scholarly journals Understanding Low-value Care and Associated De-implementation Processes: A Qualitative Study of Choosing Wisely Interventions Across Canadian Hospitals

2021 ◽  
Author(s):  
Gillian Parker ◽  
Monika Kastner ◽  
Karen Born ◽  
Nida Shahid ◽  
Whitney Berta
Keyword(s):  
Process Model ◽  
Healthcare Providers ◽  
Implementation Process ◽  
Choosing Wisely ◽  
Structured Interviews ◽  
Team Members ◽  
Implementation Processes ◽  
Healthcare Settings ◽  
National Campaigns ◽  
The Impact

Abstract Background:Choosing Wisely (CW) is an international movement comprised of national campaigns in more than 20 countries to reduce low-value care (LVC). Hospitals and healthcare providers are examining existing practices and putting interventions in place to reduce practices that offer little to no benefit to patients or may cause them harm. De-implementation, the reduction or removal of a healthcare practice is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations.Methods:Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis.Results:Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not ‘patient facing’; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, specifically the impact of harm and resources. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions.Conclusions: This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

scholarly journals Understanding low-value care and associated de-implementation processes: A qualitative study of Choosing Wisely Interventions across Canadian hospitals

2021 ◽  
Author(s):  
Gillian Parker ◽  
Monika Kastner ◽  
Karen Born ◽  
Nida Shahid ◽  
Whitney Berta
Keyword(s):  
Process Model ◽  
Healthcare Providers ◽  
Implementation Process ◽  
Choosing Wisely ◽  
Structured Interviews ◽  
Team Members ◽  
Implementation Processes ◽  
Healthcare Settings ◽  
National Campaigns ◽  
The Impact

Abstract Background:Choosing Wisely (CW) is an international movement comprised of national campaigns in more than 20 countries to reduce low-value care (LVC). Hospitals and healthcare providers are examining existing practices and putting interventions in place to reduce practices that offer little to no benefit to patients or may cause them harm. De-implementation, the reduction or removal of a healthcare practice is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations.Methods:Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis.Findings:Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not ‘patient facing’; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, specifically the impact of harm and resources. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions. Conclusions: This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

scholarly journals Development of An Implementation Process Model: A Delphi Study

2021 ◽  
Author(s):  
Gillian Parker ◽  
Monika Kastner ◽  
Karen Born ◽  
Whitney Berta
Keyword(s):  
Knowledge Translation ◽  
Clinical Outcomes ◽  
Delphi Study ◽  
Process Model ◽  
Healthcare Providers ◽  
Implementation Process ◽  
Implementation Support ◽  
Support Tool ◽  
Modified Delphi ◽  
The Impact

Abstract Background: There is general scarcity of research on key elements of implementation processes and the factors which impact implementation success. Implementation of healthcare interventions is a complex process. Tools to support implementation can facilitate this process and improve effectiveness of the interventions and clinical outcomes. Understanding the impact of implementation support tools is a critical aspect of this process. The objective of this study was to solicit knowledge and consensus from relevant implementation science and knowledge translation healthcare experts in order to refine and validate a process model of key elements in the implementation process.Methods: A two round consensus-based modified Delphi study involving international experts in knowledge translation and implementation (researchers, scientists, professors, decision-makers) was conducted. Participants rated and commented on all aspects of the process model, including the organization, content, scope, and structure. Delphi questions rated at 75% agreement or lower were reviewed and revised. Qualitative comments supported the restructuring and refinement. A second-round survey followed the same process as Round 1. Results: Fifty-four experts participated in Round 1, and 32 experts participated in Round 2. Twelve percent (n=6) of the Round 1 questions did not reach consensus. Key themes for revision and refinement were: stakeholder engagement throughout the process, iterative nature of the implementation process; importance of context; and importance of using guiding theories or frameworks. The process model was revised and refined based on the quantitative and qualitative data and reassessed by the experts in Round 2. Consensus was achieved on all items in Round 2 and the Delphi concluded. Additional feedback was obtained regarding terminology, target users and definition of the implementation process.Conclusions: High levels of agreement were attained for all sub-domains, elements, and sub-elements of the Implementation Process Model. This validated model will be used to develop an Implementation Support Tool to be used by healthcare providers to facilitate effective implementation and improved clinical outcomes.

scholarly journals Action, actor, context, target, time (AACTT): a framework for specifying behaviour

