The multi-dimensional matrix for consultation-liaison psychiatry (mMAX-LP).

OBJECTIVE: Consultation-liaison psychiatry (CLP) services are particularly susceptible to heterogeneity, developing haphazardly in response to local interests and perceived need. This hampers the generalisability of comparisons between services in terms of service models, resource requirements and outcome data. The objective of this paper therefore is to chronicle the development of a method to meaningfully describe, map and compare different CLP services. METHOD: A review of the literature was followed by multiple site visits in both New Zealand and England, and an extended process of consultation and feedback. RESULTS: Sixteen dimensions common to CLP services were extracted to create a multi-dimensional matrix (mMAX-LP) which had three broad clusters (structure, coverage and relationship with physical health services). The model was applied and discussed with the previously visited hospitals over the succeeding five years. Additionally, the matrix was tested, and its utility demonstrated during the planned reconfiguration of CLP services at a large teaching hospital in South Auckland, New Zealand by tracking the evolution of CLP services. CONCLUSIONS: mMAX-LP shows promise as a useful model for profiling and comparing CLP services; mapping their evolution over time; and sign-posting future service development.

Evaluating the implementation of collaborative teams in community family practice using the Primary Care Assessment Tool.

OBJECTIVE: To examine patients' perceptions of care outcomes following the introduction of collaborative teams into community family practices. DESIGN: Cross-sectional, longitudinal study comprising 4 patient telephone surveys between 2007 and 2016, using random sampling of telephone records based on postal codes. SETTING: Ten WestView Primary Care Network (WPCN) clinics in Alberta, serving a suburban-rural population of approximately 89 000 and an aggregate clinic panel of 61 611 (in 2016). PARTICIPANTS: Adults aged 18 and older with a visit to a family physician in a WPCN clinic at least once in the previous 18 months. INTERVENTIONS: In 2006, WPCN implemented a decentralized and distributed collaborative team model, integrating nonphysician health care professionals into member clinics. MAIN OUTCOME MEASURES: The Primary Care Assessment Tool (PCAT) was used to evaluate standardized primary care delivery domains. Between-year changes were compared using ANOVA (analysis of variance). Clinic-level subgroup analyses were performed. RESULTS: The number of completed surveys included 896 in 2007, 904 in 2010, 1000 in 2013, and 1800 in 2016, reaching 90% to 100% of the targeted sample size. In aggregate, the WPCN PCAT summary score and the scores of 4 core and 2 ancillary domains of primary care exceeded the quality threshold of 3.0: extent of affiliation, ongoing care, first-contact utilization, coordination of care, family-centredness, and cultural competence. The first-contact access domain significantly improved from 2007 to 2016 (P < .001). The domains extent of affiliation, first-contact utilization, and coordination of information systems were unchanged. Ongoing care, coordination of care, comprehensiveness, family-centredness, community orientation, and cultural competence decreased. Except for in 2010, the 2 highest scoring clinics were non-participating solo practices; the lowest-scoring clinic was the one with the largest number of physicians. Across survey years, the PCAT summary score increased statistically significantly for 1 solo practice, remained consistent at an above-quality threshold for another, but decreased for all multi-physician clinics. Unattached patients (ie, those without a family doctor) scored the lowest. CONCLUSION: This study found that WPCN provides high-quality primary care overall, but that patient-perceived outcomes do not indicate global improvement concurrent with team-based initiatives. Decreased standardization of the distributed model likely influenced study-observed variations in clinic performance. Future research should identify clinic and team characteristics that benefit most from team-based care and factors that explain solo practices outperforming models of team-based care.

The International Nutrition Care Process and Terminology Implementation Survey: Towards a Global Evaluation Tool to Assess Individual Practitioner Implementation in Multiple Countries and Languages.

