Exploring role clarity in interorganizational spread and scale-up initiatives: the 'INSPIRED' COPD collaborative.

BACKGROUND: Role clarification is consistently documented as a challenging process for inter professional healthcare teams, despite being a core tenet of interprofessional collaboration. This paper explores the role clarification process in two previously unexplored contexts: i) in the dissemination phase of a quality improvement (QI) program, and ii) as part of interorganizational partnerships for the care of chronic disease patients. METHODS: A secondary analysis using asynchronous purposive coding was conducted on an innovative pan-Canadian Chronic Obstructive Pulmonary Disease QI program. RESULTS: Our study reveals that the iterative structure of QI initiatives in the spread phase can offer numerous unique benefits to role clarification, with the potential challenge of time commitment. In addition, the role clarification process within interorganizational partnerships proved to be relatively well-structured, characterized by three phases: relationship conceptualization or early contact, familiarization, and finally, role division. Common strategies in the last stage included the establishment of working groups and new information-sharing networks. CONCLUSION: This article characterizes some ways in which providers and organizational partners negotiate their roles in a changing professional environment. As the movement towards integrated care continues, issues of role clarity are assuming increasing importance in healthcare contexts, and understanding role dynamics can provide valuable insight into the optimization of QI initiatives.

Improving care for advanced COPD through practice change: Experiences of participation in a Canadian spread collaborative.

Chronic obstructive pulmonary disease (COPD) is a leading cause of death, morbidity, and health-care spending. The Halifax, Nova Scotia-based INSPIRED COPD Outreach Program™ has proved highly beneficial for patients and the health-care system. With direct investment of <$1-million CAD, a pan-Canadian quality improvement collaborative (QIC) supported the spread of INSPIRED to 19 teams in the 10 Canadian provinces contingent upon participation in evaluation. The collaborative evaluation followed a mixed-methods summative approach relying on collated quantitative data, team documents, and surveys sent to core members of the 19 teams. Survey questions included a series of multiple-choice responses, Likert scale ratings, and open-ended questions. The qualitative evaluation entailed key informant interviews and focus groups undertaken between February and April 2016 post-collaborative. Teams reported that the year-long QIC helped bring focus to a needed, though often overlooked area of improvement, facilitating innovation spread. They report examples of new work practices as well as unanticipated cultural change (given the short QIC time frame). Most teams gained new skills in quality improvement (QI) and evidence-based medicine, showing progress in their ability to measure and implement COPD care improvements. Teams felt networking with other teams across the country toward a common solution as well as learning from a team of clinical innovators and evidence-based innovation were critical to their success. Factors affecting sustainability included local leadership support, involvement of frontline clinicians, and sharing milestones to motivate continued QI. The INSPIRED QIC enabled teams across Canada to adapt and implement a new COPD care model for high users of health-care with rapid improvements to work practices, cultural change, and skill sets, and at relatively low cost.

Number Needed To $ave?

The 'Number Needed to Treat' (NNT) is a useful measure for estimating the number of patients that would need to receive a therapeutic intervention to avoid one of the adverse events that the treatment is designed to prevent. We explored the possibility of an adaption of NNT to estimate the 'Number Needed to $ave' (NN$) as a new, conceptual systems metric to estimate potential cost-savings to the health system from implementation of a treatment, or in this case, a program. We used the outcomes of the INSPIRED COPD Outreach ProgramTM to calculate that 26 patients would need to complete the program to avoid healthcare expenditures of $100,000, based on hospital bed days avoided. The NN$ does not translate into 'cost savings' per se, but redirection of resource expenditures for other purposes. We propose that the NN$ metric, if further developed, could help to inform system-level resource allocation decisions in a manner similar to the way that the NNT metric helps to inform individual-level treatment decisions.

'INSPIRED' COPD Outreach Program™: doing the right things right.

The well-documented gaps between needed and provided care for patients and families living with chronic obstructive pulmonary disease (COPD) mandate changes to clinical practice. The multifaceted evidence-based INSPIRED COPD Outreach Program™ was first implemented in Halifax, Nova Scotia, Canada in 2010 (INSPIRED = Implementing a Novel and Supportive Program of Individualized care for patients and families living with REspiratory Disease) and undergoes ongoing evaluation. By enhancing patient confidence to manage their illness more effectively in their homes and communities, there has been a sustained and substantial reduction in facility-based care in comparison with patient care experience pre-INSPIRED. Sustaining and spreading a program recently designated a leading practice by Accreditation Canada, and especially modifying the program as new evidence emerges, requires integrating and modeling at the 'bedside' both evidence-based medicine ('doing the right things') and quality improvement ('doing them right'). In Canada, where COPD care gaps are common, a new pan-Canadian INSPIRED-based quality improvement program is supporting multidisciplinary healthcare teams to bridge the chasm between evidence and practice by working together to 'do the right things right' in COPD care.

