Suicide Risk Response: Enhancing Patient Safety Through Development of Effective Institutional Policies
Laura M. BonnerBradford FelkerEdmund F. ChaneyKaren VollenKaren BerryBarbara RevayBarbara SimónLial KofoedScott OberLinda L.M. Worley
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Abstract : A suicidal patient requires a prompt, coordinated intervention. In this paper, we describe a process for developing a suicidality policy, which may help clinics develop effective, locally adapted policies. We present the process in the framework of the Quality Improvement Plan-Do-Study-Act cycle. The process we describe occurred as part of a quality improvement project. Translating Initiatives for Depression into Effective Solutions (TIDES) is an evidence-based. quality improvement intervention for depression, implemented in seven Veterans Administration primary care clinics in five states. A multidisciplinary workgroup, the Collaboration Workgroup (CWG), created for this project supports the collaborative care process through evaluation and improvement of policies, including those for institutional response to suicidality. During the plan phase, the workgroup reviewed existing policies from each of the seven participating intervention clinics. This review revealed significant gaps and implementation difficulties. During the do phase, workgroup members developed or adapted sit-specific policies as needed based on the initial CWG review, and assisted sites in implementing them. During the study phase, workgroup members reviewed what had worked and what had not worked in implementing policies for threatened suicide at each site and identified a set of hey features of successful policies. Features included a clearly defined chain of responsibility, well-defined followup procedures, and documentation of actions in the medical record. The workgroup developed templates that emphasized these key features but allowed for necessary local adaptation. Workgroup clinicians assisted clinics to implement site-specific policies. During the act, phase which is ongoing, site policies are in effect and are being evaluated.Keywords:
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Evidence on how to implement new interventions into complex healthcare environments is often poorly reported and indexed, reducing its potential to inform initiatives to improve healthcare services. Using the implementation of a digital intervention within routine National Health Service (NHS) practice, we provide an example of how to develop a theoretically based implementation plan and how to report it transparently. In doing so we also highlight some of the challenges to implementation in routine healthcare.The implemented intervention was HeLP-Diabetes, a digital self-management programme for people with Type 2 Diabetes, which was effective in improving diabetes control. The target setting for the implementation was an inner city London Clinical Commissioning Group in the NHS comprised of 34 general practices. HeLP-Diabetes was designed to be offered to patients as part of routine diabetes care across England. Evidence synthesis, engagement of local stakeholders, a theory of implementation (Normalization Process Theory), feedback, qualitative interviews and usage data were used to develop an implementation plan.A new implementation plan was developed to implement HeLP-Diabetes within routine practice. Individual component strategies were selected and developed informed by Normalization Process Theory. These strategies included: engagement of local opinion leaders, provision of educational materials, educational visits, educational meetings, audit and feedback and reminders. Additional strategies were introduced iteratively to address barriers that arose during the implementation. Barriers largely related to difficulties in allocating resources to implement the intervention within routine care.This paper provides a worked example of implementing a digital health intervention. The learning from this work can inform others undertaking the work of planning and executing implementation activities in routine healthcare. Of particular importance is: the selection of appropriate theory to guide the implementation process and selection of strategies; ensuring that enough attention is paid to planning implementation; and a flexible approach that allows response to emerging barriers.
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The purpose of this study, conducted in a tertiary public hospital in Jordan, was to
identify and critically examine existing attributes that were seen to be problematic in
managing patient risk. The management of pressure ulcers (PUs) was chosen as a
representative exemplar to focus the research. A case study design using both
qualitative and quantitative methods was used to generate an in-depth account of safety
and quality issues. Data were analysed interpretatively and the findings used to develop
a proposed patient safety framework for patients in the acute care sector.
