The benefits and opportunities: Engaging patients in identifying and reporting patient safety incidents.

There is growing recognition that patients can and should be engaged in the identification of patient safety incidents arising during their experiences across health systems. In this article, we describe the benefits that can be harnessed from engaging patients in reporting patient safety incidents; identify opportunities to support patient engagement in reporting and learning from patient safety incidents; and describe the potential role of health leaders in connecting patient experience and patient safety using patient-reported patient safety incident data.

Facilitators and Barriers to Clinical Pathway Uptake and Utilization Among Primary Care Providers in Saskatchewan - A Qualitative Study.

PURPOSE: Clinical Pathways (CPWs) are multidisciplinary, evidence-based, complex interventions designed to standardize patient care. In Saskatchewan, development, implementation and evaluation of the seven provincial CPWs (Hip & Knee, Spine, Pelvic Floor, Prostate Assessment, Fertility Care, Lower Extremity Wound Care and Acute Stroke) present significant challenges, leading to low utilization. This study aimed to identify facilitators and barriers to CPW utilization by Saskatchewan family physicians. METHODS: To identify the facilitators and barriers to CPWs, a qualitative interpretive approach consisted of eight one-on-one key informant interviews and five focus groups held with 30 family physicians in two larger urban and two smaller Saskatchewan cities. Inductive, thematic analysis of the interviews based on the Theoretical Domain Framework for behavioral changes was used to identify facilitators and barriers to CPW uptake and utilization. RESULTS: Fifty-one themes were mapped under 14 Theoretical Domain Framework domains. Major barriers included the following: system-level (knowledge and communication, social/professional identity, family physician engagement and education); objective clarification (goals, belief about consequences of implementing CPW); and technical and resource related (administrative, access to local specialists, enforcement and incentives). The most prominent barrier was lack of systematic CPW promotion and inconsistencies in communication between the following: organization-to-practitioner; organization-to-organization; and practitioner-to-practitioner. Facilitators who mitigated barriers were need for optimized and integrated information technology services (i.e., Electronic Medical Records) and optimism towards CPW usage and patient outcomes. CONCLUSIONS: This exploratory study identified specific improvements and recommendations required to promote uptake of CPWs based on perceived facilitators and barriers.

Mid-infrared interband cascade light emitting devices grown on off-axis silicon substrates.

The high-quality growth of midwave infrared light emitters on silicon substrates will advance their incorporation into photonic integrated circuits, and also introduce manufacturing advantages over conventional devices grown on lattice-matched GaSb. Here we report interband cascade light emitting devices (ICLEDs) grown on 4 degree offcut silicon with 12% lattice mismatch. Four wafers produced functioning devices, with variations from wafer to wafer but uniform performance of devices from a given wafer. The full width at half maxima for the (004) GaSb rocking curves were as narrow as ∼ 163 arc seconds, and the root mean square surface roughness as small as 3.2 nm. Devices from the four wafers, as well as from a control structure grown to the same design on GaSb, were mounted epitaxial-side-up (epi-up). While core heating severely limited continuous wave (cw) emission from the control devices at relatively modest currents, efficient heat dissipation via the substrate allowed output from the devices on silicon to increase up to much higher currents. Although the devices on silicon had higher leakage currents, probably occurring primarily at dislocations resulting from the lattice-mismatched growth, accounting for differences in architecture the efficiency at high cw current was approximately 75% of that of our previous best-performing standard epi-down ICLEDs grown on GaSb. At 100 mA injection current, 200-µm-diameter mesas produced 184 µW of cw output power when operated at T = 25 °C, and 140 µW at 85°C. Epi-up mid-IR light emitters grown on silicon will be far simpler to process and much less expensive to manufacture than conventional devices grown on GaSb and mounted epi-down.

Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review.

BACKGROUND: Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered. The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC). METHODS: A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed. RESULTS: Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied. The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators. CONCLUSIONS: In the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience. TRIAL REGISTRATION: PROSPERO 2018 CRD42018087689.

Nurse managers implementing the lean management system: A qualitative study in Western Canada.