Opinion editorials: the science and art of combining evidence with opinion.

In the policy environment, the news media play a powerful and influential role, determining not only what issues are on the broad policy agenda, but also how the public and politicians perceive these issues. Ensuring that reporters and editors have access to information, that is, credible and evidence-based is critical for stimulating healthy public discourse and constructive political debates. EvidenceNetwork.ca is a non-partisan web-based project that makes the latest evidence on controversial health-policy issues available to the Canadian news media. This article introduces EvidenceNetwork.ca, the benefits it offers to journalists and researchers, and the important niche it occupies in working with the news media to build a more productive dialogue around healthcare.

Spreading improvements for advanced COPD care through a Canadian Collaborative.

BACKGROUND: A year-long pan-Canadian quality improvement collaborative (QIC) led by the Canadian Foundation for Healthcare Improvement (CFHI) supported the spread of the successful Halifax, Nova Scotia-based INSPIRED COPD Outreach Program™ to 19 teams in the 10 Canadian provinces. We describe QIC results, addressing two main questions: 1) Can the results of the Nova Scotia INSPIRED model be replicated elsewhere in Canada? 2) How did the teams implement and evaluate their versions of the INSPIRED program? METHODS: Collaborative faculty selected measures that were evidence-based, relatively simple to collect, and relevant to local context. Chosen process and outcome measures are related to four quality domains: 1) patient- and family-centeredness, 2) coordination, 3) efficiency, and 4) appropriateness. Evaluation of a complex intervention followed a mixed-methods approach. RESULTS: Most participants were nurse managers and/or COPD educators. Only 8% were physicians. Fifteen teams incorporated all core INSPIRED interventions. All teams carried out evaluation. Thirteen teams actively involved patients and families in customized, direct care planning, eg, asking them to complete evaluative surveys and/or conducting interviews. Patients consistently reported greater self-confidence in symptom management, a return to daily activities, and improvements to quality of life. Twelve teams collected data on care transitions using the validated three-item Care Transitions Measure (CTM-3). Twelve teams used the Lung Information Needs Questionnaire (LINQ). Admissions, emergency room visits, and patient-related costs fell substantially for two teams described in detail (combined enrollment 208 patients). Most teams reported gaining deeper knowledge around complexities of COPD care, optimizing patient care through action plans, self-management support, psychosocial support, advance care planning, and coordinating community partnerships. CONCLUSION: Quality-of-care gains are achievable in the short term among different teams across diverse geographical and social contexts. A well-designed, adequately funded public-private partnership can deliver widespread beneficial outcomes for the health care system and for those living with advanced COPD.

A Collaborative Approach to a Chronic Care Problem.

Quality improvement collaboratives (QICs) are popular vehicles for supporting healthcare improvement; however, the effectiveness of these models and the factors associated with their success are not fully understood. This paper presents a QIC in the Canadian context, where provincial healthcare systems have historically faced difficulty in transcending their structural and political limitations as well as moving from reactive models of care (prioritizing illness treatment in a hospital-reliant system) to more proactive ones (prioritizing population health in a primary care-based system). In March 2012, in a move that has been described as "unprecedented," 17 health regions across four provinces in Atlantic Canada, together with the Canadian Foundation for Healthcare Improvement (CFHI), developed a collaborative to improve chronic disease prevention and management. This paper introduces the Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC), reflecting on the experience of developing and implementing the model, which involved teams of front-line clinicians and managers working with CFHI faculty, coaches and staff to assess, design, implement, evaluate and share healthcare improvements for people living with chronic diseases. The paper shares key results and lessons learned from the AHC QIC experience, thus far, for improving chronic disease prevention and management in healthcare in Canada.

Can a Healthcare "Lean Sweep" Deliver on What Matters to Patients? Comment on "Improving Wait Times to Care for Individuals with Multimorbidities and Complex Conditions Using Value Stream Mapping".

Disconnects and defects in care - such as duplication, poor integration between services or avoidable adverse events - are costly to the health system and potentially harmful to patients and families. For patients living with multiple chronic conditions, such disconnects can be particularly detrimental. Lean is an approach to optimizing value by reducing waste (eg, duplication and defects) and containing costs (eg, improving integration of services) as well as focusing on what matters to patients. Lean works particularly well to optimize existing processes and services. However, as the burden of chronic illness and frailty overtake episodic care needs, health systems require far greater complex, adaptive change. Such change ought to take into account outcomes in population health in addition to care experiences and costs (together, comprising the Triple Aim); and involve patients and families in co-designing new models of care that better address complex, longer-term health needs.