Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

BackgroundAudit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.MethodsWe undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour.ResultsData saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years’ experience.When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages’ motives and consider gaming.Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient.ConclusionOur dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence.Trial registration numberISRCTN11126923.

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Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy.

10.21203/rs.3.rs-353206/v1 ◽

2021 ◽

Author(s):

Jamie Catlow ◽

Rashmi Bhardwaj-Gosling ◽

Linda Sharp ◽

M D Rutter ◽

Falko Sniehotta

Keyword(s):

Qualitative Study ◽

Adverse Effects ◽

A Priori ◽

Improve Patient Care ◽

Medical Professional ◽

Logic Model ◽

Audit And Feedback ◽

Negative Effects ◽

Data Saturation ◽

Clinical Background

Abstract Background Audit and feedback (A&F) interventions improve patient care but may result in negative effects. To evaluate plausible harms and maximise benefits, a-priori theorisation using dark logic models can be useful. We aimed to assess the unintended adverse effects of A&F in colonoscopy using Feedback Intervention Theory (FIT) based dark logic model. Methods As part of the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial we undertook a qualitative study exploring current A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six NHS endoscopy centres across England, purposively sampled for clinical background and professional experience. A framework method analysis of A&F in endoscopy was performed, mapping themes of paradoxical outcomes and patient harm to FIT and the theory of planned behaviour (TPB). Results Data saturation was achieved on 19th participant, with endoscopists from nursing, surgical and medical professional backgrounds and a median of 7 years’ endoscopy experience (range 2–29 years).

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A process evaluation of the improving wisely intervention: a peer-to-peer data intervention to reduce overuse in surgery

BMC Health Services Research ◽

10.1186/s12913-020-06017-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Christine Fahim ◽

William E. Bruhn ◽

John G. Albertini ◽

Marty A. Makary

Keyword(s):

Process Evaluation ◽

Improve Patient Care ◽

Peer To Peer ◽

Audit And Feedback ◽

Implementation Quality ◽

Participant Responsiveness ◽

Key Informant ◽

Improvement Interventions ◽

Perceived Impact ◽

Quality Improvement Interventions

Abstract Background The Improving Wisely intervention is a peer-to-peer audit and feedback intervention to reduce overuse of Mohs Micrographic Surgery (MMS). The objective of this study was to conduct a process evaluation to evaluate Mohs surgeons’ perceptions of the implementation quality and perceived impact of the Improving Wisely intervention. Methods Surgeons in the Improving Wisely intervention arm, comprised of members of the American College of Mohs Surgeons (ACMS) who co-led the intervention, were invited to complete surveys and key informant interviews. Participants described perceptions of implementation quality (evaluated via dose, quality of implementation, reach and participant responsiveness), perceived impact of the Improving Wisely intervention (evaluated on a 1–5 Likert and qualitatively), and barriers and facilitators to changing surgeons’ clinical practice patterns to reduce Mohs overuse. Results Seven hundred thirty-seven surgeons participated in the survey. 89% were supportive of the intervention. Participants agreed that the intervention would improve patient care and reduce the annual costs of Mohs surgery. Thirty surgeons participated in key informant interviews. 93% were interested in receiving additional data reports in the future. Participants recommended the reports be disseminated annually, that the reports be expanded to include appropriateness data, and that the intervention be extended to non ACMS members. Six themes identifying factors impacting potential MMS overuse were identified. Conclusions Participants were strongly supportive of the intervention. We present the template used to design and implement the Improving Wisely intervention and provide suggestions for specialty societies interested in leading similar quality improvement interventions among their members.

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From the Frontlines: A Qualitative Study of Staff Experiences With Clinical Event Debriefing

Hospital Pediatrics ◽

10.1542/hpeds.2021-006088 ◽

2021 ◽

Author(s):

Meghan M. Galligan ◽

Mary Haggerty ◽

Heather A. Wolfe ◽

Dawn Debrocco ◽

Katherine Kellom ◽

...