2019 ◽  
Vol 14 (1) ◽  
Author(s):  
Justin Presseau ◽  
Nicola McCleary ◽  
Fabiana Lorencatto ◽  
Andrea M. Patey ◽  
Jeremy M. Grimshaw ◽  
...  
Keyword(s):  
Process Model ◽  
Outcome Measurement ◽  
Healthcare Providers ◽  
Implementation Process ◽  
Target Time ◽  
Barriers And Enablers ◽  
Healthcare Settings ◽  
Action Context ◽  
Potential Applications ◽  
Key Steps

Abstract Background Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention’s effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system. Methods and results We used French et al.’s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions. Conclusions Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions.

scholarly journals Development of an Implementation Process Model: A Delphi Study

2020 ◽  
Author(s):  
Gillian Parker ◽  
Monika Kastner ◽  
Karen Born ◽  
Whitney Berta
Keyword(s):  
Knowledge Translation ◽  
Clinical Outcomes ◽  
Delphi Study ◽  
Process Model ◽  
Healthcare Providers ◽  
Implementation Process ◽  
Implementation Support ◽  
Support Tool ◽  
Modified Delphi ◽  
The Impact

Abstract Background: There is general scarcity of research on key elements of implementation processes and the factors which impact implementation success. Implementation of healthcare interventions is a complex process. Tools to support implementation can facilitate this process and improve effectiveness of the interventions and clinical outcomes. Understanding the impact of implementation support tools is a critical aspect of this process. The objective of this study was to solicit knowledge and consensus from relevant implementation science and knowledge translation healthcare experts in order to refine and validate a process model of key elements in the implementation process.Methods: A two round consensus-based modified Delphi study involving international experts in knowledge translation and implementation (researchers, scientists, professors, decision-makers) was conducted. Participants rated and commented on all aspects of the process model, including the organization, content, scope, and structure. Delphi questions rated at 75% agreement or lower were reviewed and revised. Qualitative comments supported the restructuring and refinement. A second-round survey followed the same process as Round 1. Results: Fifty-four experts participated in Round 1, and 32 experts participated in Round 2. Twelve percent (n=6) of the Round 1 questions did not reach consensus. Key themes for revision and refinement were: stakeholder engagement throughout the process, iterative nature of the implementation process; importance of context; and importance of using guiding theories or frameworks. The process model was revised and refined based on the quantitative and qualitative data and reassessed by the experts in Round 2. Consensus was achieved on all items in Round 2 and the Delphi concluded. Additional feedback was obtained regarding terminology, target users and definition of the implementation process.Conclusions: High levels of agreement were attained for all sub-domains, elements, and sub-elements of the Implementation Process Model. This validated model will be used to develop an Implementation Support Tool to be used by healthcare providers to facilitate effective implementation and improved clinical outcomes.

The Practice of Caring Leadership: A Resource Addressing the Duality of Health Care

2018 ◽  
Vol 24 (4) ◽  
pp. 203-210
Author(s):  
Britni Bolstad
Keyword(s):  
Home Care ◽  
Low Cost ◽  
Healthcare Providers ◽  
Professional Relationship ◽  
Caring Behaviors ◽  
Team Members ◽  
Caring Leadership ◽  
Healthcare Settings ◽  
Before And After ◽  
The Impact

Purpose:The purpose of this project was to implement a 4-week educational practicum focused on the practice of caring leadership in a senior living home care setting and to determine how this approach impacted the therapeutic interactions and leadership competencies of home care team members.Background:Caring practice models have been implemented in various healthcare settings. However, little is known about what kinds of interventions can develop leadership effectively or how to evaluate the impact of leadership on healthcare providers’ use of caring behaviors in professional practice.Design:Descriptive, mixed method.Methods:The Caring Assessment for Caregivers (CACG) instrument and the Leadership Practices Inventory–Self (LPI-S) instrument measured change in self-reported therapeutic interactions and leadership skills, respectively, before and after facilitating multi-site practicum sessions for caring leadership practice enculturation.Findings:Among practicum participants, the mean change for the LPI-S and CACG subscales represented statistically significant improvement. The themes and subthemes identified suggest that leadership and relational expertise can be described within the context of professional, relationship-based practice.Conclusion:The caring leader practicum intervention, a low-cost, workplace approach, was successful in improving the outcome variables in a 4-week period.

