Experience-based design for integrating the patient care experience into healthcare improvement: Identifying a set of reliable emotion words.

BACKGROUND: Experience-based design is an emerging method used to capture the emotional content of patient and family member healthcare experiences, and can serve as the foundation for patient-centered healthcare improvement. However, a core tool-the experience-based design questionnaire-requires words with consistent emotional meaning. Our objective was to identify and evaluate an emotion word set reliably categorized across the demographic spectrum as expressing positive, negative, or neutral emotions for experience-based design improvement work. METHODS: We surveyed 407 patients, family members, and healthcare workers in 2011. Participants designated each of 67 potential emotion words as positive, neutral, or negative based on their emotional perception of the word. Overall agreement was assessed using the kappa statistic. Words were selected for retention in the final emotion word set based on 80% simple agreement on classification of meaning across subgroups. RESULTS: The participants were 47.9% (195/407) patients, 19.4% (33/407) family members and 32.7% (133/407) healthcare staff. Overall agreement adjusted for chance was moderate (k=0.55). However, agreement for positive (k=0.69) and negative emotions (k=0.68) was substantially higher, while agreement in the neutral category was low (k=0.11). There were 20 positive, 1 neutral, and 14 negative words retained for the final experience-based design emotion word set. CONCLUSIONS: We identified a reliable set of emotion words for experience questionnaires to serve as the foundation for patient-centered, experience-based redesign of healthcare. IMPLICATIONS: Incorporation of patient and family member perspectives in healthcare requires reliable tools to capture the emotional content of care touch points.

Automating addiction treatment: enhancing the human experience and creating a fix for the future.

The country's system of providing treatment for people struggling with addiction requires a fundamental overhaul. To address these daunting problems, a group of experts from outside the addiction field met in an intensive retreat and envisioned a new future for addiction treatment that would use the latest available technology. Retreat leaders employed creative techniques to help free up thinking beyond incremental improvement ideas. Current and former addicts or alcoholics and family members also attended the retreat to provide the panelists with a real-world understanding of their lives. Through this process, the panelists generated eight idea categories that visualized future treatments for addiction using technology. They were: (1) Integrated System and Record; (2) Monitoring/Treatment; (3) Virtual Experiences; (4) Treatment Access and "One Stop Shop"; (5) Networks; (6) Tailored Media Campaigns; (7) Diagnostic Tools; and (8) Help for Family. Two stories illustrate how these ideas could help a heroin addict and an alcoholic. The sponsors plan another meeting to bring these visionary concepts closer to real application.

Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial.

OBJECTIVE: To test a multifaceted collaborative quality improvement intervention designed to promote evidence based surfactant treatment for preterm infants of 23-29 weeks' gestation. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 114 neonatal intensive care units (which treated 6039 infants of 23-29 weeks gestation born in 2001). MAIN OUTCOME MEASURES: Process of care measures: proportion of infants receiving first surfactant in the delivery room, proportion receiving first surfactant more than two hours after birth, and median time from birth to first dose of surfactant. Clinical outcomes: death before discharge home, and pneumothorax. INTERVENTION: Multifaceted collaborative quality improvement advice including audit and feedback, evidence reviews, an interactive training workshop, and ongoing faculty support via conference calls and email. RESULTS: Compared with those in control hospitals, infants in intervention hospitals were more likely to receive surfactant in the delivery room (adjusted odds ratio 5.38 (95% confidence interval 2.84 to 10.20)), were less likely to receive the first dose more than two hours after birth (adjusted odds ratio 0.35 (0.24 to 0.53)), and received the first dose of surfactant sooner after birth (median of 21 minutes v 78 minutes, P < 0.001). The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth. There were no significant differences in mortality or pneumothorax. CONCLUSION: A multifaceted intervention including audit and feedback, evidence reviews, quality improvement training, and follow up support changed the behaviour of health professionals and promoted evidence based practice.

Timing of initial surfactant treatment for infants 23 to 29 weeks' gestation: is routine practice evidence based?

OBJECTIVE: To describe the timing of initial surfactant treatment for high-risk preterm infants in routine practice and compare these findings with evidence from randomized trials and published guidelines. METHODS: Data from the Vermont Oxford Network Database for infants who were born from 1998 to 2000 and had birth weights 401 to 1500 g and gestational ages of 23 to 29 weeks were analyzed to determine the time after birth at which the initial dose of surfactant was administered. Multivariate models adjusting for clustering of cases within hospitals identified factors associated with surfactant administration and its timing. Evidence on surfactant timing from systematic reviews of randomized trials and from published guidelines was reviewed. RESULTS: A total of 47 608 eligible infants were cared for at 341 hospitals in North America that participated in the Vermont Oxford Network Database from 1998 to 2000. Seventy-nine percent of infants received surfactant treatment (77.6% in 1998, 79.4% in 1999, and 79.6% in 2000). Factors that increased the likelihood of surfactant treatment were outborn birth, lower gestational age, lower 1-minute Apgar score, male gender, white race, cesarean delivery, multiple birth, or birth later in the study period. The first dose of surfactant was administered at a median time after birth of 50 minutes (60 minutes in 1998, 51 minutes in 1999, and 42 minutes in 2000). Over the 3-year study period, inborn infants received their initial dose of surfactant earlier than outborn infants (median time: 43 minutes vs 79 minutes). Other factors associated with earlier administration of the initial surfactant dose were gestational age, lower 1-minute Apgar score, cesarean delivery, antenatal steroid treatment, multiple birth, and small size for gestational age. In 2000, 27% of infants received surfactant in the delivery room. There was wide variation among hospitals in the proportion of infants who received surfactant treatment in the delivery room (interquartile range: 0%-75%), in the median time of the initial surfactant dose (interquartile range: 20-90 minutes), and in the proportion of infants who received the first dose >2 hours after birth (interquartile range: 7%-34%). Six systematic reviews of randomized trials of surfactant timing were identified. No national guidelines addressing the timing of surfactant therapy were found. CONCLUSION: Although the time after birth at which the first dose of surfactant is administered to infants 23 to 29 weeks' gestation decreased from 1998 to 2000, in 2000 many infants still received delayed treatment, and delivery room surfactant administration was not routinely practiced at most units. We conclude that there is a gap between evidence from randomized controlled trials that supports prophylactic or early surfactant administration and what is actually done in routine practice at many units.