Keyword(s):

Qualitative Study ◽

Inductive Reasoning ◽

Improve Patient Care ◽

Barriers And Facilitators ◽

Clinical Event ◽

Frontline Staff ◽

Factors Affecting ◽

Participant Engagement ◽

Practice Recommendations ◽

Staff Experiences

OBJECTIVES Clinical event debriefing (CED) can improve patient care and outcomes, but little is known about CED across inpatient settings, and participant experiences have not been well described. In this qualitative study, we sought to characterize and compare staff experiences with CED in 2 hospital units, with a goal of generating recommendations for a hospital-wide debriefing program. METHODS We conducted 32 semistructured interviews with clinical staff who attended a CED in the previous week. We explored experiences with CED, with a focus on barriers and facilitators. We used content analysis with constant comparative coding to understand priorities identified by participants. We used inductive reasoning to develop a set of CED practice recommendations to match participant priorities. RESULTS Three primary themes emerged related to CED barriers and facilitators. (1) Factors affecting attendance: most respondents voiced a need for frontline staff inclusion in CED, but they also cited competing clinical duties and scheduling conflicts as barriers. (2) Factors affecting participant engagement: respondents described factors that influence participant engagement in reflective discussion. They described that the CED leader must cultivate a psychologically safe environment in which participants feel empowered to speak up, free from judgment. (3) Factors affecting learning and systems improvement: respondents emphasized that the CED group should generate a plan for improvement with accountable stakeholders. Collectively, these priorities propose several recommendations for CED practice, including frontline staff inclusion. CONCLUSIONS In this study, we propose recommendations for CED that are derived from first-hand participant experiences. Future study will explore implementation of CED practice recommendations.

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Experience of primary care for people with HIV: a mixed-method analysis

BJGP Open ◽

10.3399/bjgpopen19x101665 ◽

2019 ◽

Vol 3 (4) ◽

pp. bjgpopen19X101665

Author(s):

Tanvi Rai ◽

Jane Bruton ◽

Meaghan Kall ◽

Richard Ma ◽

Erica Pufall ◽

...

Keyword(s):

Primary Care ◽

Qualitative Study ◽

Mixed Method ◽

Care Staff ◽

People Living With Hiv ◽

Hiv Status ◽

Framework Analysis ◽

Complex Needs ◽

Hiv Status Disclosure ◽

Method Analysis

BackgroundAdvances in treatment have transformed HIV into a long-term condition (LTC), presenting fresh challenges for health services, HIV specialists, and GPs.AimTo explore the experience of people living with HIV (PLHIV) regarding consulting their GPs.Design & settingA mixed-method analysis using data from two sources: a nationally-representative survey of PLHIV and a qualitative study with London-based PLHIV.MethodUnivariate logistic regression was used for quantitative data and framework analysis for qualitative data.ResultsThe survey had 4422 participants; the qualitative study included 52 participants. In both studies, registration with a GP and HIV status disclosure were high. Similar to general population trends, recent GP use was associated with poor self-rated health status, comorbidities, older age, and lower socioeconomic status. Two-thirds reported a good experience with GPs; a lower proportion felt comfortable asking HIV-related questions. Actual or perceived HIV stigma were consistently associated with poor satisfaction. In the interviews, participants with additional LTCs valued sensitive and consistent support from GPs. Some anticipated, and sometimes experienced, problems relating to HIV status, as well as GPs’ limited experience and time to manage their complex needs. Sometimes they took their own initiative to facilitate coordination and communication. For PLHIV, a ‘good’ GP offered continuity and took time to know and accept them without judgment.ConclusionThe authors suggest clarification of roles and provision of relevant support to build the confidence of PLHIV in GPs and primary care staff to care for them. As the PLHIV population ages, there is a strong need to develop trusting patient–GP relationships and HIV-friendly GP practices.

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Knowledge Translation Improvement Strategies in Universities of Medical Sciences in Iran: A Qualitative Study

Ethiopian Journal of Health Sciences ◽

10.4314/ejhs.v31i1.15 ◽

2021 ◽

Vol 31 (1) ◽

Author(s):

Sogand Tourani ◽

Narges Rafiei ◽

Shahnaz Rimaz ◽

Seyed Kazem Malakouti ◽

Alireza Heidari

Keyword(s):