scholarly journals Development of an Implementation Process Model: a Delphi study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Gillian Parker ◽  
Monika Kastner ◽  
Karen Born ◽  
Whitney Berta
Keyword(s):  
Knowledge Translation ◽  
Clinical Outcomes ◽  
Delphi Study ◽  
Process Model ◽  
Healthcare Providers ◽  
Implementation Process ◽  
Implementation Support ◽  
Support Tool ◽  
Modified Delphi ◽  
The Impact

Abstract Background There is general scarcity of research on key elements of implementation processes and the factors which impact implementation success. Implementation of healthcare interventions is a complex process. Tools to support implementation can facilitate this process and improve effectiveness of the interventions and clinical outcomes. Understanding the impact of implementation support tools is a critical aspect of this process. The objective of this study was to solicit knowledge and agreement from relevant implementation science and knowledge translation healthcare experts in order to develop a process model of key elements in the implementation process. Methods A two round, modified Delphi study involving international experts in knowledge translation and implementation (researchers, scientists, professors, decision-makers) was conducted. Participants rated and commented on all aspects of the process model, including the organization, content, scope, and structure. Delphi questions rated at 75% agreement or lower were reviewed and revised. Qualitative comments supported the restructuring and refinement. A second-round survey followed the same process as Round 1. Results Fifty-four experts participated in Round 1, and 32 experts participated in Round 2. Twelve percent (n = 6) of the Round 1 questions did not reach agreement. Key themes for revision and refinement were: stakeholder engagement throughout the process, iterative nature of the implementation process; importance of context; and importance of using guiding theories or frameworks. The process model was revised and refined based on the quantitative and qualitative data and reassessed by the experts in Round 2. Agreement was achieved on all items in Round 2 and the Delphi concluded. Additional feedback was obtained regarding terminology, target users and definition of the implementation process. Conclusions High levels of agreement were attained for all sub-domains, elements, and sub-elements of the Implementation Process Model. This model will be used to develop an Implementation Support Tool to be used by healthcare providers to facilitate effective implementation and improved clinical outcomes.

scholarly journals Evaluating interventions with victims of intimate partner violence: a community psychology approach

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Cinzia Albanesi ◽  
Carlo Tomasetto ◽  
Veronica Guardabassi
Keyword(s):  
Intimate Partner Violence ◽  
Social Services ◽  
Psychological Health ◽  
Partner Violence ◽  
Process Model ◽  
Professional Training ◽  
Phenomenological Approach ◽  
Intimate Partner ◽  
Structured Interviews ◽  
The Impact

Abstract Purpose Intimate Partner Violence (IPV) is one of the most common forms of domestic violence, with profound implication for women's physical and psychological health. In this text we adopted the Empowerment Process Model (EPM) by Cattaneo and Goodman (Psychol Violence 5(1):84–94) to analyse interventions provided to victims of IPV by a Support Centre for Women (SCW) in Italy, and understand its contribution to women’s empowerment. Method We conducted semi-structured interviews with ten women who had been enrolled in a program for IPV survivors at a SCW in the past three years. The interviews focused on the programs’ aims, actions undertaken to reach them, and the impact on the women’s lives, and were analysed using an interpretative phenomenological approach. Results Results showed that the interventions provided by the SWC were adapted according to women's needs. In the early phases, women’s primary aim was ending violence, and the intervention by the SCW was deemed as helpful to the extent it provided psychological support, protection and safe housing. Women’s aims subsequently moved to self-actualisation and economic and personal independence which required professional training, internships, and social support. Although satisfying the majority of the women’s expectations, other important needs (e.g., economic support or legal services) were poorly addressed, and cooperation with other services (e.g., police or social services) was sometimes deemed as critical. Conclusions By evaluating a program offered by a SCW to IPV survivors through the lens of the EPM model, we found that women deemed the program as effective when both individual resources and empowerment processes were promoted. Strengths, limitations and implications are discussed.

scholarly journals Leadership assumptions on implementation of patient involvement methods

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kathrine Håland Jeppesen ◽  
Kirsten Frederiksen ◽  
Marianne Johansson Joergensen ◽  
Kirsten Beedholm
Keyword(s):  
Health Care ◽  
Organizational Learning ◽  
Health Care Professionals ◽  
Large Scale ◽  
Patient Involvement ◽  
Hospital Setting ◽  
Implementation Process ◽  
University Hospital ◽  
Structured Interviews ◽  
Implementation Processes