The main findings include an urgent need to begin the modification of the traditional
hierarchical bureaucracy within the organisation and the disciplines, towards structures
and processes that promote a multidisciplinary approach to patient care. Processes such
as the provision of multidisciplinary evidence-based practice guidelines to reduce
variation in practice standards, the implementation of multidisciplinary progress notes
in patients' medical records to prevent duplication inaccuracies and a team model of
nursing care are required and included in the proposed model. Improvements in the
organisational culture are likely to be achieved by engaging clinicians in organisational
decision-making structures and processes and providing them with performance
feedback by developing an incident monitoring system. The instability of the hospital
workforce makes the achievement of cultural change extremely difficult. Changes in
the employment of staff from one centralised government agency to a system that
enables managers to have more control of workforce employment in their organisations,
with staff themselves able to nominate where they work, are recommended.
Organisational managers also require more control in how funds are allocated to their
organisations to allow them to formulate budgets and identify funding priorities within
their organisations. The greatest impact on improvement will be achieved if reforms are
concurrently implemented.
A proposed framework incorporating these recommendations as a way to improve
patient safety in acute care has been developed for countries attempting health care
transition. The framework positions the patient as central to clinical care decisions and
clinical process management, and links the three key levels of the hospital together, i.e.
the clinical, organisational and ministry levels, as one interconnected activity. Such an
integrated framework will facilitate the concurrent implementation of the proposed new
structures and processes that research findings show are at the heart of patient safety.
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Process mapping is often used in quality improvement work to examine current processes and workflow and to identify areas to intervene to improve quality. Our objective in this paper is to describe process maps as a visual means of understanding modifiable behaviors and activities, in this case example to ensure that goals of care conversations are part of admitting a veteran in long-term care settings.We completed site visits to 6 VA nursing homes and reviewed their current admission processes. We conducted interviews to document behaviors and activities that occur when a veteran is referred to a long-term care setting, during admission, and during mandatory VA reassessments. We created visualizations of the data using process mapping approaches. Process maps for each site were created to document the admission activities for each VA nursing home and were reviewed by the research team to identify consistencies across sites and to identify potential opportunities for implementing goals of care conversations.We identified five consistent behaviors that take place when a veteran is referred and admitted in long-term care. These behaviors are assessing, discussing, decision-making, documenting, and re-assessing.Based on the process maps, it seems feasible that the LST note and order template could be completed along with other routine assessment processes. However, this will require more robust multi-disciplinary collaboration among both prescribing and non-prescribing health care providers. Completing the LST template during the current admission process would increase the likelihood that the template is completed in a timely manner, potentially alleviate the perceived time burden, and help with the provision of veteran-centered care.
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Introduction: Integrated networks of clinical leadership have been increasingly recognised as a strategy to improve patient care. Research has shown that these interventions can be effective vehicles for quality improvement through standardised patient care and also in improved patient outcomes. The aim of the current research is to determine whether a subset of the National Clinical Care Programmes (NCCPs) in Ireland have been implemented as intended. This study will also identify barriers and facilitators to implementation of the NCCPs.Theory/methods: A process evaluation of a complex intervention as per the UK Medical Research Council (MRC) guidance. A total of 31 key stakeholders will be interviewd via semi-structured interviews. Participants will include a patient representative, clinical leads, and health system managers from a subset of 7 NCCPs, ranging from acute to chronic care, and at different stages of implementation.Results: One of the distinctive features of the NCCPs is that they emcompass a whole range of factors from inner local/organisational factors to outer national/regulatory factors. Respondents will identifiy a number of essential factors underpinning successful and sustainable implementation of the NCCPs. These topics will include innovation, individual professional, patient, social context, organisational health system context and economic and social context. Drivers and barriers for implementation will be identified. Integrated care mechanisms such as the delivery system/governance design, decision support availability, clinical information system readiness and community context will be identified.Discussions: This study will provide evidence as to the extent to which the NCCPs are working and have been implemented as designed. It will also provide insights into the barriers and faciliators to implementation from the stakeholders’ perpectives. Our findings will provide policy-makers and service providers with insight into how to successfully plan, implement and support NCCPs and integrated care by ensuring strong leadership, localised decision-making authority, adequate resourcing, and legislation for the clinical care programmes’ operation in healthcare systems across the HSE and nationally. This will provide learning for other countries' health systems.Conclusions: An understanding of the translation of policies and strategies that underpin the NCCPs and whether these have been fully implemented as intended will be forthcoming. Large scale system change such as NCCPs and integrated care efforts could achieve increased efficiences and improved care for patients. The MRC guidance is a useful framework to evaluate a system wide intervention which comprises multiple interacting components and dimensions of complexity including the difficulty of their implementation and the number of organisational levels they target.Lessons learned: Evidence will show whether the NCCPs have been adequatly supported in order to achieve full implementation. Specific infrastructure required to measure all stages of patients' pathways are fundamental to successful healthcare delivery.Limitations: The NCCPs involved in this study (N=7) were a subset of the total number that exist (N=31). However, this is sufficient for an indepth qualitative process evaluation.Suggestions for future research: Future research should track ongoing implementaion of the NCCPs through a combination of qualitative processes and quantitative outcomes.