Qualitative Study ◽

Knowledge Translation ◽

Knowledge Production ◽

Data Organization ◽

Health Plans ◽

Medical Sciences ◽

Structured Interviews ◽

Framework Analysis ◽

Improvement Strategies

BACKGROUND፡ Recently, one of the challenges in the health system of the country is the need for research contributing to policy-making. Therefore, it is crucial to develop activities in the field of knowledge Translation (KT). This study aimed to propose KT improvement strategies in universities of medical sciences in Iran.METHODS: In this qualitative study, 18 semi-structured interviews were conducted with key informants from the medical universities in Iran during January-July 2018. The transcribed documents were analyzed using the Gale framework analysis approach. Data organization was carried out using MAXQDA version 10 software.RESULTS: According to framework analysis, six KT improvement strategies were identified including improving the abilities and skills of researchers, improving the processes and quality of knowledge production, revising policies and laws, mproving the prerequisites, culture-building, and promoting the, use of evidence.CONCLUSION: Given the challenges and strategies outlined in this study, it seems that the mechanism of KT and its effects on improving health plans for policymakers and researchers has not been elucidated yet. Therefore, considerable changes in prerequisites, knowledge production processes, academic procedures, policies and laws are necessary for implementing KT in universities of medical sciences in Iran.

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TIA and minor stroke: A qualitative study of long-term impact and experiences of follow-up care

10.21203/rs.2.13276/v2 ◽

2019 ◽

Author(s):

Grace M Turner ◽

Christel McMullan ◽

Lou Atkins ◽

Robbie Foy ◽

Jonathan Mant ◽

...

Keyword(s):

Qualitative Study ◽

Stroke Prevention ◽

Community Care ◽

Minor Stroke ◽

Framework Analysis ◽

Diverse Range ◽

Follow Up Care ◽

The Impact

Abstract Background Transient ischaemic attack (TIA) and minor stroke are often considered transient events; however, many patients experience residual problems and reduced quality of life. Current follow-up healthcare focuses on stroke prevention and care for other long-term problems is not routinely provided. We aimed to explore patient and healthcare provider (HCP) experiences of residual problems post-TIA/minor stroke, the impact of TIA/minor stroke on patients’ lives, and current follow-up care and sources of support. Methods This qualitative study recruited participants from three TIA clinics, seven general practices and one community care trust in the West Midlands, England. Semi-structured interviews were conducted with 12 TIA/minor stroke patients and 24 HCPs from primary, secondary and community care with framework analysis. Results A diverse range of residual problems were reported post-TIA/minor stroke, including psychological, cognitive and physical impairments. Consultants and general practitioners generally lacked awareness of these long-term problems; however, there was better recognition among nurses and allied HCPs. Residual problems significantly affected patients’ lives, including return to work, social activities, and relationships with family and friends. Follow-up care was variable and medically focused. While HCPs prioritised medical investigations and stroke prevention medication, patients emphasised the importance of understanding their diagnosis, individualised support regarding stroke risk, and addressing residual problems. Conclusion HCPs could better communicate lay information about TIA/minor stroke diagnosis and secondary stroke prevention, and improve their identification of and response to important residual impairments affecting patients.

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Aesthetic Work as Cultural Competence: Chasing Beauty in the Coproduction of Aesthetic Services

Journal of Service Research ◽

10.1177/10946705211047983 ◽

2021 ◽

pp. 109467052110479

Author(s):

Aphrodite Vlahos ◽

Anna E. Hartman ◽

Julie L. Ozanne

Keyword(s):

Qualitative Study ◽

Cultural Competence ◽

Communities Of Practice ◽

Service Providers ◽

Social Resources ◽

Unintended Consequences ◽

Consumer Participation ◽

Social Standards ◽

Managerial Implications

Prior research stresses the importance of consumer participation in service coproduction. We examine the coproduction of aesthetic services, which are services in which beauty is a critical outcome. Consumers face challenges communicating their aesthetic tastes because of technical constraints that are understood by service providers but that consumers do not fully understand. To fill this gap, consumers do aesthetic work in communities of practice. Service providers also face challenges, as they must coproduce with consumers whose aesthetic tastes are formed amid shifting social standards. In this qualitative study, we highlight aesthetic work as a different type of consumer work that involves developing cultural competence. We identify four types of aesthetic coproduction in which cultural competence is distributed differently within the service dyad: aesthetic codesigning, aesthetic consenting, aesthetic yielding, and aesthetic reigning. We explore the managerial implications that arise as consumers increasingly use online social resources that shape and increase aesthetic expectations. We examine the unintended consequences of aesthetic service coproduction in which providers’ technical and aesthetic expertise is difficult for consumers to understand often leading to disappointing outcomes.