NIC/Q 2000: establishing habits for improvement in neonatal intensive care units.

OBJECTIVES: The Vermont Oxford Network is a group of health professionals who are committed to improving the quality and safety of medical care for newborn infants and their families. Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was the second in a series of multiorganization improvement collaboratives organized and administered by the Vermont Oxford Network. The objective of this collaborative was to make measurable improvements in the quality and safety of neonatal intensive care, develop new tools and resources for improvement specific to the neonatal intensive care unit setting, evaluate improvement progress, and disseminate the learning. METHODS: The 34 centers that participated in NIC/Q 2000 learned and applied 4 key habits for improvement: the habit for change, the habit for evidence-based practice, the habit for systems thinking, and the habit for collaborative learning. A plan-do-study-act method of rapid-cycle improvement was an integral part of the habit for change. Multidisciplinary teams from the participating centers worked closely together in face-to-face meetings, conference calls, and dedicated e-mail listservs under the guidance of trained facilitators and expert faculty. Focus groups formed around specific improvement topics used critical appraisal of the published literature, detailed process analysis, benchmarking, and round-robin site visits to identify potentially better practices (PBPs). RESULTS: The focus groups developed a total of 51 PBPs. Each focus group has developed a "resource kit" summarizing its work. Many of these PBPs have been tested and implemented at the participating centers using rapid-cycle improvement. The PBPs and descriptions of individual center PDSA cycles are available to participants on NICQ.org, the dedicated Internet site for the collaborative. CONCLUSIONS: Collaborative quality improvement based on the 4 key habits can assist multidisciplinary neonatal intensive care unit teams in identifying, testing, and successfully implementing change.

Effect of a scoring system and protocol for sedation on duration of patients' need for ventilator support in a surgical intensive care unit.

PROBLEM: Need for improved sedation strategy for adults receiving ventilator support. DESIGN: Observational study of effect of introduction of guidelines to improve the doctors' and nurses' performance. The project was a prospective improvement and was part of a national quality improvement collaborative. BACKGROUND AND SETTING: A general mixed surgical intensive care unit in a university hospital; all doctors and nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than 24 hours. KEY MEASURES FOR IMPROVEMENT: Reduction in patients' mean time on a ventilator and length of stay in intensive care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of consequences of changes. STRATEGIES FOR CHANGE: Multiple measures (protocol development, educational presentations, written guidelines, posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if beneficial. EFFECTS OF CHANGE: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from 7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to 8.3 days. No accidental extubations or other incidents were identified. LESSONS LEARNT: Relatively simple changes in sedation practice had significant effects on length of ventilator support. The change process was well received by the staff and increased their interest in identifying other areas for improvement.

Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative.

BACKGROUND: Health care organizations have suffered a steady decrease in operating margins in recent years while facing increased competition and pressure to provide ever-higher levels of customer service, quality of care, and innovation in delivery methodologies. The ability to rapidly find and implement changes that will lead to strategic improvement is critical. To assist member organizations in dealing with these issues, VHA Upper Midwest launched the Coaching and Leadership Initiative (VHA-CLI) in January 1999. The initiative was intended to develop new methods of collaborating for organizational learning of best practices, with a focus on generalizable change and deliberate leadership supports for deployment, diffusion, and sustainability. The emphasis was on the spread of ideas for improvement into all relevant corners of the organization. STRUCTURE AND PROCESS OF THE COLLABORATIVE: The structure of the VHA-CLI collaborative involved four waves of demonstration teams during 2 years. Each meeting of the collaborative included an executive session, team learning sessions (concepts applied to their improvement projects), and planning for the 6-month action period following the meeting. An important feature of the collaborative is the way in which teams in the various waves overlapped. For example, the Wave 1 team for a given organization came to a learning session in January 1999. At the second collaborative meeting in June 1999, the Wave 1 teams reported on the progress in their pilot sites. This meeting was also the kick-off session for the Wave 2 teams, which could learn about organizational culture and the improvement model from the efforts of their colleagues on Wave 1. Wave 1 teams also learned about and planned for spreading their efforts to other sites beyond the pilot. The pattern of multiple teams stretching across two waves of activity was repeated at every meeting of the collaborative. SUCCESS: Each organization in the collaborative has achieved improved outcomes around its selected clinical topics. In total, 26 teams have made significant improvement in 17 different topic areas. In addition, each organization has been able to successfully spread tested improvements to other individuals, teams, or locations, and the improvement work has become easier and more rapid with each successive cycle. CONCLUSIONS: The learning process initiated by this project will continue for at least another year in the VHA Upper Midwest region and will be expanded as participating organizations in other regions enroll in the VHA's national effort.