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Background Recent evidence shows that patient engagement is an important strategy in achieving a high performing healthcare system. While there is considerable evidence of implementation initiatives in direct care context, there is limited investigation of implementation initiatives in decision-making context as it relates to program planning, service delivery and developing policies. Research has also shown a gap in consistent application of system-level strategies that can effectively translate organizational policies around patient and family engagement into practice. Methods The broad objective of this initiative was to develop a system-level implementation strategy to include patient and family advisors (PFAs) at decision-making points in primary healthcare (PHC) based on wellestablished evidence and literature. In this opportunity sponsored by the Canadian Foundation for Healthcare Improvement (CFHI) a co-design methodology, also well-established was applied in identifying and developing a suitable implementation strategy to engage PFAs as members of quality teams in PHC. Diabetes management centres (DMCs) was selected as the pilot site to develop the strategy. Key steps in the process included review of evidence, review of the current state in PHC through engagement of key stakeholders and a co-design approach. Results The project team included a diverse representation of members from the PHC system including patient advisors, DMC team members, system leads, providers, Public Engagement team members and CFHI improvement coaches. Key outcomes of this 18-month long initiative included development of a working definition of patient and family engagement, development of a Patient and Family Engagement Resource Guide and evaluation of the resource guide. Conclusion This novel initiative provided us an opportunity to develop a supportive system-wide implementation plan and a strategy to include PFAs in decision-making processes in PHC. The well-established co-design methodology further allowed us to include value-based (customer driven quality and experience of care) perspectives of several important stakeholders including patient advisors. The next step will be to implement the strategy within DMCs, spread the strategy PHC, both locally and provincially with a focus on sustainability.
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The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)
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Objective: The implementation of evidence-based treatments (EBTs) to address posttraumatic stress disorder (PTSD) is a public health priority. Successful EBT implementation requires effective collaboration between multiple stakeholder groups, including hospital leaders, providers, and patients, to build buy-in for this effort. Method: We describe our implementation science approach to meaningful stakeholder engagement, as part of a hybrid type I effectiveness-implementation trial of Skills Training in Affective and Interpersonal Regulation for PTSD treatment in primary care (STAIR-PC) at a large safety net hospital. We used primary care and patient community advisory boards (CABs) to interpret key informant interviews and identify strategies to adapt the intervention to ensure fit with the primary care setting. We documented our stakeholder engagement methodology through comprehensive field notes and minutes from CAB meetings, detailing the focus of meetings, suggestions for intervention and delivery adaptations, decision-making processes, and how disagreements about adaptations between stakeholders were resolved. To support replicability, we specify and operationalize implementation strategies to be used across each implementation phase of the trial. Results: Key strategies involved a) ensuring that research questions are relevant to both patients and clinical providers; b) tailoring interventions that are flexible and adaptable to the needs of the local setting; c) continuous engagement of patients and providers throughout the implementation process; and d) building mutual respect, trust, and credibility between the research team, various provider groups, and patients. Conclusions: Our approach to engaging stakeholders informed an implementation blueprint to guide implementation of EBTs for PTSD in safety net hospital primary care clinics. