problems interfering with primary care physicians' work. All potentially eligible titles/abstracts were screened by 1 reviewer; 30% were subject to second screening. We conducted an iterative critique, analysis, and synthesis of included studies. RESULTS: Our search retrieved 8,544 unique citations. Though no paper explicitly referred to "operational failures," we identified 95 papers that conformed to our general definition. The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures-including those relating to technology, information, and coordination-over which physicians often had limited control. Operational failures actively configured physicians' work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience. CONCLUSIONS: Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.

Interventions to improve team effectiveness within health care: a systematic review of the past decade.

BACKGROUND: A high variety of team interventions aims to improve team performance outcomes. In 2008, we conducted a systematic review to provide an overview of the scientific studies focused on these interventions. However, over the past decade, the literature on team interventions has rapidly evolved. An updated overview is therefore required, and it will focus on all possible team interventions without restrictions to a type of intervention, setting, or research design. OBJECTIVES: To review the literature from the past decade on interventions with the goal of improving team effectiveness within healthcare organizations and identify the "evidence base" levels of the research. METHODS: Seven major databases were systematically searched for relevant articles published between 2008 and July 2018. Of the original search yield of 6025 studies, 297 studies met the inclusion criteria according to three independent authors and were subsequently included for analysis. The Grading of Recommendations, Assessment, Development, and Evaluation Scale was used to assess the level of empirical evidence. RESULTS: Three types of interventions were distinguished: (1) Training, which is sub-divided into training that is based on predefined principles (i.e. CRM: crew resource management and TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety), on a specific method (i.e. simulation), or on general team training. (2) Tools covers tools that structure (i.e. SBAR: Situation, Background, Assessment, and Recommendation, (de)briefing checklists, and rounds), facilitate (through communication technology), or trigger (through monitoring and feedback) teamwork. (3) Organizational (re)design is about (re)designing structures to stimulate team processes and team functioning. (4) A programme is a combination of the previous types. The majority of studies evaluated a training focused on the (acute) hospital care setting. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements. CONCLUSION: Over the last decade, the number of studies on team interventions has increased exponentially. At the same time, research tends to focus on certain interventions, settings, and/or outcomes. Principle-based training (i.e. CRM and TeamSTEPPS) and simulation-based training seem to provide the greatest opportunities for reaching the improvement goals in team functioning.

Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement.

BACKGROUND: The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY: We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS: Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning.

The US Health Provider Workforce: Determinants and Potential Paths to Enhancement.

The health provider workforce is shaped by factors collectively influencing the education, training, licensing, and certification of physicians and allied health professionals, through professional organizations with interlocking and often opaque governance relationships within a state-based licensing system. This system produces a workforce is that is insufficiently responsive to current needs and opportunities, including those created by new technologies. This lack of responsiveness reflects the complex, nontransparent, and cautious nature of the controlling organizations, influenced by the economic interests of the organized professions, which seek protection from competitors both local and international. The first step in addressing this is to comprehensively examine the organizational complexity and conflicted interests within this critical ecosystem. Doing so suggests areas ripe for change, to enhance the health workforce and benefit public health.

Promoting excellence using a novel educational tool in the North of Scotland.

The General Medical Council (GMC) sets the standards and requirements for the delivery of all stages of medical education and training in the United Kingdom (UK). Using a novel educational tool (the 'Digital Carousel'), we set out to determine to what extent current systems and process sit alongside standards as set out in GMC document 'Promoting excellence' and establish key foci of work going forward to promote excellence in the Caledonian-Rural track (CRT) General Practice Specialty Training (GPST) educational programmes by engaging key stakeholders in the process. The 'Digital Carousel' allowed a large group of participants (including the Deanery team, GPSTs and ESs) to efficiently collaborate views on how our current GP training programme reflects guidance in 'Promoting excellence' and on areas for development. There was a sense of 'working together' in identifying key priorities of work for 'our' GP training programme. The tool may have value in a variety of medical educational settings.