AIM: This study explores the perceptions and experiences of nurse managers involved in implementing the Lean management system in a Western Canadian province. BACKGROUND: The provincial government of Saskatchewan, Canada, implemented a multimillion-dollar investment in the Lean management system to transform health care delivery by reducing waste and increasing efficiency of processes and outcomes. METHODS: This qualitative exploratory study employed semi-structured interviews with 14 nurse managers in urban and rural health regions in one Canadian province. RESULTS: Six themes outline the difficulties nurse managers experienced in juggling role responsibilities alongside a poorly implemented change system with scarce resources. CONCLUSION: The results showed tensions in the implementation of a Lean model adapted in the context of health care organisations. The expectations for nurse managers to be pivotal players in the implementation of transformative health care practices that promote and sustain strategies to reduce waste, improve coordination and increase patient safety require investment in leadership development. IMPLICATIONS FOR NURSING MANAGEMENT: Lean management systems significantly impact the roles of nurse managers who require adequate resources and training to successfully adapt. The results of this study may be used for more effective support mechanisms for nurse managers.

Hospital nurse-staffing models and patient- and staff-related outcomes.

BACKGROUND: Nurses comprise the largest component of the health workforce worldwide and numerous models of workforce allocation and profile have been implemented. These include changes in skill mix, grade mix or qualification mix, staff-allocation models, staffing levels, nursing shifts, or nurses' work patterns. This is the first update of our review published in 2011. OBJECTIVES: The purpose of this review was to explore the effect of hospital nurse-staffing models on patient and staff-related outcomes in the hospital setting, specifically to identify which staffing model(s) are associated with: 1) better outcomes for patients, 2) better staff-related outcomes, and, 3) the impact of staffing model(s) on cost outcomes. SEARCH METHODS: CENTRAL, MEDLINE, Embase, two other databases and two trials registers were searched on 22 March 2018 together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included randomised trials, non-randomised trials, controlled before-after studies and interrupted-time-series or repeated-measures studies of interventions relating to hospital nurse-staffing models. Participants were patients and nursing staff working in hospital settings. We included any objective reported measure of patient-, staff-related, or economic outcome. The most important outcomes included in this review were: nursing-staff turnover, patient mortality, patient readmissions, patient attendances at the emergency department (ED), length of stay, patients with pressure ulcers, and costs. DATA COLLECTION AND ANALYSIS: We worked independently in pairs to extract data from each potentially relevant study and to assess risk of bias and the certainty of the evidence. MAIN RESULTS: We included 19 studies, 17 of which were included in the analysis and eight of which we identified for this update. We identified four types of interventions relating to hospital nurse-staffing models:- introduction of advanced or specialist nurses to the nursing workforce;- introduction of nursing assistive personnel to the hospital workforce;- primary nursing; and- staffing models.The studies were conducted in the USA, the Netherlands, UK, Australia, and Canada and included patients with cancer, asthma, diabetes and chronic illness, on medical, acute care, intensive care and long-stay psychiatric units. The risk of bias across studies was high, with limitations mainly related to blinding of patients and personnel, allocation concealment, sequence generation, and blinding of outcome assessment.The addition of advanced or specialist nurses to hospital nurse staffing may lead to little or no difference in patient mortality (3 studies, 1358 participants). It is uncertain whether this intervention reduces patient readmissions (7 studies, 2995 participants), patient attendances at the ED (6 studies, 2274 participants), length of stay (3 studies, 907 participants), number of patients with pressure ulcers (1 study, 753 participants), or costs (3 studies, 617 participants), as we assessed the evidence for these outcomes as being of very low certainty. It is uncertain whether adding nursing assistive personnel to the hospital workforce reduces costs (1 study, 6769 participants), as we assessed the evidence for this outcome to be of very low certainty. It is uncertain whether primary nursing (3 studies, > 464 participants) or staffing models (1 study, 647 participants) reduces nursing-staff turnover, or if primary nursing (2 studies, > 138 participants) reduces costs, as we assessed the evidence for these outcomes to be of very low certainty. AUTHORS' CONCLUSIONS: The findings of this review should be treated with caution due to the limited amount and quality of the published research that was included. We have most confidence in our finding that the introduction of advanced or specialist nurses may lead to little or no difference in one patient outcome (i.e. mortality) with greater uncertainty about other patient outcomes (i.e. readmissions, ED attendance, length of stay and pressure ulcer rates). The evidence is of insufficient certainty to draw conclusions about the effectiveness of other types of interventions, including new nurse-staffing models and introduction of nursing assistive personnel, on patient, staff and cost outcomes. Although it has been seven years since the original review was published, the certainty of the evidence about hospital nurse staffing still remains very low.