BACKGROUND: The Nutrition Care Process (NCP) and NCP Terminology (NCPT) is a systematic framework for critical thinking, decision making, and communication for dietetics practitioners worldwide, aiming to improve quality and patient safety in nutrition care. Although dietetics practitioners in several countries have implemented the NCP/NCPT during recent years, to date there is no globally validated instrument for the evaluation of NCP/NCPT implementation that is available in different languages and applicable across cultures and countries. OBJECTIVE: The aim of this study was to develop and test a survey instrument in several languages to capture information at different stages of NCP/NCPT implementation across countries and cultures. SETTING: In this collaboration between dietetics practitioners and researchers from 10 countries, an International NCP/NCPT Implementation Survey tool was developed and tested in a multistep process, building on the experiences from previous surveys. The tool was translated from English into six other languages. It includes four modules and describes demographic information, NCP/NCPT implementation, and related attitudes and knowledge. METHODS: The survey was reviewed by 42 experts across 10 countries to assess content validity and clarity. After this, 30 dietetics practitioners participated in cognitive interviews while completing the survey. A pilot study was performed with 210 participants, of whom 40 completed the survey twice within a 2- to 3-week interval. RESULTS: Scale content validity index average was 0.98 and question clarity index was 0.8 to 1.0. Cognitive interviews and comments from experts led to further clarifications of the survey. The repeated pilot test resulted in Krippendorff's α=.75. Subsequently, refinements of the survey were made based on comments submitted by the pilot survey participants. CONCLUSIONS: The International NCP/NCPT Implementation Survey tool demonstrated excellent content validity and high test-retest reliability in seven different languages and across an international context. This tool will be valuable in future research and evaluation of implementation strategies.

Validity, internal consistency reliability and one-year stability of the Slovene translation of the Measure of Processes of Care (20-item version).

BACKGROUND: The Measure of Processes of Care (MPOC) was developed as a self-administered questionnaire for parents to report on behaviours of healthcare providers. The original (MPOC-56) and the 20-item version (MPOC-20) have established reliability and validity, but the instrument must be rechecked whenever translated and applied in a different social and cultural setting. The aim of our study was to evaluate validity, internal consistency reliability and 1-year stability of the Slovene translation of MPOC-20. METHODS: Parents of children who were admitted as inpatients or outpatients of several hospitals and health centres were invited to participate. MPOC-20, the Client Satisfaction Questionnaire (CSQ-8) and a separate question on stress and worries were sent by mail. Descriptive item analysis was performed. Cronbach's alpha coefficient and corrected item-total correlations were used to assess internal consistency for each of the five MPOC-20 subscales. To evaluate validity, we correlated the MPOC-20 subscale scores with CSQ-8 scores and a stress alleviation rating. Assessment with MPOC-20 was performed again 1 year later and we used paired-samples tests to compare mean scores of both assessments. RESULTS: Parents of 235 children participated in the study (80% mothers). They reported high general satisfaction as 15 out of the 20 MPOC-20 mean item scores were above 5 (out of 7) and none was below 4. The mean MPOC-20 mean subscale scores were 5.83 (SD 1.10) for Coordinated and Comprehensive Care for Child and Family, 5.62 (SD 1.12) for Respectful and Supportive Care, 5.45 (SD 1.23) for Enabling and Partnership, 5.33 (SD 1.61) for Providing Specific Information about the Child and 4.59 (SD 1.65) for Providing General Information. The ranking order of the mean rating of the MPOC-20 subscales was similar to previous studies. The parents reported that they felt their stress and worries had been notably or slightly reduced through the process of care in the last year in more than two-thirds of the cases. All the MPOC-20 subscales (as well as the CSQ-8 scale) showed high internal consistency: the corrected item-total correlations were far above the lower limit for item's acceptance of 0.3. After 1 year (66 returned questionnaires) none of the mean subscale scores changed statistically significantly (P-values 0.159-0.910). CONCLUSION: The Slovene translation of the MPOC-20 can be considered as a valid and reliable instrument that shows good stability over a period of 1 year, and as such it can be adopted in clinical practice.

Use of the Measure of Processes of Care (MPOC-20) to evaluate health service delivery for children with cerebral palsy and their families in Jordan: validation of Arabic-translated version (AR-MPOC-20).