[Do quality improvement teams contribute to the improvement of community Health Workers' performance in Benin?] / Les équipes d'amélioration de la qualité contribuent-elles à la performance des agents de santé communautaire au Bénin ?

OBJECTIVE: Community Health Workers (CHWs) were promoted in Benin to improve maternal and child health care (MCH). To improve community health workers' performance, a Quality Improvement Team (QIT) was set up to reinforce CHW capacities. The objective of this work is to present an assessment of QIT's contribution to CHW's performance and MCH coverage in the municipality of Savè. METHODOLOGY: The design of the study includes a pre- and post- analysis. Data were extracted from CHWs' activity reports and routine health information systems from 2011 to 2014 in 22 health facilities. Individual in-depth interviews were also performed with some key informants. The performance of CHW and the MCH indicators were determined according to the National Community Health Policy. RESULTS: The QIT improved Community Health Workers' performance and maternal and child health indicators in Savè. Educational sessions, skilled delivery care coverage, percentage of newborn seen over twice a week, percentage of children treated according national standards, percentage of children fully immunized, percentage of women using family planning methods were increased. CONCLUSION: The establishment of QIT improved CHW's performance and the use of maternal and child health services in Savè. This strategy could be useful for community-based surveillance.

Educational renewal of physician training in Australia and New Zealand: Multiple educational innovations in a complex environment.

AIM: The Royal Australasian College of Physicians is renewing its specialty training programs and shifting towards competency-based medical education. Our aim is to improve the quality and rigor of training and graduate outcomes, and promote high standards of physician practice to serve the health of patients, families, and communities in a changing healthcare environment. METHODS: We are progressing holistic change and multiple educational innovations in a complex environment. Numerous stakeholders, a disparate training landscape and a largely volunteer supervisor workforce pose challenges in supporting effective implementation. This paper describes our progress and experience with three key components of our education renewal program: curricular renewal, a new selection process and faculty development. It offers reflections on the practical challenges, lessons learned and factors critical for success. CONCLUSIONS: Our experience highlights opportunities for training organizations to maximize their influence over workplace training experiences and outcomes by taking a systems approach to the design, delivery and evaluation of the components of education renewal. We found that design, development and delivery of our multiple educational innovations have benefited from co-design approaches, progressive and concurrent development, continual exploration of new strategies, and implementation as soon as viable with a commitment to iterative improvements over time.

Improving access to health services in Canada.

The Commonwealth Fund 2017 report ranked Canada's healthcare system low in access to care and last among all 11 counties studied in terms of timeliness of care. While long wait times for certain elective surgical procedures appear to be emblematic of Canadian Medicare, they are not inevitable. Wait times could be improved by focusing on public awareness and measurement of wait times and improving the appropriateness, efficiency (eg, with implementation of single-entry models for surgical referrals and greater use of ambulatory surgery), and productivity of surgical care (eg, by activity-based funding for surgical procedures and by reducing the cost of perioperative care). Ideas on how physician leaders can build on recent accomplishments are provided.

Nurses who work in rural and remote communities in Canada: a national survey.

BACKGROUND: In Canada, as in other parts of the world, there is geographic maldistribution of the nursing workforce, and insufficient attention is paid to the strengths and needs of those providing care in rural and remote settings. In order to inform workforce planning, a national study, Nursing Practice in Rural and Remote Canada II, was conducted with the rural and remote regulated nursing workforce (registered nurses, nurse practitioners, licensed or registered practical nurses, and registered psychiatric nurses) with the intent of informing policy and planning about improving nursing services and access to care. In this article, the study methods are described along with an examination of the characteristics of the rural and remote nursing workforce with a focus on important variations among nurse types and regions. METHODS: A cross-sectional survey used a mailed questionnaire with persistent follow-up to achieve a stratified systematic sample of 3822 regulated nurses from all provinces and territories, living outside of the commuting zones of large urban centers and in the north of Canada. RESULTS: Rural workforce characteristics reported here suggest the persistence of key characteristics noted in a previous Canada-wide survey of rural registered nurses (2001-2002), namely the aging of the rural nursing workforce, the growth in baccalaureate education for registered nurses, and increasing casualization. Two thirds of the nurses grew up in a community of under 10 000 people. While nurses' levels of satisfaction with their nursing practice and community are generally high, significant variations were noted by nurse type. Nurses reported coming to rural communities to work for reasons of location, interest in the practice setting, and income, and staying for similar reasons. Important variations were noted by nurse type and region. CONCLUSIONS: The proportion of the rural nursing workforce in Canada is continuing to decline in relation to the proportion of the Canadian population in rural and remote settings. Survey results about the characteristics and practice of the various types of nurses can support workforce planning to improve nursing services and access to care.

