Evidence Based Practice (EBP) - Barriers, Facilitators, and Implementation Contexts

Evidence based practice (EBP) is a key recommendation in healthcare delivery. It is interesting to understand barriers and facilitators to the implementation of EBP to realize optimal care outcomes. Although there may be common elements in all care settings, specific contexts may be studied further. This helps clinicians and nurses further decipher how it may be possible to integrate new interventions based on evidence for positive outcomes relating to all stakeholders involved in care delivery.

Geography: United States; Focus Area: Evidence-based practice

Definition and Typical Approach in Implementing Evidence Based Practice

According to John Hopkins Medicine Center for Nursing Inquiry, evidence-based practice involves reviewing, analyzing, and translating the latest evidence to incorporate it with patient preference and clinical experience for informed patient-care decisions.  Evidence-based practice facilitates high quality care, lower costs, higher nurse satisfaction, and optimal patient outcomes. 

The American Journal of Nursing explains a typical EBP process for clinical decision making. EBP takes place when an inquiry is initiated, formatted using the PICOT approach (population, intervention in area of interest, comparison intervention, outcome, time), evidence searched from available databases with chosen keywords, results combined to find pertinent literature, exclusion criteria applied, and articles appraised for validity, reliability, relevance, and applicability to the clinical question. The evidence is integrated with patient preference and clinical expertise, and outcomes of practice decisions are evaluated. Disseminating EBP results is an important aspect of avoiding duplication of effort.

Promotion: Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice Paperback – Import, 1 October 2018 by Bernadette Melnyk (Author)

   

Barriers and Facilitators to EBP Implementation

The barriers to implementing EBP are a lack of inclusion into nursing curriculum and a lack of internet search skills to implement EBP. Shayan and team (2019) identified that barriers were related to limited resources, information, lack of institutional support, inadequate staffing, lack of communication and teamwork, negative image about the profession, scope of practice, time constraints, and individual barriers. 

Li and team (2019) identified that although nurses had a positive attitude towards EBP, unprepared implementation and insufficient knowledge was a concern. A lack of time and resources made it difficult to transform attitude and knowledge to implementation. Management function, younger age, and academic training were facilitators to EBP success. 

Kilbourne and team (2019) describe a relevant concept - the learning health systems such as the US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) roadmap that incorporates implementation science and quality improvement. This approach enables stakeholder participation (consumer, clinician, health leader, administrator) to “plan, deploy, evaluate, and sustain” EBPs in a plausible manner.  Barriers and facilitators may be identified and addressed for each care setting. The following section describes the dynamics of evidence-based practice for three specific contexts.

EBP Implementation Cases in Diverse Contexts

Mathieson and team (2018) discuss the implementation of evidence-based practice in community nursing through a framework of barriers, facilitators, and implementation theory in their chosen context. Community nursing has not been studied as much as other health care delivery settings. Practice innovations are not known and seldom translated into care delivery. Researchers found that a limited use of theory and lack of consistent terminology is a potential barrier. The process of implementation requires support from management for successful adoption by the individual and organization. The final decision-maker is the community nurse who influences implementation of the EBP if it has a recognized positive impact on the patient. Community nurses may be motivated by improved patient care and nurse-patient relations, interpersonal relations with healthcare professionals, and professional development. They were also more likely to adopt the innovation when there was autonomy and flexibility. 

They were less likely to adopt the innovation in times of organizational change as this made them preoccupied with the ongoing change. They were resistant to the innovation if it was likely to have an adverse influence on their existing relationships. Team reorganization, working with interdisciplinary teams, patient’s unwillingness to comply with the innovation, no significant enhancement in care, and organizational goals were other probable roadblocks. On-going education was a major facilitator, but a lack of time was a barrier to engagement with the EBP. 