BACKGROUND: Family-centred service (FCS) is widely accepted now as best practice in paediatric rehabilitation. The Measure of Processes of Care-20 items set (MPOC-20) is a valid and reliable self-report measure of parents' perceptions of the extent to which health services are family-centred. Arabic-translated and validated version of the MPOC-20 (AR-MPOC-20) is used to examine Jordanian families' perception of service providers' caregiving behaviours as they receive rehabilitation services for their children with cerebral palsy (CP). METHODS: Parents of 114 children with CP who are receiving services at different settings in Jordan were interviewed using the AR-MPOC-20. Participating children aged 4.1 ± 4.4 years, 53.5% were males. Children varied across gross motor functional classification system (GMFCS). Parents were mostly mothers (76.3%), with at least high school education (71.9%). RESULTS: Factor analyses of the AR-MPOC-20 yielded a five-factor solution with items loaded differently from the original measure. All items correlated best and significantly with their own Arabic scale score (rs: 0.91-0.26, P < 0.01). Internal consistency values of AR-MPOC-20 scales were acceptable (Cronbach's α: 0.69-0.82). Scale 'Providing Written Information' has the lowest average score (1.9 ± 1.6), while scale 'Respectful & Coordinated Care' has the highest average score (5.2 ± 1.5). CONCLUSION: The AR-MPOC-20 is found to be a valid and reliable measure for use with Arabic-Jordanian families of children with CP. FCS is not yet well implemented in Jordan, with parents reporting more need for information about their children's health and available services. Service providers are encouraged to apply FCS in paediatric rehabilitation, and giving more attention to effective communication and information exchange with families. AR-MPOC-20 is recommended for use for program evaluation.

A study of clinical and information management processes in the surgical pre-assessment clinic.

BACKGROUND: Establishing day-case surgery as the preferred hospital admission route for all eligible patients requires adequate preoperative assessment of patients in order to quickly distinguish those who will require minimum assessment and are suitable for day-case admission from those who will require more extensive management and will need to be admitted as inpatients. METHODS: As part of a study to elucidate clinical and information management processes within the patient surgical pathway in NHS Scotland, we conducted a total of 10 in-depth semi-structured interviews during 4 visits to the Dumfries & Galloway Royal Infirmary surgical pre-assessment clinic. We modelled clinical processes using process-mapping techniques and analysed interview data using qualitative methods. We used Normalisation Process Theory as a conceptual framework to interpret the factors which were identified as facilitating or hindering information elucidation tasks and communication within the multi-disciplinary team. RESULTS: The pre-assessment clinic of Dumfries & Galloway Royal Infirmary was opened in 2008 in response to clinical and workflow issues which had been identified with former patient management practices in the surgical pathway. The preoperative clinic now operates under well established processes and protocols. The use of a computerised system for managing preoperative documentation substantially transformed clinical practices and facilitates communication and information-sharing among the multi-disciplinary team. CONCLUSION: Successful deployment and normalisation of innovative clinical and information management processes was possible because both local and national strategic priorities were synergistic and the system was developed collaboratively by the POA staff and the health-board IT team, resulting in a highly contextualised operationalisation of clinical and information management processes. Further concerted efforts from a range of stakeholders are required to fully integrate preoperative assessment within the health-board surgical care pathway. A substantial - yet unfulfilled - potential benefit in embedding information technology in routine use within the preoperative clinic would be to improve the reporting of surgical outcomes.

Assessing patient management plans of doctors and medical students: an illness script perspective.

INTRODUCTION: Illness script theory offers explanations for expert-novice differences in clinical reasoning. However, it has mainly focused on diagnostic (Dx) performance, while patient management (Mx) has been largely ignored. The aim of the present study was to show the role of Mx knowledge in illness script development and how it relates to diagnostic knowledge in the course of development toward expertise. METHODS: The participants were 10 fourth-year and 10 sixth-year medical students, and 10 experienced physicians (ie, internists). Participants were asked to study 4 written clinical cases and provide management plans. Based on propositional analysis the management plans were examined for accuracy and elaborateness as well as the number of Mx and Dx items. RESULTS: Providing accurate Mx plans that concurrently pay attention to Dx and Mx was a characteristic of doctors' performance. The Mx plans of sixth-year students were as accurate as fourth-year students, but the format and the size of sixth-year students' plans was more similar to those of doctors. While sixth-year students generated plans with an Mx focus, the plans of fourth-year students were characterized by a Dx focus. DISCUSSION: The experienced physicians' accurate management plans are characterized by a high number of the Mx and Dx items. For sixth-year students the management plans are still incomplete, which leads to generic as well as inaccurate Mx orders. For fourth-year students, the Mx focus is lacking, and hence they seem to treat an Mx task as if it were a Dx task.