A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africa.

BACKGROUND: Community health workers (CHWs) play key roles in delivering health programmes in many countries worldwide. CHW programmes can improve coverage of maternal and child health services for the most disadvantaged and remote communities, leading to substantial benefits for mothers and children. However, there is limited evidence of effective mentoring and supervision approaches for CHWs. METHODS: This is a cluster randomised controlled trial to investigate the effectiveness of a continuous quality improvement (CQI) intervention amongst CHWs providing home-based education and support to pregnant women and mothers. Thirty CHW supervisors were randomly allocated to intervention (n = 15) and control (n = 15) arms. Four CHWs were randomly selected from those routinely supported by each supervisor (n = 60 per arm). In the intervention arm, these four CHWs and their supervisor formed a quality improvement team. Intervention CHWs received a 2-week training in WHO Community Case Management followed by CQI mentoring for 12 months (preceded by 3 months lead-in to establish QI processes). Baseline and follow-up surveys were conducted with mothers of infants <12 months old living in households served by participating CHWs. RESULTS: Interviews were conducted with 736 and 606 mothers at baseline and follow-up respectively; socio-demographic characteristics were similar in both study arms and at each time point. At follow-up, compared to mothers served by control CHWs, mothers served by intervention CHWs were more likely to have received a CHW visit during pregnancy (75.7 vs 29.0%, p < 0.0001) and the postnatal period (72.6 vs 30.3%, p < 0.0001). Intervention mothers had higher maternal and child health knowledge scores (49 vs 43%, p = 0.02) and reported higher exclusive breastfeeding rates to 6 weeks (76.7 vs 65.1%, p = 0.02). HIV-positive mothers served by intervention CHWs were more likely to have disclosed their HIV status to the CHW (78.7 vs 50.0%, p = 0.007). Uptake of facility-based interventions were not significantly different. CONCLUSIONS: Improved training and CQI-based mentoring of CHWs can improve quantity and quality of CHW-mother interactions at household level, leading to improvements in mothers' knowledge and infant feeding practices. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01774136.

Where there is no policy: governing the posting and transfer of primary health care workers in Nigeria.

The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in-depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high-performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.

Practical Quality Improvement Implementation in Orthopaedic Clinical Practice.

The passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (HR 2) helps ensure patient access to care and stable physician reimbursement for the near future. HR 2's underlying theme is the improvement of value to address the unsustainable rise in national healthcare spending. Quality improvement and performance improvement, which affect outcomes and costs as well as address variation, are the keys to improve the value of orthopaedic healthcare delivery. Orthopaedic surgeons should examine quality and performance strategies as well as several examples before they begin to implement these processes to improve quality and performance in their practices.

Building a Value-Based Workforce in North Carolina.

Health care in the United States is likely to change more in the next 10 years than in any previous decade. However, changes in the workforce needed to support new care delivery and payment models will likely be slower and less dramatic. In this issue of the NCMJ, experts from education, practice, and policy reflect on the "state of the state" and what the future holds for multiple health professional groups. They write from a broad range of perspectives and disciplines, but all point toward the need for change-change in the way we educate, deploy, and recruit health professionals. The rapid pace of health system change in North Carolina means that the road map is being redrawn as we drive, but some general routes are evident. In this issue brief we suggest that, to make the workforce more effective, we need to broaden our definition of who is in the health workforce; focus on retooling and retraining the existing workforce; shift from training workers in acute settings to training them in community-based settings; and increase accountability in the system so that public funds spent on the health professions produce the workforce needed to meet the state's health care needs. North Carolina has arguably the best health workforce data system in the country; it has historically provided the data needed to inform policy change, but adequate and ongoing financial support for that system needs to be assured.