McArthur and colleagues (2021) discussed the implementation of EBP in long-term care settings. The main barriers identified were cost, inadequate resource and staffing, lack of organizational support and teamwork. Leadership, effective strategies, protocols, and adequate resources and time. Several interventions were identified as feasible such as resident-centered care, environmental restructuring, and neighborhood team development for service reorganization and collaborative care. Change fatigue and knowledge gaps, poor job satisfaction, and work-related burnout were potential barriers. Barriers related to reflective and automatic motivation and psychological capability could be overcome through education and training. 

Promotion: Evidence-Based Medicine: How to Practice and Teach it Paperback – 8 December 2010 by Straus (Author)

   

Finally, in a scoping review pertaining to EBP implementation in stroke rehabilitation, Juckett and colleagues (2020) examined the implementation of occupational therapy interventions for the adult stroke population. They identified that translation of research into practice remains a challenge among rehabilitation professionals. Evidence-based interventions in the domain of stroke are related to postural, functional, cognitive, behavioral, and motor impairments. The implementation of EBP in stroke rehabilitation decreases the effects of disability and enhances the quality of life of stroke survivors. 

Researchers identified determinants that impeded and promoted occupational therapy practitioners for EBP implementation. They also examined implementation strategies that encouraged occupational therapy practitioners. There was a difficulty in implementing the EBP when there was inconsistent adherence to the intervention, low rate of adherence, or complexity associated with the intervention. Other barriers were lack of resources, staff, and EBP experts, logistic challenges, inadequate equipment, time constraints, inconsistent leadership engagement, decreased interdisciplinary communication, and perceived ability to implement EBPs. On an individual level, barriers included decreased confidence in utilizing the intervention, lack of knowledge of the intervention, difficulty adopting a new intervention, and an unfavorable view of an EBP. 

Facilitators for implementation included electronic education, online support guides, availability of EBP experts, relationship building among stakeholders, and communication from organizational leadership. Factors that predicted successful implementation included the value that practitioners found in an EBP intervention, enthusiasm to support and adopt the intervention in rehabilitation, and a strong working knowledge of available EBP interventions and their clinical applicability. Further, patient preference and engagement strongly predicted successful implementation of the EBP intervention. Acknowledging barriers and facilitators was integral to successful implementation. Implementing the intervention was dependent on practitioner adherence, value placed by practitioner in the intervention, using multimodal knowledge translation or a combination of implementation strategies, and utilizing available EBP tools and resources.

In essence, the successful implementation and dissemination of EBP interventions in diverse contexts depends on identifying barriers and facilitators to implementation. Several stakeholders influence the successful implementation and adherence to a new innovation in EBP including patients, practitioners, the organization, healthcare leadership, and the attitudes and beliefs concerning the intervention. 

Nursing, evidence-based practice, PICOT, clinical question, EBP, clinical decision-making, health learning systems, community nurses, nurse-patient relations, stroke rehabilitation, long-term care, EBP intervention, EBP implementation.

Promotion: Evidence-based Practice in Social Work: Development of a New Professional Culture (Core Concepts in Health and Social Care) Paperback – Illustrated, 20 August 2014 by Haluk Soydan (Author), Lawrence A. Palinkas (Author)

   

Keywords: 

stroke rehabilitation, community nurses, evidence-based practice, EBP, Nursing, PICOT, long-term care, clinical question, EBP implementation, clinical decision-making, nurse-patient relations

References

Juckett, L. A., Wengerd, L. R., Faieta, J., & Griffin, C. E. (2019). Evidence-Based Practice Implementation in Stroke Rehabilitation: A Scoping Review of Barriers and Facilitators. American Journal of Occupational Therapy, 74(1), 7401205050p1. https://doi.org/10.5014/ajot.2020.035485 https://doi.org/10.5014/ajot.2020.035485

Kelly, R. (2022). Evidence-Based Practice. Www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/nursing/center-nursing-inquiry/nursing-inquiry/evidence-based-practice.html#:~:text=EBP%20is%20a%20process%20used

Kilbourne, A. M., Goodrich, D. E., Miake-Lye, I., Braganza, M. Z., & Bowersox, N. W. (2019). Quality Enhancement Research Initiative Implementation Roadmap. Medical Care, 57, S286–S293. https://doi.org/10.1097/mlr.0000000000001144