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Introduction: Polypharmacy and medication adherence in the older population are significant public health issues throughout the European Union (EU), and are critical issues in integrated care. SIMPATHY (Stimulating Innovation Management of Polypharmacy and Adherence in The Elderly) is a consortium of 10 organizations representing 8 EU countries with the goal of stimulating innovation around polypharmacy and adherence, ultimately providing the tools for EU policy makers to adopt new programmes addressing this issue into existing healthcare systems.Methods: A mixed-methods case study was performed to identify and characterize factors that influenced the development and implementation of Swedish policies on the management of polypharmacy in the elderly, specifically regarding medication reconciliation and review activities. Data extraction included a desk review of these policy documents and guidelines at national and regional (Uppsala County) level. To fill knowledge gaps from the desk review, four key informant interviews were conducted, highlighting the employed change management strategies. Interview transcriptions were coded using the Kotter’s Eight Step Change Model and the Normalization Process Theory (NPT). As a validation method, the findings from the desk review and interviews were presented to and discussed by a focus group consisting of six policymakers and clinicians, one of which was a key informant interviewee as well.Results:Both presence and absence of characteristics of change management were identified within all Kotter’s principles and NPT domains. Taking into account the focus group validation, we report the following key findings.Facilitators of change:- availability of data from national prescribing indicators and research showing the urgency to increase the quality of care for the elderly;- awareness of the problem among the public at national level and the political will to fund activities for improvement;- engagement of key individuals within healthcare, university and governmental bodies at regional level leading to a strong collaboration with many different stakeholders;- investment in educational activities, the formation of multi-disciplinary healthcare teams including pharmacists and the possibilities to show positive results at regional level;- use of a pay-for-performance structure based on monthly-updated results from the national prescribing indicators;- availability of shared electronic medical records between hospitals and primary care centres at regional level.Barriers of change:- lack of a common belief that medication reviews are an essential and effective activity;- lack of knowledge and consensus on how and by whom exactly these reviews should be performed;- lack of the integration of specially trained clinicians within healthcare teams;- some physicians possess a certain scepticism towards collaboration with pharmacists;- absence of a strategy to fully implement and evaluate medication review policies at a national level;- absence of a legislative impact analysis.Conclusion: This case study provides valuable insight into _how_ and _why_ medication review policies were developed and implemented in Sweden. These results combined with the other SIMPATHY case studies will be used to create strategy tools for policymakers, researchers, and clinicians throughout Europe as they move to integrate polypharmacy and adherence activities into existing health care systems.Funding: This poster is part of the SIMPATHY project (663082) which has received funding from the European Union’s Health Programme (2014-2020).
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To examine activities conducted, challenges encountered and supports used when sustaining nursing practice guideline implementation in multiple healthcare organisations over 3 years.Numerous models and frameworks exist to guide the implementation of guidelines, yet very few focus on sustaining improved practice changes. It is not known if one intervention or multiple interventions are required, nor the long-term activities, challenges and supports for sustaining improved practices.Qualitative descriptive study.We conducted focus group interviews with steering committee members and individual interviews with leaders and direct care providers at the end of a 3-year guideline implementation study. The National Health Service Sustainability Model was used to guide data collection and analysis.The eight sites included three teaching hospitals, a community hospital, a long-term care facility, two community health agencies and a community health centre. Individual interviews were conducted with 36 leaders and 26 direct care providers. Focus group interviews were conducted with steering committee members (n = 70) at each site. Guideline implementation activities (n = 45) included developing new outcome monitoring systems, conducting chart audits, communicating progress to internal stakeholders, appointing interprofessional staff to steering committees, developing educational sessions and resources for staff and patients, revising policies and procedures, and developing partnerships with external organisations. Supports included lessons learned from previous and concurrent change initiatives, and commitment, involvement and positive attitudes of staff and leaders.Activities identified by the participants addressed all 10 factors in the Sustainability Model in the three areas of process, staff and organisation. The challenges and supports encountered provide insights into the process of guideline implementation and sustainability.A multilevel action plan for staff, leaders and the organisation is recommended when introducing and sustaining practice changes.
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