Strategic partnering to improve community health worker programming and performance: features of a community-health system integrated approach.

BACKGROUND: There is robust evidence that community health workers (CHWs) in low- and middle-income (LMIC) countries can improve their clients' health and well-being. The evidence on proven strategies to enhance and sustain CHW performance at scale, however, is limited. Nevertheless, CHW stakeholders need guidance and new ideas, which can emerge from the recognition that CHWs function at the intersection of two dynamic, overlapping systems - the formal health system and the community. Although each typically supports CHWs, their support is not necessarily strategic, collaborative or coordinated. METHODS: We explore a strategic community health system partnership as one approach to improving CHW programming and performance in countries with or intending to mount large-scale CHW programmes. To identify the components of the approach, we drew on a year-long evidence synthesis exercise on CHW performance, synthesis records, author consultations, documentation on large-scale CHW programmes published after the synthesis and other relevant literature. We also established inclusion and exclusion criteria for the components we considered. We examined as well the challenges and opportunities associated with implementing each component. RESULTS: We identified a minimum package of four strategies that provide opportunities for increased cooperation between communities and health systems and address traditional weaknesses in large-scale CHW programmes, and for which implementation is feasible at sub-national levels over large geographic areas and among vulnerable populations in the greatest need of care. We postulate that the CHW performance benefits resulting from the simultaneous implementation of all four strategies could outweigh those that either the health system or community could produce independently. The strategies are (1) joint ownership and design of CHW programmes, (2) collaborative supervision and constructive feedback, (3) a balanced package of incentives, and (4) a practical monitoring system incorporating data from communities and the health system. CONCLUSIONS: We believe that strategic partnership between communities and health systems on a minimum package of simultaneously implemented strategies offers the potential for accelerating progress in improving CHW performance at scale. Comparative, retrospective and prospective research can confirm the potential of these strategies. More experience and evidence on strategic partnership can contribute to our understanding of how to achieve sustainable progress in health with equity.

[Organizational capacity for continuous improvement of health services]. / Estrategia integral de formación para la mejora continua de la calidad de los servicios de salud.

While the Mexican health system has achieved significant progress, as reflected in the growing improvement in population health, heterogeneity in the quality of services and its impact on health in different population groups is still a challenge. The costs or poor quality represent about 20 to 40% of the health system's expenditure. We need to develop organizational capacity to implement quality management systems in order to identify, evaluate, prevent and eventually overcome the health system's challenges. A competency-based comprehensive strategy for training human resources is proposed including undergraduate and graduate education as well as continuing education, which will contribute to improve the quality function at the various levels of responsibility in the health system. The proposed strategy responds to the context of the Mexican health system, but it could be adapted to other systems and contexts.

Engaging health care professionals in quality improvement: A qualitative study exploring the synergies between projects of professionalisation and institutionalisation in quality improvement collaborative implementation in Denmark.

OBJECTIVE: To examine the projects of professionalisation and institutionalisation forming health care professions' engagement in quality improvement collaborative (QIC) implementation in Denmark, and to analyse the synergies and tensions between the two projects given the opportunities afforded by the QICs. METHODS: This was a cross-sectional interview study with professionals involved in the implementation of two national QICs in Denmark involving 23 individual interviews and focus group discussions with 75 people representing different professional groups. We conducted a reflexive thematic analysis of the data, drawing on institutional contributions to organisational studies of professions. RESULTS: Study participants engaged widely in QIC implementation. This engagement was formed by a constructive interplay between the professions' projects of professionalisation and institutionalisation, with only few tensions identified. The project of professionalisation relates to a self-oriented agenda of contributing professional expertise and promoting professional recognition and development, while the project of institutionalisation focuses on improving health care processes and outcomes and advancing quality improvement. Both projects were largely similar across professional groups. The interplay between the two projects was enabled by the bottom-up approach to implementation, participation of QI specialists, and a clear focus on developing and delivering high-quality patient care. CONCLUSIONS: Future strategies for QIC implementation should position QICs as a framework that promotes the integration of professions' projects of professionalisation and institutionalisation to successfully engage professionals in the implementation process, and thereby optimise the effectiveness of QICs in health care.