Quality of decision making is related to decision outcome for patients with cardiac arrhythmia.

OBJECTIVE: Clinical consultations with patients should be informed by the evidence-based and involve shared decision making (SDM). We aimed to determine the delivery of SDM by clinicians with patients referred for invasive treatment of cardiac electrical disease and to establish whether decisions made corresponded with patient and referring physician expectations. METHODS: Forty-nine outpatient consultations with two consultant cardiologists in one large tertiary centre were audio-recorded. Demographic data, diagnosis, reasons for referral and decision reached were compared directly with patient and referring physician expectations. The OPTION instrument was used to measure SDM. Patient expectations and satisfaction were elicited. RESULTS: Quality of SDM was good (mean OPTION score 49%) and there was broad patient satisfaction. While all patients were suitable for invasive treatment, and the majority (80%, n=39) had been explicitly referred for it, only 59% (n=29) opted to proceed. Consultation quality with respect to SDM was significantly greater for patients choosing a less invasive option. CONCLUSION: These consultations often change expected management. Where decision making in the consultation is of higher quality, patients were more likely to change to a less invasive option. PRACTICE IMPLICATIONS: Clinicians performing invasive cardiac treatment should be able to demonstrate high quality decision making.

Antimicrobial stewardship: a matter of process or outcome?

The risk of antimicrobial resistance and superinfection is increasing alongside rates of hospital-acquired infection. Imprudent antibiotic use combined with few novel antimicrobials can speed resistance. Antimicrobial stewardship programs (ASPs) advocate for judicious use of available antimicrobials to preserve their usefulness. Decreased antibiotic expenditures was the backbone of early justification for ASPs, but the function of these programs has evolved into measuring the quality and appropriateness of antimicrobial use. Proper evaluation of an ASP helps to inform which methods work best for a particular institution and can help to define best practices at a more global level. Study design and duration limitations, however, can make it difficult to measure the impact of these programs. Process measures have been validated and can evaluate quality of care; however, they do not adequately describe the clinical impact of these programs at the patient level. Outcome measures also have limitations; they are not a direct measure of quality of care. Therefore, both process and outcome measures need to be defined and assessed when evaluating an ASP to confirm that goals of the intervention are attained and clinical objectives are met. Most available well-designed studies judging the effectiveness of ASPs use process measures alone. Adding improvements in clinical outcomes to process measures would theoretically attract the attention of a broader audience and provide additional support to expand current ASPs and develop novel ASPs.

Factors contributing to successful interorganizational collaboration: the case of CS2day.

Continuing medical education's transition from an emphasis on dissemination to changing clinical practice has made it increasingly necessary for CME providers to develop effective interorganizational collaborations. Although interorganizational collaboration has become commonplace in most sectors of government, business, and academia, our review of the literature and experience as practitioners and researchers suggest that the practice is less widespread in the CME field. The absence of a rich scholarly literature on establishing and maintaining interorganizational collaborations to provide continuing education to health professionals means there is little information about how guidelines and principles for effective collaboration developed in other fields might apply to continuing professional development in health care and few models of successful collaboration. The purpose of this article is to address this gap by describing a successful interorganizational CME collaboration-Cease Smoking Today (CS2day)-and summarizing what was learned from the experience, extending our knowledge by exploring and illustrating points of connection between our experience and the existing literature on successful interorganizational collaboration. In this article, we describe the collaboration and the clinical need it was organized to address, and review the evidence that led us to conclude the collaboration was successful. We then discuss, in the context of the literature on effective interorganizational collaboration, several factors we believe were major contributors to success. The CS2day collaboration provides an example of how guidelines for collaboration developed in various contexts apply to continuing medical education and a case example providing insight into the pathways that lead to a collaboration's success.

Shared component modelling as an alternative to assess geographical variations in medical practice: gender inequalities in hospital admissions for chronic diseases.

