High-Performing Teamlets in Primary Care: A Qualitative Comparative Analysis.

PURPOSE: In efforts to improve patient care, collaborative approaches to care have been highlighted. The teamlet model is one such approach, in which a primary care clinician works consistently with the same clinical staff member. The purpose of this study is to identify the characteristics of high-performing primary care teamlets, defined as teamlets with low rates of ambulatory care sensitive emergency department (ACSED) visits and ambulatory care sensitive hospital admissions (ACSAs). METHODS: Twenty-six individual qualitative interviews were performed with physicians and their teamlet staff member across 13 teamlets. Potentially important characteristics related to high-performing primary care teamlets were identified, calibrated, and analyzed using qualitative comparative analysis (QCA). RESULTS: Key characteristics identified by the QCA that were often present in teamlets with low rates of ACSED visits and, to a lesser extent, ACSAs were staff proactiveness in anticipating physician needs and physician-reported trust in their staff member. CONCLUSION: This study suggests that physician trust in their staff and proactiveness of staff in anticipating physician needs are important in promoting high-performing teamlets in primary care. Additional studies are indicated to further explore the relationship between these characteristics and high-performing teamlets, and to identify other characteristics that may be important.

Prospective Study of the Multisite Spread of a Medication Safety Intervention: Factors Common to Hospitals With Improved Outcomes.

Context and implementation approaches can impede the spread of patient safety interventions. The objective of this article is to characterize factors associated with improved outcomes among 9 hospitals implementing a medication safety intervention. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a pharmacist-driven intervention that led to a sustained reduction in nephrotoxic medication-associated acute kidney injury (NTMx-AKI) at 1 hospital. Using qualitative comparative analysis, the team prospectively assessed the association between context and implementation factors and NTMx-AKI reduction during NINJA spread to 9 hospitals. Five hospitals reduced NTMx-AKI. These 5 had either (1) a pharmacist champion and >2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (2) a nephrologist-implementing NINJA with minimal competing organizational priorities (Scon 1.0, Scov 0.2). Interviews identified ways NINJA team leaders obtained pharmacist support or successfully implemented without that support. In conclusion, these findings have implications for future spread of NINJA and suggest an approach to study spread of safety interventions more broadly.

Models for Delivering Weight Management in Primary Care: Qualitative Results from the MOST Obesity Study.

BACKGROUND: Obesity is a leading cause of morbidity and mortality in the United States (US). Primary care medical practices can educate patients about the health effects of obesity and help patients with obesity lose and manage their weight. However, implementation of weight management in primary care is challenging. We sought to examine how practices that implement weight management services do so feasibly. METHODS: Multiple methods including site visits, observations, interviews, and document reviews were utilized to identify and learn from primary care practices located across the US. A qualitative multidimensional classification of empirical cases was performed to identify unique delivery features that were feasible to implement in primary care. RESULTS: Across 21 practices, 4 delivery models were identified: group, integrated into standard primary care, hiring an "other" professional, and using a specific program. Model characteristics included who delivered the weight management services, whether delivered to an individual or group, the types of approaches used, and how the care was reimbursed or paid. Most practices integrated weight management services and primary care delivery, although some created specific carve-out programs. CONCLUSION: This study identified 4 models that may serve to overcome challenges in delivering weight management services in primary care. Based on practice characteristics, preferences, and resources, primary care practices can identify a model for successfully implementing weight management services that best fits their context and needs. It is time for primary care to truly address obesity care as the health issue it is and make it a standard of care for all patients with obesity.

Methods for capturing and analyzing adaptations: implications for implementation research.

BACKGROUND: Interventions are often adapted; some adaptations may provoke more favorable outcomes, whereas some may not. A better understanding of the adaptations and their intended goals may elucidate which adaptations produce better outcomes. Improved methods are needed to better capture and characterize the impact of intervention adaptations. METHODS: We used multiple data collection and analytic methods to characterize adaptations made by practices participating in a hybrid effectiveness-implementation study of a complex, multicomponent diabetes intervention. Data collection methods to identify adaptations included interviews, observations, and facilitator sessions resulting in transcripts, templated notes, and field notes. Adaptations gleaned from these sources were reduced and combined; then, their components were cataloged according to the framework for reporting adaptations and modifications to evidence-based interventions (FRAME). Analytic methods to characterize adaptations included a co-occurrence table, statistically based k-means clustering, and a taxonomic analysis. RESULTS: We found that (1) different data collection methods elicited more overall adaptations, (2) multiple data collection methods provided understanding of the components of and reasons for adaptation, and (3) analytic methods revealed ways that adaptation components cluster together in unique patterns producing adaptation "types." These types may be useful for understanding how the "who, what, how, and why" of adaptations may fit together and for analyzing with outcome data to determine if the adaptations produce more favorable outcomes rather than by adaptation components individually. CONCLUSION: Adaptations were prevalent and discoverable through different methods. Enhancing methods to describe adaptations may better illuminate what works in providing improved intervention fit within context. TRIAL REGISTRATION: This trial is registered on clinicaltrials.gov under Trial number NCT03590041 , posted July 18, 2018.