Blue Sky Thinking: Physician Assistant Accreditation and the Potential Impact on the Programs, Faculty, and the Profession.

ABSTRACT: Blue sky thinking references the opportunity to brainstorm about a topic without limits… to consider what things might be like if creative thoughts were unconstrained by current philosophies or other boundaries. This article is a call to our fellow educators to consider how blue sky thinking applied to physician assistant (PA) program accreditation might further advance programs, faculty, and the profession. To develop and maintain a PA program, institutions must voluntarily undergo evaluation by the Accreditation Review Commission on Education for the Physician Assistant. Compliance with accreditation encourages sound educational practices, promotes program self-study, stimulates innovation, maintains confidence with the public, and focuses on continuous quality improvement. In addition, accreditation "can hold institutions accountable for desired outcomes and professional standards." Indeed, while the PA profession has promulgated across the globe, the 50+ years of graduating PAs educated with the highest quality education assures that the United States remains a gold standard. As the 5th edition of the standards are implemented and planning for the 6th edition is underway, in the spirit of continuous quality improvement, we encourage stakeholders of the PA profession to contemplate ways in which accreditation might continue to purposefully advance a desired future state for the profession. In this article, we draw on examples from other health professions which might inform a discussion around the future of PA accreditation. Specifically, the topics of a unified profession title and degree, a specific title and position for program leadership, a modification to how PA programs receive medical direction, and efforts to advance scholarship are addressed.

Strengthening health workforce capacity through work-based training.

BACKGROUND: Although much attention has been given to increasing the number of health workers, less focus has been directed at developing models of training that address real-life workplace needs. Makerere University School of Public Health (MakSPH) with funding support from the Centers for Disease Control and Prevention (CDC) developed an eight-month modular, in-service work-based training program aimed at strengthening the capacity for monitoring and evaluation (M&E) and continuous quality improvement (CQI) in health service delivery. METHODS: This capacity building program, initiated in 2008, is offered to in-service health professionals working in Uganda. The purpose of the training is to strengthen the capacity to provide quality health services through hands-on training that allows for skills building with minimum work disruptions while encouraging greater involvement of other institutional staff to enhance continuity and sustainability. The hands-on training uses practical gaps and challenges at the workplace through a highly participatory process. Trainees work with other staff to design and implement 'projects' meant to address work-related priority problems, working closely with mentors. Trainees' knowledge and skills are enhanced through short courses offered at specific intervals throughout the course. RESULTS: Overall, 143 trainees were admitted between 2008 and 2011. Of these, 120 (84%) from 66 institutions completed the training successfully. Of the trainees, 37% were Social Scientists, 34% were Medical/Nursing/Clinical Officers, 5.8% were Statisticians, while 23% belonged to other professions. Majority of the trainees (80%) were employed by Non-Government Organizations while 20% worked with the public health sector. Trainees implemented 66 projects which addressed issues such as improving access to health care services; reducing waiting time for patients; strengthening M&E systems; and improving data collection and reporting. The projects implemented aimed to improve trainees' skills and competencies in M&E and CQI and the design of the projects was such that they could share these skills with other staff, with minimal interruptions of their work. CONCLUSIONS: The modular, work-based training model strengthens the capacity of the health workforce through hands-on, real-life experiences in the work-setting and improves institutional capacity, thereby providing a practical example of health systems strengthening through health workforce capacity building.