Christina T. Yuan

Incorporating the World Health Organization Surgical Safety Checklist into Practice at Two Hospitals in Liberia

BACKGROUND The impact of the World Health Organizations Patient Safety Programmes 19-item Surgical Safety Checklist on surgical processes and outcomes was assessed in 2008-2009 at two hospitals in the resource-limited setting of Liberia. METHODS In the preintervention phase, data were prospectively collected on surgical processes and outcomes from 232 consecutively enrolled patients who were undergoing surgery. In the postintervention phase, data were collected on 249 consecutively enrolled patients after the introduction of the Surgical Safety Checklist. Multivariable logistic regression was used to determine the adjusted association between the introduction of the checklist and surgical process and outcome measures. These analyses were conducted among the pooled data, as well as for data stratified by hospital. RESULTS The introduction of the checklist was associated with significant (p < 0.05) improvements in terms of overall surgical processes and surgical outcomes. The stratified analysis presented a more nuanced result by hospital. In Hospital 1, the checklist was significantly associated with improved adherence to the composite measure of surgical processes but was not associated with improved surgical outcomes. In contrast, in Hospital 2, it was significantly associated with improved surgical outcomes but was not associated with improved adherence to the composite measure of surgical processes. CONCLUSIONS Although the implementation of a surgical safety checklist in Liberia was associated with significant improvements in processes and outcomes overall, differences at the hospital level suggest that the checklists mechanism of improvement may be influenced by the availability of resources needed to complete recommended processes, variation in team functioning, and organizational context.

National Efforts to Improve Door-to-Balloon Time. Results From the Door-to-Balloon Alliance

OBJECTIVES The purpose of this study was to determine if enrollment in the Door-to-Balloon (D2B) Alliance, a national quality campaign sponsored by the American College of Cardiology and 38 partner organizations, was associated with increased likelihood of patients who received primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) being treated within 90 min of hospital presentation. BACKGROUND The D2B Alliance, launched in November 2006, sought to achieve the goal of having 75% of patients with STEMI treated within 90 min of hospital presentation. METHODS We conducted a longitudinal study of D2B times in 831 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry, April 1, 2005, to March 31, 2008. RESULTS By March 2008, >75% of patients had D2B times of < or = 90 min, compared with only about one-half of patients with D2B times within 90 min in April 2005. Trends since the launch of the D2B Alliance showed that patients treated in hospitals enrolled in the D2B Alliance for at least 3 months were significantly more likely than patients treated in nonenrolled hospitals to have D2B times within 90 min, although the magnitude of the difference was modest (odds ratio: 1.16; 95% confidence interval: 1.07 to 1.27). CONCLUSIONS The D2B Alliance reached its goal of 75% of patients with STEMI having D2B times within 90 min by 2008.

A model for scale up of family health innovations in low-income and middle-income settings: a mixed methods study.

Background Many family health innovations that have been shown to be both efficacious and cost-effective fail to scale up for widespread use particularly in low-income and middle-income countries (LMIC). Although individual cases of successful scale-up, in which widespread take up occurs, have been described, we lack an integrated and practical model of scale-up that may be applicable to a wide range of public health innovations in LMIC. Objective To develop an integrated and practical model of scale-up that synthesises experiences of family health programmes in LMICs. Data sources We conducted a mixed methods study that included in-depth interviews with 33 key informants and a systematic review of peer-reviewed and grey literature from 11 electronic databases and 20 global health agency web sites. Study eligibility criteria, participants and interventions We included key informants and studies that reported on the scale up of several family health innovations including Depo-Provera as an example of a product innovation, exclusive breastfeeding as an example of a health behaviour innovation, community health workers (CHWs) as an example of an organisational innovation and social marketing as an example of a business model innovation. Key informants were drawn from non-governmental, government and international organisations using snowball sampling. An article was excluded if the article: did not meet the studys definition of the innovation; did not address dissemination, diffusion, scale up or sustainability of the innovation; did not address low-income or middle-income countries; was superficial in its discussion and/or did not provide empirical evidence about scale-up of the innovation; was not available online in full text; or was not available in English, French, Spanish or Portuguese, resulting in a final sample of 41 peer-reviewed articles and 30 grey literature sources. Study appraisal and synthesis methods We used the constant comparative method of qualitative data analysis to extract recurrent themes from the interviews, and we integrated these themes with findings from the literature review to generate the proposed model of scale-up. For the systematic review, screening was conducted independently by two team members to ensure consistent application of the predetermined exclusion criteria. Data extraction from the final sample of peer-reviewed and grey literature was conducted independently by two team members using a pre-established data extraction form to list the enabling factors and barriers to dissemination, diffusion, scale up and sustainability. Results The resulting model—the AIDED model—includes five non-linear, interrelated components: (1) assess the landscape, (2) innovate to fit user receptivity, (3) develop support, (4) engage user groups and (5) devolve efforts for spreading innovation. Our findings suggest that successful scale-up occurs within a complex adaptive system, characterised by interdependent parts, multiple feedback loops and several potential paths to achieve intended outcomes. Failure to scale up may be attributable to insufficient assessment of user groups in context, lack of fit of the innovation with user receptivity, inability to address resistance from stakeholders and inadequate engagement with user groups. Limitations The inductive approach used to construct the AIDED model did not allow for simultaneous empirical testing of the model. Furthermore, the literature may have publication bias in which negative studies are under-represented, although we did find examples of unsuccessful scale-up. Last, the AIDED model did not address long-term, sustained use of innovations that are successfully scaled up, which would require longer-term follow-up than is common in the literature. Conclusions and implications of key findings Flexible strategies of assessment, innovation, development, engagement and devolution are required to enable effective change in the use of family health innovations in LMIC.