A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on sustainability of a lean intervention in pediatric healthcare.

BACKGROUND: In 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation. Research has been conducted on the implementation processes of this system-wide Lean implementation. However, no research has been done on the sustainability of these Lean efforts. We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare. METHODS: We employed a case study research design. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units 'cases' at one acute hospital. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching. RESULTS: We conducted thirty-two interviews across the four cases. Five CMOcs emerged from our realist interview data. These configurations illustrated a 'ripple-effect' from implementation outcomes to contexts for sustainability. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. Failure to trigger these mechanisms resulted in resistance. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor 'sense-making' and a lack of engagement for frontline staff. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Overall, there was variation between leadership and frontline staff's perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability. CONCLUSIONS: This research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement.

Patient family advisors' perspectives on engagement in health-care quality improvement initiatives: Power and partnership.

BACKGROUND: Engagement of the public in defining and shaping the organization and delivery of health care is increasingly viewed as integral to improving quality and promoting transparent decision making. Meaningful engagement of the public in health-care reform is predicated on shifting entrenched power imbalances between health-care systems and those it claims to serve. OBJECTIVES: To describe the expressions, forms and spaces of power from the perspectives of persons who participated as Patient/Family Advisors (PFAs) in Rapid Process Improvement Workshops (RPIWs) within Saskatchewan, Canada. METHODS: Using a qualitative, interpretive approach, in-depth interviews were conducted with a purposive sample of 18 PFAs who had participated in at least one RPIW over the past year. Deductive thematic analysis was informed by Gaventa's model of power. RESULTS: Motivations for serving as a PFA included a sense of obligation to contribute to the improvement of a public system, recognition of their rights as citizens within a publicly funded system and an opportunity to openly express their concerns where previous encounters had been very negative. The invited spaces of the RPIWs were created by policymakers to accord visible power to PFAs. Participation resulted in PFAs gaining new insights into the structure and operations of the system, affirmation of their right to advocate and recognition of the potential to claim spaces of power as consumers. Advisement on specific health-care initiatives using the vehicle of PFAs shaped and promoted new forms and spaces of power, representing one step in a very long road to full engagement of consumers in health care.

Assessing the implementation processes of a large-scale, multi-year quality improvement initiative: survey of health care providers.

BACKGROUND: Beginning in 2012, Lean was introduced to improve health care quality and promote patient-centredness throughout the province of Saskatchewan, Canada with the aim of producing coordinated, system-wide change. Significant investments have been made in training and implementation, although limited evaluation of the outcomes have been reported. In order to better understand the complex influences that make innovations such as Lean "workable" in practice, Normalization Process Theory guided this study. The objectives of the study were to: a) evaluate the implementation processes associated with Lean implementation in the Saskatchewan health care system from the perspectives of health care professionals; and b) identify demographic, training and role variables associated with normalization of Lean. METHODS: Licensed health care professionals were invited through their professional associations to complete a cross-sectional, modified, online version of the NoMAD questionnaire in March, 2016. Analysis was based on 1032 completed surveys. Descriptive and univariate analyses were conducted. Multivariate multinomial regressions were used to quantify the associations between five NoMAD items representing the four Normalization Process Theory constructs (coherence, cognitive participation, collective action and reflexive monitoring). RESULTS: More than 75% of respondents indicated that neither sufficient training nor resources (collective action) had been made available to them for the implementation of Lean. Compared to other providers, nurses were more likely to report that Lean increased their workload. Significant differences in responses were evident between: leaders vs. direct care providers; nurses vs. other health professionals; and providers who reported increased workload as a result of Lean vs. those who did not. There were no associations between responses to normalization construct proxy items and: completion of introductory Lean training; participation in Lean activities; age group; years of professional experience; or employment status (full-time or part-time). Lean leader training was positively associated with proxy items reflecting coherence, cognitive participation and reflexive monitoring. CONCLUSIONS: From the perspectives of the cross-section of health care professionals responding to this survey, major gaps remain in embedding Lean into healthcare. Strategies that address the challenges faced by nurses and direct care providers, in particular, are needed if intended goals are to be achieved.

