The role of the psychologist in the inpatient pain service: development and initial outcomes.

AIM: This article describes the development and initial evaluation of introducing a psychologist role within an adult inpatient pain service (IPS) in a large North West of England National Health Service (NHS) trust. BACKGROUND: The role of a psychologist in the management of outpatient chronic pain has been well documented, but their role within the IPS is less well described and rarely evaluated. We describe the development of a psychologist role within the team and initial service evaluation outcomes. METHODS: Following an initial needs assessment, a band 8c psychologist joined the IPS one day per week offering brief one-to-one psychological interventions to people struggling with acute or chronic pain in hospital referred by inpatient pain team. The psychologist had an indirect role offering training, supervision and support to members of the inpatient pain team. Regarding direct patient work, following psychometric screening for pain-related disability and distress, a cognitive behavioural therapy (CBT) approach was applied including identifying unhelpful beliefs about pain, psychoeducation about acute and persistent pain, developing and sharing formulations, skills training including breathing and relaxation exercises and where appropriate, signposting onto an outpatient chronic pain services for further pain self-management advice (e.g. pain management programme. To explore the impact of this direct intervention, a prospective service evaluation with a controlled before and after design was conducted. This compared (a) number of admissions and (b) length-of-stay outcomes in the 12 months following psychometric screening for patients who received psychological input (n = 34, the treatment group) and a sample who did not receive input because of discharge before intervention or non-availability of the psychologist, for example, annual leave (n = 30, control group). Demographic information and summaries of psychometric questionnaires were also analysed. RESULTS: Of the sample of 64 patients, 50 were women, ages ranged from 18-80 years, 72% reported being currently unemployed or off sick from work and on screening and 39% and 48% met criteria for severe depression and pain-related anxiety, respectively. Hospital admissions in the intervention group reduced significantly (by 60%) in the 12 months following screening but increased (by 7%) for the control group (F(1,62) = 7.21, p = .009). Days of stay in hospital reduced significantly more (by 84%) in the intervention group than in the control group (by 41%) (F(1,62) = 8.90, p = .004). Illustrated case studies of brief psychological intervention with three people struggling with pain-related distress are presented. CONCLUSIONS: The psychologist became a valuable member of the multi-disciplinary IPS team, offering brief direct and indirect psychological interventions. While a relatively small sample, our prospective service evaluation data suggest brief psychological intervention may contribute to reduced length of stay and hospital admissions for people experiencing pain-related distress in hospital.

Measuring quality improvement in public health: the development and psychometric testing of a QI Maturity Tool.

There is growing interest and investment in improving the quality of public health services and outcomes. Following the lead of other sectors, efforts are underway to introduce systematic quality improvement (QI) tools and approaches to state and local public health agencies. Little is known, however, about how to describe and reliably measure the level of QI maturity within a public health agency. The authors describe the development of a QI Maturity Tool using research from the fields of organizational design, psychology, health care, and complexity theory. The 37-item assessment tool is based on four quality domains derived from the literature: (a) organizational culture, (b) capacity and competency, (c) practice, and (d) alignment and spread. The tool was designed to identify features of an organization that may be enhancing or impeding QI; monitor the impact of efforts to create a more favorable environment for QI; and define potential cohorts of public health agencies for evaluation purposes. The article presents initial steps in testing and validating the QI Maturity Tool including: (a) developing a theoretical framework, (b) assuring face and content validity, (c) determining the tool's reliability based on estimates of internal consistency, (d) assessing the dimensionality, and (f) determining the construct validity of the instrument. The authors conclude that there is preliminary evidence that the QI Maturity Tool is a promising instrument. Further work is underway to explore whether self-reported survey results align with an agency's actions and the products of their QI efforts.

Assessing quality improvement in local health departments: results from the Multi-State Learning Collaborative.

OBJECTIVE: This study examined changes in quality improvement: (1) over a 3-year period, (2) among mini-collaborative participants, and (3) among agencies that were classified in the lowest QI performance quartile. METHODS: : A QI Maturity Tool was administered to all local health departments in the Multi-State Learning Collaborative states. Factorial ANOVA was performed to determine differences in composite factor scores and interaction effects were explored. RESULTS: : The results revealed a significant increase in the percent of agencies that reported ever implementing a formal QI process from 2009 to 2011 and agencies that participated in a mini-collaborative were more likely than their non-mini-collaborative counterparts to report QI implementation. The findings also suggested significant changes in QI capacity and competency as well as alignment and spread over the course of the grant, among mini-collaborative participants, and among agencies that were originally identified in the lowest QI maturity quartile. No significant changes in organizational culture were revealed by year or among mini-collaborative participants. However, agencies in the lowest quartile saw significant changes in organizational culture during the project period. CONCLUSIONS: Significant changes in specific QI domains are possible to detect during a 3-year period. Our research gives us confidence that the QI Maturity Tool measures the right domains and is an important contribution to quantifying the adoption and spread of QI in public health. However, further refinement is needed to better standardize language and definitions of the component parts of a QI system.

Quality improvement learning collaboratives in public health: findings from a multisite case study.

OBJECTIVES: This study was designed to (1) test a theory on the key drivers of a successful mini-collaborative, (2) describe the application of quality improvement (QI) approaches and techniques among mini-collaborative participants, and (3) identify key attributes that affect the spread and sustainability of QI efforts within a local public health agency. METHODS: A multisite case study methodology was used to evaluate a subset of mini-collaboratives and their participating local health departments that were working in specific target areas. Data were collected during semistructured interviews and while observing mini-collaborative meetings. Documentation reviews were also conducted. We used standard techniques to code the data on the basis of themes and connections between themes. RESULTS: The findings provide early evidence that support our case study theory on the drivers of a successful mini-collaborative including advanced planning, the selection of faculty, timely training and technical assistance, the role of senior leaders, the application of evidence-based practices, the use of an improvement model, evaluation efforts, communication, the availability of resources, target selection, and prior experience with and application of QI. While the case studies provided limited evidence of sustainability and broad spread of QI within participating states, mini-collaboratives appear to have had a major impact and will likely influence the work of participating local health departments going forward. CONCLUSIONS: Our findings suggest that the mini-collaboratives served as a catalyst for engaging local health departments in the theory and practice of QI.

Evaluating the Multi-State Learning Collaborative.

The third phase of the Multi-State Learning Collaborative (MLC) is a 3-year Robert Wood Johnson Foundation initiative designed to build quality improvement capacity within state and local health departments. This commentary provides a brief overview of the MLC, a methodological description of its evaluation, and preliminary findings. Major evaluation data sources include quarterly reports, surveys, case studies, and key informant interviews. Preliminary survey data and quarterly reports from year 1 provide some early evidence that states are progressing toward MLC goals. Approximately 27 percent of local health departments in the 16 participant states report that they have begun to prepare for national accreditation and approximately 39 percent report implementation of at least one quality improvement project within the past 12 months. Ongoing data collection efforts are underway to more fully address the evaluation questions.

Linked Data Analysis of Dually Eligible Beneficiaries in New England.

Analysis of linked Medicare/Medicaid data files from four New England States (Connecticut, Maine, Massachusetts, and New Hampshire) confirm that dually eligible beneficiaries used a disproportionate amount of both Medicare and Medicaid resources in 1995, driven largely by the significant subset of the population that used institutional long-term care (LTC). If States and the Federal Government are successful in developing approaches to dually eligible beneficiaries that reduce the use of institutional LTC, overall public costs per person could decline while Federal costs remained constant, and beneficiaries could have a greater selection of community-based options and experience greater satisfaction.