Li, S., Cao, M., & Zhu, X. (2019). Evidence-based practice. Medicine, 98(39), e17209. https://doi.org/10.1097/md.0000000000017209

Mathieson, A., Grande, G., & Luker, K. (2019). Strategies, facilitators and barriers to implementation of evidence-based practice in community nursing: A systematic mixed-studies review and qualitative synthesis. Primary Health Care Research & Development, 20(20). https://doi.org/10.1017/s1463423618000488

McArthur, C., Bai, Y., Hewston, P., Giangregorio, L., Straus, S., & Papaioannou, A. (2021). Barriers and facilitators to implementing evidence-based guidelines in long-term care: a qualitative evidence synthesis. Implementation Science, 16(1). https://doi.org/10.1186/s13012-021-01140-0

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-Based Practice: Step by Step: The Seven Steps of Evidence-Based Practice. AJN, American Journal of Nursing, 110(1), 51–53. https://doi.org/10.1097/01.naj.0000366056.06605.d2

Shayan, S. J., Kiwanuka, F., & Nakaye, Z. (2019). Barriers Associated With Evidence‐Based Practice Among Nurses in Low‐ and Middle‐Income Countries: A Systematic Review. Worldviews on Evidence-Based Nursing, 16(1), 12–20. https://doi.org/10.1111/wvn.12337

Patient Centered Medical Home (PCMH) - Origins, Definitions, and Benefits

The patient centered medical home (PCMH) model is a proven framework for the implementation of complex care through a patient-centered primary care approach. The NCQA, AHRQ, and CDC define PCMH implementations, collectively targeting better quality, access and lower costs for patients. The PCMH model has evolved overtime, although its primary applicability to the outpatient setting makes it hugely beneficial to all stakeholders involved in the delivery of comprehensive and coordinated care. 

Geography: United States; Focus Area: State of implemetation of the medical home model

Definitions of the Patient Centered Medical Home (PCMH)

The definition of the patient-centered medical home has evolved overtime. According to the National Committee for Quality Assurance (NCQA), the model of a PCMH puts the patient at the core of the framework. A PCMH fosters effective relationships between the patients and their physician and care team. Outcomes of the PCMH include improved quality, patient experience, reduced healthcare costs and increased satisfaction of healthcare staff. The PCMH model reduces fragmentation in care delivery through teamwork, coordination, and communication, provides the means for better management of chronic conditions, and provides a better alignment with state and federal initiatives and payers. Organizations receiving recognition as PCMH are committed to patient-centered care and continuous quality improvement.

According to the Agency for Healthcare Research and Quality (AHRQ), a PCMH is a primary care organization and delivery model offering patient-centered comprehensive care, promoting accessible services, care coordination, safety, and quality. 

In the definition by Centers for Disease Control and Prevention (CDC), the PCMH approach is focused on cost effective and high quality primary care. The key elements in this definition relate to culturally appropriate, patient centered care, delivered through a team-based approach, and care coordination across the health delivery system. The PCMH model offers increased provider and patient satisfaction, chronic disease management, preventive care, improved care quality, and cost savings.

Origins of the Patient Centered Medical Home (PCMH)

The joint principles of the PCMH were first defined in 2007 by the American Academy of Pediatrics (AAP), American Academy of Family physicians (AAFP), American Osteopathic Association (AOA), and American College of Physicians (ACP) as first contact, continuous, and comprehensive care by a personal physician, whole person orientation for patient healthcare needs, collective responsibility of care team led by physician for ongoing patient care, coordinated and integrated care across complex healthcare system, communities, registries, and health information exchange, in a manner that is linguistically and culturally appropriate. Other tenets of the PCMH include enhanced access to care, safety and quality, and value-added payment structure.