An economic analysis of a system wide Lean approach: cost estimations for the implementation of Lean in the Saskatchewan healthcare system for 2012-2014.

BACKGROUND: The costs of investing in health care reform initiatives to improve quality and safety have been underreported and are often underestimated. This paper reports direct and indirect cost estimates for the initial phase of the province-wide implementation of Lean activities in Saskatchewan, Canada. METHODS: In order to obtain detailed information about each type of Lean event, as well as the total number of corresponding Lean events, we used the Provincial Kaizen Promotion Office (PKPO) Kaizen database. While the indirect cost of Lean implementation has been estimated using the corresponding wage rate for the event participants, the direct cost has been estimated using the fees paid to the consultant and other relevant expenses. RESULTS: The total cost for implementation of Lean over two years (2012-2014), including consultants and new hires, ranged from $44 million CAD to $49.6 million CAD, depending upon the assumptions used. Consultant costs accounted for close to 50% of the total. The estimated cost of Lean events alone ranged from $16 million CAD to $19.5 million CAD, with Rapid Process Improvement Workshops requiring the highest input of resources. CONCLUSIONS: Recognizing the substantial financial and human investments required to undertake reforms designed to improve quality and contain cost, policy makers must carefully consider whether and how these efforts result in the desired transformations. Evaluation of the outcomes of these investments must be part of the accountability framework, even prior to implementation.

The development, implementation and evaluation of clinical pathways for chronic obstructive pulmonary disease (COPD) in Saskatchewan: protocol for an interrupted times series evaluation.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has substantial economic and human costs; it is expected to be the third leading cause of death worldwide by 2030. To minimize these costs high quality guidelines have been developed. However, guidelines alone rarely result in meaningful change. One method of integrating guidelines into practice is the use of clinical pathways (CPWs). CPWs bring available evidence to a range of healthcare professionals by detailing the essential steps in care and adapting guidelines to the local context. METHODS/DESIGN: We are working with local stakeholders to develop CPWs for COPD with the aims of improving care while reducing utilization. The CPWs will employ several steps including: standardizing diagnostic training, unifying components of chronic disease care, coordinating education and reconditioning programs, and ensuring care uses best practices. Further, we have worked to identify evidence-informed implementation strategies which will be tailored to the local context. We will conduct a three-year research project using an interrupted time series (ITS) design in the form of a multiple baseline approach with control groups. The CPW will be implemented in two health regions (experimental groups) and two health regions will act as controls (control groups). The experimental and control groups will each contain an urban and rural health region. Primary outcomes for the study will be quality of care operationalized using hospital readmission rates and emergency department (ED) presentation rates. Secondary outcomes will be healthcare utilization and guideline adherence, operationalized using hospital admission rates, hospital length of stay and general practitioner (GP) visits. Results will be analyzed using segmented regression analysis. DISCUSSION: Funding has been procured from multiple stakeholders. The project has been deemed exempt from ethics review as it is a quality improvement project. Intervention implementation is expected to begin in summer of 2017. This project is expected to improve quality of care and reduce healthcare utilization. In addition it will provide evidence on the effects of CPWs in both urban and rural settings. If the CPWs are found effective we will work with all stakeholders to implement similar CPWs in surrounding health regions. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT03075709 ). Registered 8 March 2017.

The potential for nurses to contribute to and lead improvement science in health care.