BACKGROUND: Small area analysis is the most prevalent methodological approach in the study of unwarranted and systematic variation in medical practice at geographical level. Several of its limitations drive researchers to use disease mapping methods -deemed as a valuable alternative. This work aims at exploring these techniques using - as a case of study- the gender differences in rates of hospitalization in elderly patients with chronic diseases. METHODS: Design and study setting: An empirical study of 538,358 hospitalizations affecting individuals aged over 75, who were admitted due to a chronic condition in 2006, were used to compare Small Area Analysis (SAVA), the Besag-York-Mollie (BYM) modelling and the Shared Component Modelling (SCM). Main endpoint: Gender spatial variation was measured, as follows: SAVA estimated gender-specific utilization ratio; BYM estimated the fraction of variance attributable to spatial correlation in each gender; and, SCM estimated the fraction of variance shared by the two genders, and those specific for each one. RESULTS: Hospitalization rates due to chronic diseases in the elderly were higher in men (median per area 21.4 per 100 inhabitants, interquartile range: 17.6 to 25.0) than in women (median per area 13.7 per 100, interquartile range: 10.8 to 16.6). Whereas Utilization Ratios showed a similar geographical pattern of variation in both genders, BYM found a high fraction of variation attributable to spatial correlation in both men (71%, CI95%: 50 to 94) and women (62%, CI95%: 45 to 77). In turn, SCM showed that the geographical admission pattern was mainly shared, with just 6% (CI95%: 4 to 8) of variation specific to the women component. CONCLUSIONS: Whereas SAVA and BYM focused on the magnitude of variation and on allocating where variability cannot be due to chance, SCM signalled discrepant areas where latent factors would differently affect men and women.

A Danish population-based cohort study of newly diagnosed asthmatic children's care pathway - adherence to guidelines.

BACKGROUND: Asthma is the most common chronic disease in childhood. Large variations exist concerning the number of children being treated by general practitioners and by specialists. Consequently, health related costs due to this disease vary as care by specialists is more expensive compared with care by general practitioners. Little is known of the consequences of these variations concerning the quality of care. The aim of the study was to analyse associations between care providers and adherence to guidelines concerning frequency of contacts with the health service due to asthma. METHODS: A cohort study was performed of 36,940 incident asthmatic children's (aged 6-14) contacts with the health service using the unique personal registration number to link data from five national registries. The prevalence ratios were calculated for associations between provider (general practitioner, primary care specialist, hospital specialist or both GP and specialist) and adherence with guidelines concerning three indicators of quality of care pathway: 1) diagnostic examination of lung function at start of medical treatment 2) follow-up the first six months and 3) follow-up the next six months. The associations were adjusted for sex, age, socioeconomic status, county, and severity of disease. RESULTS: Most children (70.3%) had only been seen by their GP. About 80% of the children were treated with inhaled steroids, 70% were treated with inhaled steroids as well as inhaled beta2agonists and 13% were treated with inhaled beta2agonists only. A total of 12,650 children (34.2%) had no registered asthma-related contacts with the health service except when redeeming prescriptions. Care was in accordance with guidelines in all three indicators of quality in 7% of the cases (GPs only: 3%, primary care specialists only: 16%, hospital specialists: 28%, and both GP and specialists: 13%). Primary care specialists had a 5.01, hospital specialists a 8.81 and both GP and specialists a 4.32 times higher propensity to provide a clinical pathway according to guidelines compared to GPs alone. CONCLUSION: The majority of the children were seen in general practice. Hospital specialists provided care in accordance with guidelines nine times more often compared with GPs, but still only one quarter of these children had pathways in accordance with guidelines. It is relevant to study further if these lacks of adherence to guidelines have implications for the asthmatic children or if guidelines are too demanding concerning frequency of follow-up or if asthmatic children should be stratified to different care pathways.

The road to tuberculosis treatment in rural Nepal: A qualitative assessment of 26 journeys.