The origin of the PCMH originated in the specialty of pediatrics when children needed care for complex illnesses. Henceforth, PCMH concepts were applied to primary care and multiple other organizations. A PCMH is alternatively referred to as a medical home or advanced primary care practice. The first models of PCMH came to be known as Medical Home for children with special health care needs (CSHCN). The pediatric medical home was a source of information for the CSHCN, the former often involved in care coordination with a fragmented profile of providers and physicians. The term medical home was first used by the American Academy of Pediatrics (AAP) to resolve problems with fragmentation of care.

In highly developed countries, the development of PCMH led to superior outcomes, reduced costs, long-term person-centered care, and comprehensive and coordinated care. A higher ratio of primary care physicians (PCPs) was linked to more equity in care, lower costs, and high care quality. Further studies indicated that superior outcomes, improved quality, and reduced costs were the result of systematic delivery of primary care rather than higher PCP ratio.

Promotion: 2. the Patient - Centered Medical Home: Closing the Quality Gap: Revisiting the State of the Science (Evidence Report/Technology Assessment Number 208) Paperback – Import, 22 March 2013 by U. S. Department of Health and Human Services (Author), Agency for Healthcare Research and Quality (Author)

   

Beneficiaries of the Patient Centered Medical Home (PCMH)

Payers, health systems, patients, and physicians benefit by implementing the PCMH model of care. Low cost and high quality offers value for payers and patients. In addition to cost and quality benefits, patients also receive improved access and coordination of care. The PCMH model addresses key concerns of physicians including dissatisfaction and distress related to work-life balance, and burnout. Key changes in practice processes lead to higher physician satisfaction and retention.  Empanelment by involving a community of patients is an integral aspect of PCMH, although it may be difficult to determine the demographics, chronic illness status, preventive measures, and follow-up care. Teamwork, delegation, standardized processes, accountability, and interdisciplinary training drive successful PCMHs. The financing of most PCMHs is guided by the Medicare Reform Law and CHIP Reauthorization Act of 2015 (MACRA).

Over the years, healthcare teams have attempted to implement the patient centered medical home (PCMH) across military care, emergency care, cardiovascular care, stroke and complex conditions to achieve coordinated, high quality, comprehensive care for diverse populations globally. The core principles of patient-centered care, team-based care coordination, and value-based services addresses complex patient needs through a robust model of primary care.

Promotion: A Retrospective Review of Patient Satisfaction: And the Relationship to Patient Centered Medical Home Paperback – Import, 17 June 2019 by Jacquelene S Hamer-McGhee (Author)

   

Keywords

patient centered medical home, patient satisfaction, NCQA, continuous quality improvement, CDC, coordinated care, comprehensive care, preventive care, AHRQ, PCMH, chronic care management, patient centered care

References

AHRQ. (2021). Defining the PCMH. Www.ahrq.gov. https://www.ahrq.gov/ncepcr/research/care-coordination/pcmh/define.html

American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), & American Osteopathic Association (AOA). (2007). Joint Principles of the Patient-Centered Medical Home. In AAFP. https://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf

CDC. (2021). Patient-Centered Medical Home (PCMH) Model | cdc.gov. Centers for Disease Control and Prevention. https://www.cdc.gov/dhdsp/policy_resources/pcmh.htm

National Committee for Quality Assurance. (2011). Patient-Centered Medical Home (PCMH) - NCQA. NCQA. https://www.ncqa.org/programs/health-care-providers-practices/patient-centered-medical-home-pcmh

O’Dell, M. L. (2016). What is a Patient-Centered Medical Home? Missouri Medicine, 113(4), 301–304. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6139911/

AHRQ CCRM Atlas - A Benchmark and Roadmap for Clinician-Community Collaboration in Preventive Care

The Clinical Community Relationships Measures (CCRM) Atlas “defines, measures, and evaluates” programs relying on clinical-community relationships in order to deliver clinical preventive services. The CCRM Atlas was developed for Agency for Healthcare Research and Quality (AHRQ) as a means to improve primary care through a preventive and chronic care program. 