AIM: A discussion of how nurses can contribute to and lead improvement science activities in health care. BACKGROUND: Quality failures in health care have led to the urgent need for healthcare quality improvement. However, commonly quality improvement interventions proceed to practice implementation without rigorous methods or sufficient empirical evidence. This lack of evidence for quality improvement has led to the development of improvement science, which embodies quality improvement research and quality improvement practice. This paper discusses how the discipline of nursing and the nursing profession possesses many strengths that enable nurses to lead and to play an integral role in improvement science activities. However, we also discuss that there are insufficiencies in nursing education that require attention for nurses to truly contribute to and lead improvement science in health care. DESIGN: Discussion paper. DATA SOURCES: This paper builds on a collection of our previous work, a 12-month scoping review (March 2013-March 2014), baseline study on a quality improvement management system (Lean), interviews with nurses on quality improvement implementation and supporting literature. IMPLICATIONS FOR NURSING: This paper highlights how nurses have the philosophical, theoretical, political and ethical positioning to contribute to and lead improvement science activities. However up to now, the potential for nurses to lead improvement science activities has not been fully used. CONCLUSION: We suggest that one starting point is to include improvement science in nursing education curricula. Specifically, there needs to be increased focus on the nursing roles and skills needed to contribute to and lead healthcare improvement science activities.

What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review.

Clinical pathways (CPWs) are a common component in the quest to improve the quality of health. CPWs are used to reduce variation, improve quality of care, and maximize the outcomes for specific groups of patients. An ongoing challenge is the operationalization of a definition of CPW in healthcare. This may be attributable to both the differences in definition and a lack of conceptualization in the field of clinical pathways. This correspondence article describes a process of refinement of an operational definition for CPW research and proposes an operational definition for the future syntheses of CPWs literature. Following the approach proposed by Kinsman et al. (BMC Medicine 8(1):31, 2010) and Wieland et al. (Alternative Therapies in Health and Medicine 17(2):50, 2011), we used a four-stage process to generate a five criteria checklist for the definition of CPWs. We refined the operational definition, through consensus, merging two of the checklist's criteria, leading to a more inclusive criterion for accommodating CPW studies conducted in various healthcare settings. The following four criteria for CPW operational definition, derived from the refinement process described above, are (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions' (i.e. the intervention had time-frames or criteria-based progression); and (4) the intervention aimed to standardize care for a specific population. An intervention meeting all four criteria was considered to be a CPW. The development of operational definitions for complex interventions is a useful approach to appraise and synthesize evidence for policy development and quality improvement.

The impact of web-based and face-to-face simulation on patient deterioration and patient safety: protocol for a multi-site multi-method design.

BACKGROUND: There are international concerns in relation to the management of patient deterioration which has led to a body of evidence known as the 'failure to rescue' literature. Nursing staff are known to miss cues of deterioration and often fail to call for assistance. Medical Emergency Teams (Rapid Response Teams) do improve the management of acutely deteriorating patients, but first responders need the requisite skills to impact on patient safety. METHODS/DESIGN: In this study we aim to address these issues in a mixed methods interventional trial with the objective of measuring and comparing the cost and clinical impact of face-to-face and web-based simulation programs on the management of patient deterioration and related patient outcomes. The education programs, known as 'FIRST(2)ACT', have been found to have an impact on education and will be tested in four hospitals in the State of Victoria, Australia. Nursing staff will be trained in primary (the first 8 min) responses to emergencies in two medical wards using a face-to-face approach and in two medical wards using a web-based version FIRST(2)ACTWeb. The impact of these interventions will be determined through quantitative and qualitative approaches, cost analyses and patient notes review (time series analyses) to measure quality of care and patient outcomes. DISCUSSION: In this 18 month study it is hypothesised that both simulation programs will improve the detection and management of deteriorating patients but that the web-based program will have lower total costs. The study will also add to our overall understanding of the utility of simulation approaches in the preparation of nurses working in hospital wards. (ACTRN12616000468426, retrospectively registered 8.4.2016).

Lean and leadership practices: development of an initial realist program theory.