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Personality disorder co-morbidity in primary care ‘Improving Access to Psychological Therapy’ (IAPT) services: a qualitative study exploring patient perspectives on treatment experience

Behavioural and Cognitive Psychotherapy ◽

10.1017/s1352465820000594 ◽

2020 ◽

pp. 1-15

Author(s):

Gary Lamph ◽

John Baker ◽

Tommy Dickinson ◽

Karina Lovell

Keyword(s):

Mental Health ◽

Primary Care ◽

Personality Disorder ◽

Qualitative Study ◽

Patient Group ◽

Stepped Care ◽

Research Approach ◽

Structured Interviews ◽

Framework Analysis ◽

Co Morbidity

Abstract Background: High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care ‘Improving Access to Psychological Therapies’ (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England. Aims: This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the ‘Standardised Assessment of Personality – Abbreviated Scale’ (SAPAS) in receipt of primary care-based IAPT treatment. Method: A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach. Results: Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important. Conclusions: For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach.

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Exploring psychiatrists’ perspectives of working with patients with dissociative seizures in the UK healthcare system as part of the CODES trial: a qualitative study

BMJ Open ◽

10.1136/bmjopen-2018-026493 ◽

2019 ◽

Vol 9 (5) ◽

pp. e026493 ◽

Cited By ~ 1

Author(s):

Harriet Jordan ◽

Sarah Feehan ◽

Iain Perdue ◽

Joanna Murray ◽

Laura H Goldstein

Keyword(s):

Qualitative Study ◽

Patient Group ◽

Controlled Trial ◽

Improve Patient Care ◽

Knowledge Gap ◽

Link Type ◽

Interpersonal Difficulties ◽

Randomised Controlled ◽

The Uk ◽

Dissociative Seizures

ObjectiveThere is currently limited research exploring healthcare professionals’ (HCPs) experiences of working with patients with dissociative seizures (DS). Existing studies do not focus on the role of psychiatrists in treating this complex condition. The objective of this study was to gain an understanding of UK-based psychiatrists’ experiences of the DS patient group. Against the backdrop of a UK-wide randomised controlled trial (RCT), the focus was broadened to encompass issues arising in everyday practice with the DS patient group.Design, participants and methodsA qualitative study using semistructured interviews was undertaken with 10 psychiatrists currently working with DS patients within the context of a large RCT investigating treatments for DS. Thematic analysis was used to identify key themes and subthemes.SettingThe psychiatrists were working in Liaison or Neuropsychiatry services in England.ResultsThe key themes identified were other HCPs’ attitudes to DS and the challenges of the DS patient group. There is a clear knowledge gap regarding DS for many HCPs and other clinical services can be reluctant to take referrals for this patient group. Important challenges posed by this patient group included avoidance (of difficult emotions and help), alexithymia and interpersonal difficulties. Difficulties with alexithymia meant DS patients could struggle to identify triggers for their seizures and to express their emotions. Interpersonal difficulties raised included difficulties in attachment with both HCPs and family members.ConclusionsA knowledge gap for HCPs regarding DS has been identified and needs to be addressed to improve patient care. Given the complexity of the patient group and that clinicians from multiple disciplines will come into contact with DS patients, it is essential for any educational strategy to be implemented across the whole range of specialties, and to account for those already in practice as well as future trainees.Trial registration numberISRCTN05681227;NCT02325544; Pre-results.

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Utilizing Animal Models of Infantile Spasms

Epilepsy Currents ◽

10.5698/1535-7597.18.2.107 ◽

2018 ◽

Vol 18 (2) ◽

pp. 107-112 ◽

Cited By ~ 4

Author(s):

Chris G. Dulla

Keyword(s):

Animal Models ◽

Adverse Effects ◽

Early Life ◽

Improve Patient Care ◽

Epileptic Encephalopathy ◽

Infantile Spasms ◽

Critical Component ◽

Improve Patient ◽

Review Current ◽

New Strategies

Infantile spasms are a devastating epileptic encephalopathy characterized by early life spasms and later seizures. Clinical outcomes of infantile spasms are poor and therapeutic options are limited with significant adverse effects. Therefore, new strategies to treat infantile spasms are of the utmost importance. Animals models of infantile spasms are a critical component of developing new therapies. Here, we review current chronic animal models of infantile spasms and consider future advances that may help improve patient care, as well as our scientific understanding of this debilitating disease.

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