Geography: United States; Focus Area: Deployment of preventive services through clinician-community connections

The approaches detailed in the CCRM Atlas enable community-based organizations to cooperate, coordinate, and collaborate in the delivery of preventive care services in clinical settings. Important components of the CCRM Atlas include a measurement framework (measures of clinical-community relationships), interventions to improve research, quality, and delivery of clinical preventive services.

The CCRM Atlas for Enabling Preventive Services through Clinical-Community Connections

The CCRM Atlas provides a rationale and recommendations to deliver preventive services without insurance cost-sharing, to address high costs of healthcare and morbidity rates. Several barriers exist for the delivery of preventive services in primary care settings, such as staffing shortage, time constraints, and problems with reimbursements.

The delivery of these services may be possible through successful partnerships of primary care providers with community-based organizations and local health departments (non-clinical organizations with shared interests).

The CCRM measurement framework (defining clinical-community relationships to deliver preventive care) includes a structure, process, and outcome measures. It defines the characteristics of patients, clinicians, and community organizations, and their relationships and interactions.

An example of a clinical-community relationship is when a primary care provider makes a connection with a a community resource to provide a preventive service such as tobacco screening and counseling. The clinical setting and community resource then work together with at least one of the Himmelman strategies i.e. coordinating, cooperating, networking, and collaborating.

There is a distinction between care coordination and clinical-community relationships in that the former happens between healthcare organizations, while the latter is a subset of care coordination happening between community-based resources (not considered healthcare organizations) and clinics. In this regard, the Expanded Chronic Care Model provides a broader context, with a clinician supported by a team of care professionals with diverse roles.

Key Elements of the AHRQ CCRM Framework

Characteristics for and m “foundational anchors” on each side of the bridge of a clinical-community relationship, form one dimension of the framework. The other dimension is the Donabedian’s structure-process-outcome model.

Different measurement domains are defined such as access to primary care or community resource, service delivery, clinician experience, communication, follow-up, and feedback, familiarity with community resource, marketing, organizational structure, patient centeredness and experience, shared decision-making, timeliness, training, and many more.

Measurement frameworks also have contexts within which the clinician, community resource, and patient exist, and are influenced by many other factors. The elements defined by the framework may differ from community to community owing to their wealth, population size, cultural diversity, educational attainment, challenges faced and coping strategies. Health and community resources available in a community influence relationships between patient and clinician. Patients are affected by their characteristics, family structure, organizational environment, and community policies.

Measures of structure, process, and outcomes may be examined at six different points - the clinic/clinician, patient, community resource elements, and the three intersections i.e. patient-clinician, clinician-community resource, and patient-community resource.

Promotion: Community Palliative Care and COVID-19: A handbook for clinicians who care for palliative patients with COVID-19 in community settings Kindle Edition by Tania Blackmore (Author), Georgina Parker (Author) 

   

Definition of Structure-Process-Outcome Measures

AHRQ CCRM Atlas defines three examples of implementing measures within a specific framework. An example of a structure domain within a measurement framework is that of a primary care clinic with an IT infrastructure that makes electronic referrals to a community center. In this case, measures of infrastructure are placed within the IT infrastructure domain. Further, a community organization delivering allied health services (mental health, substance abuse counseling) may have increased capacity to deliver preventive services. In this case, the measures of capacity are placed within the service capacity domain. Thirdly, a patient may not be able to access a community resource either due to an inability to travel or time constraints. The prevalence of such barriers may be measured through the ability to access the community resource domain.

In the process domain, a clinician may undertake work to acquire knowledge of existing community resources. These measures may be placed under outreach to obtain knowledge and familiarity with community resources. Furthermore, marketing activities for promoting patient and clinician may be placed under the marketing of services domain.

Finally, in the outcome domain, a physician may collaborate with a community organization to provide preventive services to have more time to see patients in a typical work week. These measures may be placed under cost and efficiency domain. Further, a patient receiving behavioral counseling through a community organization where they have been referred may be measured for rate of completion of counseling services under the delivery of service domain.