BACKGROUND: Lean as a management system has been increasingly adopted in health care settings in an effort to enhance quality, capacity and safety, while simultaneously containing or reducing costs. The Ministry of Health in the province of Saskatchewan, Canada has made a multi-million dollar investment in Lean initiatives to create "better health, better value, better care, and better teams", affording a unique opportunity to advance our understanding of the way in which Lean philosophy, principles and tools work in health care. METHODS: In order to address the questions, "What changes in leadership practices are associated with the implementation of Lean?" and "When leadership practices change, how do the changed practices contribute to subsequent outcomes?", we used a qualitative, multi-stage approach to work towards developing an initial realist program theory. We describe the implications of realist assumptions for evaluation of this Lean initiative. Formal theories including Normalization Process Theory, Theories of Double Loop and Organization Leaning and the Theory of Cognitive Dissonance help understand this initial rough program theory. Data collection included: key informant consultation; a stakeholder workshop; documentary review; 26 audiotaped and transcribed interviews with health region personnel; and team discussions. RESULTS: A set of seven initial hypotheses regarding the manner in which Lean changes leadership practices were developed from our data. We hypothesized that Lean, as implemented in this particular setting, changes leadership practices in the following ways. Lean: a) aligns the aims and objectives of health regions; b) authorizes attention and resources to quality improvement and change management c) provides an integrated set of tools for particular tasks; d) changes leaders' attitudes or beliefs about appropriate leadership and management styles and behaviors; e) demands increased levels of expertise, accountability and commitment from leaders; f) measures and uses data effectively to identify actual and relevant local problems and the root causes of those problems; and g) creates or supports a 'learning organization' culture. CONCLUSIONS: This study has generated initial hypotheses and realist program theory that can form the basis for future evaluation of Lean initiatives. Developing leadership capacity and culture is theorized to be a necessary precursor to other systemic and observable changes arising from Lean initiatives.

"The largest Lean transformation in the world": the implementation and evaluation of lean in Saskatchewan healthcare.

The Saskatchewan Ministry of Health has committed to a multi-million dollar investment toward the implementation of Lean methodology across the province's healthcare system. Originating as a production line discipline (the Toyota Production System), Lean has evolved to encompass process improvements including inventory management, waste reduction and quality improvement techniques. With an initial focus on leadership, strategic alignment, training and the creation of a supportive infrastructure (Lean promotion offices), the goal in Saskatchewan is a whole health system transformation that produces "better health, better value, better care, and better teams." Given the scope and scale of the initiative and the commitment of resources, it is vital that a comprehensive, longitudinal evaluation plan be implemented to support ongoing decision-making and program design. The nature of the initiative also offers a unique opportunity to contribute to health quality improvement science by advancing our understanding of the implementation and evaluation of complex, large-scale healthcare interventions. The purpose of this article is to summarize the background to Lean in Saskatchewan and the proposed evaluation methods.

The effectiveness of individual interpersonal psychotherapy as a treatment for major depressive disorder in adult outpatients: a systematic review.

BACKGROUND: This systematic review describes a comparison between several standard treatments for major depressive disorder (MDD) in adult outpatients, with a focus on interpersonal psychotherapy (IPT). METHODS: Systematic searches of PubMed and PsycINFO studies between January 1970 and August 2012 were performed to identify (C-)RCTs, in which MDD was a primary diagnosis in adult outpatients receiving individual IPT as a monotherapy compared to other forms of psychotherapy and/or pharmacotherapy. RESULTS: 1233 patients were included in eight eligible studies, out of which 854 completed treatment in outpatient facilities. IPT combined with nefazodone improved depressive symptoms significantly better than sole nefazodone, while undefined pharmacotherapy combined with clinical management improved symptoms better than sole IPT. IPT or imipramine hydrochloride with clinical management showed a better outcome than placebo with clinical management. Depressive symptoms were reduced more in CBASP (cognitive behavioral analysis system of psychotherapy) patients in comparison with IPT patients, while IPT reduced symptoms better than usual care and wait list condition. CONCLUSIONS: The differences between treatment effects are very small and often they are not significant. Psychotherapeutic treatments such as IPT and CBT, and/or pharmacotherapy are recommended as first-line treatments for depressed adult outpatients, without favoring one of them, although the individual preferences of patients should be taken into consideration in choosing a treatment.