Lost in Translation: Reproductive Health Care Experiences of Somali Bantu Women in Hartford, Connecticut

INTRODUCTION Reproductive health problems are the leading cause of womens morbidity and mortality worldwide. In the United States, officially sponsored refugee women continue to face challenges in accessing reproductive health programs despite having access to health insurance. METHODS The objective of this study was to explore the reproductive health experiences of 1 such population--Somali Bantu women in Connecticut--to identify potential barriers to care experienced by marginalized populations. The study was qualitative, consisting of key informant interviews, a focus group session, and a semistructured survey. RESULTS Although all the women in the study reported having access to reproductive health care services, they also reported having unmet health needs resulting from barriers to care that included ethnic distinction/language barriers, passive acceptance of incorrect care, cultural discordance in family planning services, patient-provider sex discordance, and desire but limited scope for ownership in health care outcomes. The root cause of the various types of patient-provider discordance was the lack of recognition that the Somali Bantu are distinct in culture, language, and solidarity from ethnic Somalis, resulting in Language Line translation services being conducted in a Somali language that the Somali Bantu women did not understand. DISCUSSION The results of the study primarily highlight the larger issue of information asymmetry within the health care system that, if left unaddressed, will persist as new vulnerable populations of refugees arrive in the United States.

Contemporary evidence: Baseline data from the D2B Alliance

BackgroundLess than half of U.S. hospitals meet guidelines for prompt treatment of ST-segment elevation myocardial infarction (STEMI). The Door-to-Balloon (D2B) Alliance is a collaborative effort of more than 900 hospitals committed to implementing a set of evidence-based strategies for reducing D2B time. This study presents data on (1) the prevalence of evidence-based strategies in U.S. hospitals that participated in the D2B Alliance and (2) identifies key hospital characteristics associated with their use.MethodsWe conducted a cross-sectional study of U.S. hospitals that joined the D2B Alliance through a Web-based survey about their current practices for patients with STEMI who received primary percutaneous coronary intervention (PCI). We used multivariate logistic regression to identify hospital characteristics associated with use of each strategy.ResultsOf the 915 U.S. hospitals enrolled in the D2B Alliance as of June 2007, 797 (87%) completed the survey. Only 30.4% of responding hospitals reported employing at least 4 of the 5 key strategies (emergency medicine activates catheterization laboratory, single-call activation, expectation that catheterization team is available in the laboratory within 20–30 minutes after page, prompt data feedback on D2B times, use of pre-hospital electrocardiograms to activate the laboratory while the patient is en route to the hospital); 9.3% employed none of the strategies. There was no clear pattern of correlation between hospital characteristics and reported strategies.ConclusionAs of 2007, many hospitals had implemented few of the key strategies to reduce D2B time, suggesting substantial opportunity to improve care for patients with STEMI.

The relationship between voice climate and patients' experience of timely care in primary care clinics.