BACKGROUND: The fact that tuberculosis can be treated with the DOTS strategy (Directly Observed Treatment, Short-course) is not enough to control the disease. Patients have to find their way to tuberculosis treatment first. To better understand the route to tuberculosis treatment in rural Nepal we interviewed twenty-six patients under treatment. METHODS: In semi-structured interviews patients shared their disease history and health seeking behaviour. The analysis focused on the encounters with the health care system before enrolment in the tuberculosis treatment program. RESULTS: Patient routes often started in the medical shop and led via intricate routes with multiple providers to facilities with higher qualified and more competent staff where tuberculosis was diagnosed. Several factors influenced the route to tuberculosis treatment. Besides known patients factors (such as severity of complaints, the ability to pay for services, availability of services and peer support for choosing a provider) specific health services factors were also identified. These included the perceived quality, costs and service level of a provider, and lack of provider initiated referral. Self referral because of waned trust in the provider was very common. In contrast, once tuberculosis was considered a possible diagnosis, referral to diagnostic testing and tuberculosis treatment was prompt. CONCLUSION: Patient routes towards tuberculosis treatment are characterised by self referral and include both private and public health care providers. Once tuberculosis is suspected referral for diagnosis and treatment is prompt. Given the importance of the private practitioners in the patient routes, quality improvement initiatives need to address not only the public sector but the private health care sector as well.

Process evaluation of the Senegal-Community Nutrition Project: an adequacy assessment of a large scale urban project.

OBJECTIVE: Although essential for understanding the reasons for success or failure of large scale nutritional interventions, process evaluation results are rarely reported. Our objective was to assess whether the process output objectives of the Community Nutrition Project (CNP) in Senegal, West Africa, were adequately met. METHODS: An adequacy assessment study based on monitoring data for individuals collected during the CNP was used to assess 'fidelity', 'extent' and 'reach' of participants recruitment and of the services provided. The CNP provided underweight or nutritionally at risk 6- to 35-month-old children in poor districts with monthly growth monitoring and promotion and a weekly food supplementation for 6 month periods, provided that mothers attended weekly nutrition education sessions. An exhaustive sample of the participating children (n = 4084) in Diourbel was used for evaluation over the first 2 years. RESULTS: At recruitment, only 66% of children were underweight (vs. 90% expected) varying with the CNP center and cohort, and the child's sex and age. Attendance at growth monitoring reached expected levels (93%vs. 90%) whereas numbers of food supplements distributed and education sessions attended were lower than expected (45%vs. 90% and 62%vs. 80%, respectively). At the end of follow-up, 61% of underweight children recovered vs. 80% expected. CONCLUSIONS: Because of CNP design for underweight diagnosis and bias in the targeting process, respect for selection criteria was low and consequently under coverage and leakage occurred. Besides a globally satisfactory process, wide discrepancies were observed between CNP centres concerning the utilization and effectiveness of services. This formative evaluation helped diagnose weaknesses; ongoing feedback enabled the CNP to improve targeting and supply of supplements. It also informed a larger impact evaluation. Some generalizable lessons for similar programmes have been highlighted.

Backus Hospital earns high ranking for QI, patient safety.

Focusing on quality improvement and patient safety, 213-bed William W. Backus Hospital, in Norwich, CT, changed a number of medical and administrative processes over the past three years to win a top 5% hospital ranking by HealthGrades, a Golden, CO-based health care ratings company.

Use of the measure of process of care for families (MPOC-56) and service providers (MPOC-SP) to evaluate family-centred services in a paediatric disability setting.

BACKGROUND: The value of family-centred principles in paediatric professional caregiving services is widely acknowledged. However, the degree to which such services adhere to these principles is not well documented. AIM: To examine the perceptions of both families and service providers of the extent to which family-centred services were being implemented by a paediatric disability service provider and to pinpoint areas for improvement. METHOD: A sample of 158 families receiving services from the Cerebral Palsy Association of Western Australia completed the Measure of Processes of Care for families (MPOC-56) and 43 clinicians (most of them physiotherapists, speech pathologists and occupational therapists) completed the Measure of Processes of Care for service providers (MPOC-SP). RESULTS: As in previous studies, the families rated 'respectful and supportive care' highest and 'providing general information' lowest. Clinicians rated 'showing interpersonal sensitivity' highest and 'providing general information' lowest. Analysis of individual items revealed that the following areas of family-centred services were in need of improvement: provision of general written information to families on a range of issues, continuity of care, greater involvement of the family in therapy and provision of more detailed information about therapy issues and provision of more general support to whole families. CONCLUSIONS: The MPOC tools have been found useful in enabling disability service providers to identify areas for improvement and move towards providing services that are more family centred.