The Impact of Primary Care Practice Models on Indicators of Unplanned Health Care Utilization for Ontario Adults Newly Diagnosed With Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic disease. Most of the care for this population occurs within the primary care setting; however, the extent to which different primary care practice models influence the outcomes of patients with COPD remains unclear. OBJECTIVE: The study aimed to compare and analyze the influence of different primary care practice models on indicators of unplanned health care utilization among newly diagnosed COPD patients in Ontario. DESIGN: A retrospective cohort study was conducted using health administrative database within the Institute for Clinical Evaluative Sciences. The cohort included persons who were 35 years and older with physician-diagnosed COPD between January 1, 2014 and December 31, 2019. Patients were assigned into 3 practice models: team-based, traditional, and no enrolment. The primary outcomes examined was unplanned health care utilization, specifically emergency department (ED) visits and hospitalizations. To account for excessive zero values, the zero inflated negative binomial (ZINB) models were used to analyze the association between different practice models and unplanned health care utilization. RESULTS: Among 57,145 individuals who met the inclusion criteria, 55,994 were included in the regression analysis. Of the included participants, 62.8% of patients were in the traditional group, 30.3% were in the team-based group, and 6.9% were in the no enrolment group. Between 2014 and 2019, 70.7% of the cohort had at least 1 all-cause ED visit without hospitalization. The adjusted ZINB models showed no significant difference in risks of experiencing an unplanned health care utilization between the team-based and traditional groups. However, patients in the no enrolment group had a significantly higher risk of ED visit without hospitalization regardless of cause, ED visit with hospitalization regardless of cause, and 30-day readmissions regardless of cause. CONCLUSIONS: Primary care practice models are complex, influenced by remuneration and organizational structures, reinforcing the need for further research to enhance our understanding of primary care reforms. Furthermore, given the growing shortage of primary care providers, patients with COPD and other chronic conditions are particularly vulnerable.

The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials.

BACKGROUND: The purpose of this article is to report on the quality of the existing evidence base regarding the effectiveness of clinical pathway (CPW) research in the hospital setting. The analysis is based on a recently published Cochrane review of the effectiveness of CPWs. METHODS: An integral component of the review process was a rigorous appraisal of the methodological quality of published CPW evaluations. This allowed the identification of strengths and limitations of the evidence base for CPW effectiveness. We followed the validated Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria for randomized and non-randomized clinical pathway evaluations. In addition, we tested the hypotheses that simple pre-post studies tend to overestimate CPW effects reported. RESULTS: Out of the 260 primary studies meeting CPW content criteria, only 27 studies met the EPOC study design criteria, with the majority of CPW studies (more than 70 %) excluded from the review on the basis that they were simple pre-post evaluations, mostly comparing two or more annual patient cohorts. Methodologically poor study designs are often used to evaluate CPWs and this compromises the quality of the existing evidence base. CONCLUSIONS: Cochrane EPOC methodological criteria, including the selection of rigorous study designs along with detailed descriptions of CPW development and implementation processes, are recommended for quantitative evaluations to improve the evidence base for the use of CPWs in hospitals.

Do clinical pathways enhance access to evidence-based acute myocardial infarction treatment in rural emergency departments?

OBJECTIVE: The objective of this study is to measure the impact of a five-step implementation process for an acute myocardial infarction (AMI) clinical pathway (CPW) on thrombolytic administration in rural emergency departments. DESIGN: Cluster randomised controlled trial. SETTING: Six rural Victorian emergency departments participated. INTERVENTION: The five-step CPW implementation process comprised (i) engaging clinicians; (ii) CPW development; (iii) reminders; (iv) education; and (v) audit and feedback. MAIN OUTCOME MEASURES: The impact of the intervention was assessed by measuring the proportion of eligible AMI patients receiving a thrombolytic and time to thrombolysis and electrocardiogram. RESULTS: Nine hundred and fifteen medical records were audited, producing a final sample of 108 patients eligible for thrombolysis. There was no significant difference between intervention and control groups for median door-to-needle time (29 mins versus 29 mins; P = 0.632), proportion of those eligible receiving a thrombolytic (78% versus 84%; P = 0.739), median time to electrocardiogram (7 mins versus 6 mins; P = 0.669) and other outcome measures. Results showed superior outcome measures than other published studies. CONCLUSIONS: The lack of impact of the implementation process for a chest pain CPW on thrombolytic delivery or time to electrocardiogram in these rural hospitals can be explained by a ceiling effect in outcome measures but was also compromised by the small sample. Results suggest that quality of AMI treatment in rural emergency departments (EDs) is high and does not contribute to the worse mortality rate reported for AMIs in rural areas.