Background: Aspects of the patient care experience, despite being central to quality care, are often problematic. In particular, patients frequently report problems with timeliness of care. As yet, research offers little insight on setting characteristics that contribute to patients’ experience of timely care. Purpose: The aims of this study were to assess the relationship between organizational climate and patients’ reports of timely care in primary care clinics and to broadly examine the link between staff’s work environment and patient care experiences. We test hypotheses about the relationship between voice climate—staff feeling safe to speak up about issues—and reported timeliness of care, consistency in reported voice climate across professions, and how climate differences for various professions relate to timely care. Methodology: We conducted a cross-sectional study of employees (n = 1,121) and patients (n = 8,164) affiliated with 37 clinics participating in a statewide reporting initiative. Employees were surveyed about clinics’ voice climate, and patients were surveyed about the timeliness of care. Hypotheses were tested using analysis of variance and generalized estimating equations. Findings: Clinical and administrative staff (e.g., nurses and office assistants) reported clinics’ climates to be significantly less supportive of voice than did clinical leaders (e.g., physicians). The greater the difference in reported support for voice between professional groups, the less patients reported experiencing timely care in three respects: obtaining an appointment, seeing the doctor within 15 minutes of appointment time, and receiving test results. In clinics where staff reported climates supportive of voice, patients indicated receiving more timely care. Clinical leaders’ reports of voice climate had no relationship to reported timeliness of care. Practical Implications: Our findings suggest the importance of clinics developing a strong climate for voice, particularly for clinical and administrative staff, to support better service quality for patients.

A mixed methods study of how clinician ‘super users’ influence others during the implementation of electronic health records

BackgroundDespite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users’ mechanisms of influence and examine their effects on EHR implementation outcomes.MethodsWe conducted a longitudinal (October 2012 – June 2013), comparative case study of super users’ behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users’ behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians’ information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians’ IS proficiency and the clinical unit in which they worked.ResultsSuper users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians’ IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users’ role engagement, which was influenced by how the two units’ managers selected super users and shaped the implementation climate.ConclusionsSuper users’ behaviors in implementing EHRs vary substantively and can have important influence on implementation success.

National quality campaigns: who benefits?

Background The use of national quality campaigns to foster evidence-based hospital practices is increasing. Because campaigns typically do not limit access to their resources, they may influence non-enrolled hospitals as well. Objective To examine the relative impact of a national campaign, the Door-to-Balloon (D2B) Alliance, on enrolled and non-enrolled hospitals. Methods In this prospective cohort study, we compared the use of D2B Alliance resources (eg, webinars, online community, mentor network), changes in the use of strategies recommended by the D2B Alliance, and perceived impact of the D2B Alliance between hospitals that enrolled in the D2B Alliance (n=264) and hospitals that declined enrolment (n=101). Results More than half (53.2%) of non-enrolled hospitals reported using at least some of the resources made available by the D2B Alliance to improve door-to-balloon times. This compared with 83.5% of enrolled hospitals reporting that they used D2B Alliance resources (p<0.01). Both enrolled and non-enrolled hospitals significantly increased their use of recommended hospital strategies between 2005 and 2008, although the use of strategies remained incomplete (35.5–91.5% use). There was no significant difference between the use of these strategies between enrolled and non-enrolled hospitals at follow-up (p≥0.51), adjusted for baseline use. About half of all hospitals reported that door-to-balloon times would have been worse at their hospital without the existence of the D2B Alliance. Conclusions This research suggests that national quality campaigns with open access to campaign resources may have substantial spillover effects on non-enrolled hospitals.

Process evaluation of knowledge transfer across industries: Leveraging Coca-Cola’s supply chain expertise for medicine availability in Tanzania

Persistent gaps in the availability of essential medicines have slowed the achievement of global health targets. Despite the supply chain knowledge and expertise that ministries of health might glean from other industries, limited empirical research has examined the process of knowledge transfer from other industries into global public health. We examined a partnership designed to improve the availability of medical supplies in Tanzania by transferring knowledge from The Coca-Cola system to Tanzania’s Medical Stores Department (MSD). We conducted a process evaluation including in-depth interviews with 70 participants between July 2011 and May 2014, corresponding to each phase of the partnership, with focus on challenges and strategies to address them, as well as benefits perceived by partners. Partners faced challenges in (1) identifying relevant knowledge to transfer, (2) translating operational solutions from Coca-Cola to MSD, and (3) maintaining momentum between project phases. Strategies to respond to these challenges emerged through real-time problem solving and included (1) leveraging the receptivity of MSD leadership, (2) engaging a boundary spanner to identify knowledge to transfer, (3) promoting local recognition of commonalities across industries, (4) engaging external technical experts to manage translation activities, (5) developing tools with visible benefits for MSD, (6) investing in local relationships, and (7) providing time and space for the partnership model to evolve. Benefits of the partnership perceived by MSD staff included enhanced collaboration and communication, more proactive orientations in managing operations, and greater attention to performance management. Benefits perceived by Coca-Cola staff included strengthened knowledge transfer capability and enhanced job satisfaction. Linking theoretical constructs with practical experiences from the field, we highlight the challenges, emergent strategies, and perceived benefits of a partnership across industry boundaries that may be useful to others seeking to promote the transfer of knowledge to improve global health.