A study protocol to evaluate the implementation and effectiveness of the Clinical Nurse Leader Care Model in improving quality and safety outcomes.

AIMS: Patients are harmed or die every year because of unsafe, inappropriate or inadequate healthcare delivery. Registered Nurses are a recognized patient safety strategy. However, variability in research findings indicate the relationship is not as simple as "more nurses=better outcomes." Hence, currently there exists no evidence-based frontline nursing care model. One emerging model is the Clinical Nurse Leader care model. DESIGN: This Hybrid Type II Implementation-Effectiveness study will evaluate the effect of the care model on standardized quality and safety outcomes and identify implementation characteristics that are sufficient and necessary to achieve outcomes. METHODS: This study leverages a natural experiment in 66 clinical care units in nine hospitals across five states in the United States that have implemented the Clinical Nurse Leader care model. RESULTS: Findings will elucidate Registered Nurse's mechanisms of action as organized into frontline models of care and link actions to improved care quality and safety.

What Makes for Successful Registry Implementation: A Qualitative Comparative Analysis.

PURPOSE: Registry implementation is an important component of successfully achieving patient-centered medical home designation and an important part of population-based health. The purpose of this study was to examine what factors are evident in the successful implementation of a registry in a selection of Colorado practices involved in quality-improvement activities. METHODS: In-depth, small-group interviews occurred at 13 practices. The data were recorded, transcribed, and qualitatively analyzed to identify key themes regarding elements of successful registry implementation. Key elements were described as conditions, then calibrated and analyzed using qualitative comparative analysis (QCA). RESULTS: The QCA revealed several formulas to successful registry implementation. Key conditions included the importance of Resources and Leadership along with either a Quality Improvement Mindset or a Key Person driving efforts (or both). Health System membership affected the specific formula. DISCUSSION: This study is innovative in that it examines which factors and in what combination are necessary for successful implementation of a registry. The findings have implications for primary care quality-improvement efforts.

Protecting children from violence and maltreatment: a qualitative comparative analysis assessing the implementation of U.N. CRC Article 19.

OBJECTIVES: (1) To identify which United Nations Convention on the Rights of the Child (CRC) recommended child protection (CP) measures, such as policy, reporting systems, and services for child abuse and neglect (CAN) victims, individually or in combination, were most important in establishing a basic level of child protection in 42 countries; and (2) to assess whether these measures were necessary or sufficient to achieve basic child protection in developing and industrialized countries. METHOD: Child protection and/or rights expert respondents from 42 countries completed a questionnaire on CRC Article 19 (CRC19) required CP measures implementation and rated their country's effectiveness in implementation, the current level of effectiveness of child protection, and the relevance of improvements in child protection since the CRC was adopted in 1989. Information from the Committee on the Rights of the Child Concluding Observations, as well as UNICEF and WHO indicators on child health and protection issues were used to check and supplement responses. Qualitative comparative analysis (QCA) was used to identify child protection measure implementation effectiveness. RESULTS: Results indicate that child protection judged as comparatively more successful among study countries is a result of having the following measures in place from two types of social programs: a CP infrastructure (legislation plus services) and at least one information-based intervention support program. CONCLUSIONS: Fourteen (33%) countries were determined to have established at least a basic CP system toward protection of children from violence and maltreatment. These countries reported having the three required elements described above. The study reinforces the need for governments to take a systems approach to child protection, including policy/legislation, information-based programs and social services, as well as professional training and public awareness raising. The top-ranked countries included: Australia, Bahrain, Belgium, Brazil, Canada, Estonia, Germany, Italy, Jordan, Lebanon, Malaysia, Republic of Korea, the Russian Federation, and the United Kingdom. PRACTICE IMPLICATIONS: Governments need to establish CP systems with multiple, well-integrated, effective CP measures as elaborated above, working with trained professionals and also raising public awareness to ensure successful protection for all children in every country. Partial measures are not effective. Further, in addition to establishing, implementing, and evaluating the effectiveness of professional interventions, the actual outcomes for children, not studied or reported on here, need to be the priority focus for child protection going forward.