Abstract Background From 2014 to 17, a large-scale project, ‘The User-involving Hospital’, was implemented at a Danish university hospital. Research highlights leadership as crucial for the outcome of change processes in general and for implementation processes in particular. According to the theory on organizational learning by Agyris and Schön, successful change requires organizational learning. Argyris and Schön consider that the assumptions of involved participants play an important role in organizational learning and processes. The purpose was to explore leaders’ assumptions concerning implementation of patient involvement methods in a hospital setting. Methods Qualitative explorative interview study with the six top leaders in the implementation project. The semi-structured interviews were conducted and analyzed in accordance with Kvale and Brinkmanns’ seven stages of interview research. Result The main leadership assumptions on what is needed in the implementation process are in line with the perceived elements in organizational learning according to the theory of Argyris and Schön. Hence, they argued that implementation of patient involvement requires a culture change among health care professionals. Two aspects on how to obtain success in the implementation process were identified based on leadership assumptions: “The health care professionals’ roles in the implementation process” and “The leaders’ own roles in the implementation process”. Conclusion The top leaders considered implementation of patient involvement a change process that necessitates a change in culture with health care professionals as crucial actors. Furthermore, the top leaders considered themselves important facilitators of this implementation process.

scholarly journals Exploring the potential for introducing home monitoring of blood pressure during pregnancy into maternity care: current views and experiences of staff—a qualitative study

BMJ Open ◽  
2020 ◽  
Vol 10 (12) ◽  
pp. e037874
Author(s):  
Lisa Hinton ◽  
James Hodgkinson ◽  
Katherine L Tucker ◽  
Linda Rozmovits ◽  
Lucy Chappell ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Maternity Care ◽  
Healthcare Providers ◽  
Home Monitoring ◽  
Structured Interviews ◽  
Group Discussions ◽  
Self Monitoring ◽  
Team Members ◽  
Registration Number ◽  
In Pregnancy

ObjectiveOne in 20 women are affected by pre-eclampsia, a major cause of maternal and perinatal morbidity, death and premature birth worldwide. Diagnosis is made from monitoring blood pressure (BP) and urine and symptoms at antenatal visits after 20 weeks of pregnancy. There are no randomised data from contemporary trials to guide the efficacy of self-monitoring of BP (SMBP) in pregnancy. We explored the perspectives of maternity staff to understand the context and health system challenges to introducing and implementing SMBP in maternity care, ahead of undertaking a trial.DesignExploratory study using a qualitative approach.SettingEight hospitals, English National Health Service.ParticipantsObstetricians, community and hospital midwives, pharmacists, trainee doctors (n=147).MethodsSemi-structured interviews with site research team members and clinicians, interviews and focus group discussions. Rapid content and thematic analysis undertaken.ResultsThe main themes to emerge around SMBP include (1) different BP changes in pregnancy, (2) reliability and accuracy of BP monitoring, (3) anticipated impact of SMBP on women, (4) anticipated impact of SMBP on the antenatal care system, (5) caution, uncertainty and evidence, (6) concerns over action/inaction and patient safety.ConclusionsThe potential impact of SMBP on maternity services is profound although nuanced. While introducing SMBP does not reduce the responsibility clinicians have for women’s health, it may enhance the responsibilities and agency of pregnant women, and introduces a new set of relationships into maternity care. This is a new space for reconfiguration of roles, mutual expectations and the relationships between and responsibilities of healthcare providers and women.Trial registration numberNCT03334149.

scholarly journals ‘It’s a real fine balancing act’: directly employed care workers’ experiences of engaging with health services

2021 ◽  
Author(s):  
Jane Wilcock ◽  
Jill Manthorpe ◽  
Jo Moriarty ◽  
Steve Iliffe
Keyword(s):  
Health Services ◽  
Healthcare Professionals ◽  
Healthcare Providers ◽  
Well Being ◽  
Care Work ◽  
Structured Interviews ◽  
Care Workers ◽  
The Impact ◽  
Health And Well Being

Little is known of the experiences of directly employed care workers communicating with healthcare providers about the situations of their employers. We report findings from 30 in-depth semi-structured interviews with directly employed care workers in England undertaken in 2018–19. Findings relate to role content, communication with healthcare professionals and their own well-being. Directly employed care workers need to be flexible about the tasks they perform and the changing needs of those whom they support. Having to take on health liaison roles can be problematic, and the impact of care work on directly employed workers’ own health and well-being needs further investigation.

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