Asta Sorensen

A Multidisciplinary Approach to Promoting Healthy Subsistence Fish Consumption in Culturally Distinct Communities

Methyl mercury is a potent neurotoxin that causes developmental delays in young and unborn children and has been linked to neurological and cardiovascular degeneration in adults. Methyl mercury is the basis of a state-sponsored fish advisory to limit consumption of local fish in North Carolina. This study employed methods and analytic constructs from the behavioral and social sciences to assess the determinants of subsistence fishing and to promote informed fish consumption among culturally distinct and lower income subsistence fishers in southeastern North Carolina. Formative research revealed that Native American and African American were more likely than Latino residents to know of the fish advisory, and to practice procurement and preparation strategies that are mistakenly believed to render locally caught fish safe for consumption. Fish advisories were developed for each community to promote informed fish consumption intentions among residents who consume local fish. The interventions were successful in increasing knowledge and healthy intentions among most residents. Adherence to some safe fish consumption practices were constrained by cultural and economic factors. These results demonstrate the utility of multidisciplinary approaches for assessing and reducing human exposure to methyl mercury through subsistence fish consumption.

Accelerating What Works: Using Qualitative Research Methods in Developing a Change Package for a Learning Collaborative

BACKGROUND Learning (quality improvement) collaboratives are effective vehicles for driving coordinated organizational improvements. A central element of a learning collaborative is the change package-a catalogue of strategies, change concepts, and action steps that guide participants in their improvement efforts. Despite a vast literature describing learning collaboratives, little to no information is available on how the guiding strategies, change concepts, and action items are identified and developed to a replicable and actionable format that can be used to make measurable improvements within participating organizations. METHODS The process for developing the change package for the Health Resources and Services Administrations (HRSA) Patient Safety and Clinical Pharmacy Services Collaborative entailed environmental scan and identification of leading practices, case studies, interim debriefing meetings, data synthesis, and a technical expert panel meeting. Data synthesis involved end-of-day debriefings, systematic qualitative analyses, and the use of grounded theory and inductive data analysis techniques. This approach allowed systematic identification of innovative patient safety and clinical pharmacy practices that could be adopted in diverse environments. A case study approach enabled the research team to study practices in their natural environments. Use of grounded theory and inductive data analysis techniques enabled identification of strategies, change concepts, and actionable items that might not have been captured using different approaches. DISCUSSION Use of systematic processes and qualitative methods in identification and translation of innovative practices can greatly accelerate the diffusion of innovations and practice improvements. This approach is effective whether or not an individual organization is part of a learning collaborative.

Strategies for safe medication use in ambulatory care settings in the United States.

Objective: This study aims to identify strategies for safe medication use practices in ambulatory care settings, with a special focus on clinical pharmacy services. Methods: We conducted case studies on 34 organizations, more than half of which were safety net providers. Data included discussions with 186 key informants, 3 interim debriefings, and a technical expert panel. We analyzed qualitative data using inductive analysis techniques and grounded theory approach. Results: Ambulatory care organizations practice a broad range of safe medication use strategies. The inclusion of clinical pharmacy services is a culture change that supports efforts to improve patient safety and patient-centered care. Organizations integrated clinical pharmacy services when they introduced such services in a purposefully paced and gradual manner. Organizations sustained such services when they collected and reported data demonstrating improvements in patient outcomes and cost savings. Clinical pharmacy services were generally accompanied by strategies that helped organizations to provide patient-centered care; collect and measure process, safety, and clinical outcomes; promote leadership commitment; and integrate care delivery processes. These strategies interacted within organizations in synergistic rather than hierarchical or linear way. Organizational ability to provide safe, patient-centered, and efficient care that is supported by measurable data largely depends on leadership commitment and ability to integrate care processes. Conclusions: Ambulatory care organizations use multiple strategies for safe medication use systems. Understanding processes that promote such strategies will provide a helpful road map for other organizations in implementation and sustainability of safe medication use systems.

Strategies to Improve Management of Shoulder Dystocia Under the AHRQ Safety Program for Perinatal Care

Objective: To assess implementation of safety strategies to improve management of births complicated by shoulder dystocia in labor and delivery units. Design: Mixed‐methods implementation evaluation. Setting/Local Problem: Labor and delivery units (N = 18) in 10 states participating in the Safety Program for Perinatal Care (SPPC). Shoulder dystocia is unpredictable, requiring rapid and coordinated action. Participants: Key informants were labor and delivery unit staff who implemented SPPC safety strategies. Intervention/Measurements: The SPPC was implemented by using the TeamSTEPPS teamwork and communication framework and tools, applying safety science principles (standardization, independent checks, and learn from defects) to shoulder dystocia management, and establishing an in situ simulation program focused on shoulder dystocia to practice teamwork and communication skills. Unit staff received training, a toolkit, technical assistance, and unit‐specific feedback reports. Quantitative data on unit‐reported process improvement measures and qualitative data from staff interviews were used to understand changes in use of safety principles, teamwork/communication, and in situ simulation. Results: Use of shoulder dystocia safety strategies improved on the units. Differences between baseline and follow‐up (10 months) were as follows: in situ simulation (50% vs. 89%), teamwork and communication (67% vs. 94%), standardization (67% to 94%), learning from defects (67% vs. 89%), and independent checks (56% vs. 78%). Interview data showed reasons to address management of shoulder dystocia, various approaches to implement safety practices, and facilitators and barriers to implementation. Conclusion: Successful management of shoulder dystocia requires a rapid, standardized, and coordinated response. The SPPC strategies to increase safety of shoulder dystocia management are scalable, replicable, and adaptable to unit needs and circumstances.

Advancing perinatal patient safety through application of safety science principles using health IT

BackgroundThe use of health information technology (IT) has been shown to promote patient safety in Labor and Delivery (L&D) units. The use of health IT to apply safety science principles (e.g., standardization) to L&D unit processes may further advance perinatal safety.MethodsSemi-structured interviews were conducted with L&D units participating in the Agency for Healthcare Research and Quality’s (AHRQ’s) Safety Program for Perinatal Care (SPPC) to assess units’ experience with program implementation. Analysis of interview transcripts was used to characterize the process and experience of using health IT for applying safety science principles to L&D unit processes.ResultsForty-six L&D units from 10 states completed participation in SPPC program implementation; thirty-two (70%) reported the use of health IT as an enabling strategy for their local implementation. Health IT was used to improve standardization of processes, use of independent checks, and to facilitate learning from defects. L&D units standardized care processes through use of electronic health record (EHR)-based order sets and use of smart pumps and other technology to improve medication safety. Units also standardized EHR documentation, particularly related to electronic fetal monitoring (EFM) and shoulder dystocia. Cognitive aids and tools were integrated into EHR and care workflows to create independent checks such as checklists, risk assessments, and communication handoff tools. Units also used data from EHRs to monitor processes of care to learn from defects. Units experienced several challenges incorporating health IT, including obtaining organization approval, working with their busy IT departments, and retrieving standardized data from health IT systems.ConclusionsUse of health IT played an integral part in the planning and implementation of SPPC for participating L&D units. Use of health IT is an encouraging approach for incorporating safety science principles into care to improve perinatal safety and should be incorporated into materials to facilitate the implementation of perinatal safety initiatives.