Delivering Effective Clinical-Community Relationships for Positive Patient Outcomes

Interactions between the elements of the framework are integral to effective clinical-community relationships. The clinician at the primary care clinic initiates clinical-community liaison, measured under the delivery system design domain. The patient may be affected by factors outside the relationship with the clinician or community, which may be measured under the patient’s ability to access community resource. A community resource constituting a range of programs and organizations providing patient services must maintain the necessary resources and staffing, which may be measured under the service capacity domain. Clinical-patient relationships define level of trust and an understanding of needs and expectations, measured under informed and activated patient domain. Clinical-community relationships are formed on the basis of common benefit, and establishing routines that produce positive cost-benefit ratio, effective service delivery, efficiency and sustainability, and may be measured under nature and strength of inter-organizational relationship domain. Finally, the patient-community resource relationship involves patient engagement with community resource to provide appropriate preventive services, and may be measured using informed and activated patient and ready community resource domains.

To sum it all up, the CCRM Atlas is a comprehensive resource that defines a roadmap for executing preventive care through a clinician-community resource relationship. By defining core measurements in terms of structure, process, and outcome, the CCRM framework facilitates a broad range of domains and relationships to work in a collaborative manner and maximize positive patient outcomes in the long run.

Promotion: The Social Norms Approach to Preventing School & College Age Substance Abuse - A Handbook for Educators, Counselors & Clinicians: A Handbook for Educators, Counselors, and Clinicians Hardcover – Import, 11 March 2003 by HW Perkins (Author)

   

Keywords

AHRQ CCRM Atlas, clinician-community relationship, chronic care model, measure of clinical-community relationships. structure process outcome measures, preventive care, positive patient outcomes

References

Westat, & Oregon Rural Practice-based Research Network (ORPRN). (2013). Clinical-Community Relationships Measures (CCRM) Atlas. In www.ahrq.gov. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-measures-atlas/index.html

Care Provider Burnout, Adverse Outcomes, and Recommendations for Patient Safety Culture

Patient safety may be compromised by internal and external factors. Burnout among healthcare professionals is an important predictor of adverse patient outcomes. Understanding specific concerns among healthcare leadership, nurses, physicians, healthcare staff, and patients leads to a positive safety culture - a culture where mutual learning, productivity, and teamwork leads to patient safety, reduced adverse events, and enhanced care quality.

Geography: United States; Focus Area: Patient safety culture

The Importance of Patient Safety

Patient safety is directly related to adverse outcomes and compromises care quality. Adverse events are complications arising from patient care, due to errors that are not directly related to disease. Medical error is the third leading cause of mortality in the United States. Adverse events arising from errors are avoidable adverse events.

Burnout among healthcare providers poses a significant risk to patient safety. Physiological and psychological overload of the care team has a direct impact on patient outcomes. In the systematic review and meta analysis carried out by Garcia and team (2019), twenty one studies indicated that burnout was associated with worsening patient safety. Statistical analysis showed that the association between burnout and patient safety was more than 60%.

Factors that Compromise Patient Safety

Patient safety and burnout may be the result of several causal factors.

• Patient safety may be compromised by management error, system failure, inefficient processes, communication problems, teamwork, and psychological health of professionals (anxiety, depression, and burnout syndrome, depersonalization, low professional achievement, and emotional exhaustion).

• Healthcare staff may experience burnout as a result of long journeys, high workload, and compromised interpersonal relationships. Occupational stress and exhaustion among healthcare providers reduces effectiveness in care leading to adverse outcomes for patients and health services delivery.

• In physicians, imbalance between personal and professional lives was directly related to consequences of patient safety and care quality

• Hospital working conditions consist of human and systemic factors compromising patient safety - lack of professionalism, poor use of technology and tools, increased workload, hierarchical culture, messy workspace.

• Higher burnout rates were associated with lower teamwork, professional tiredness, and lower job satisfaction. Further, it was related to unfavorable outcomes for patients, patient and family complaints, and patient dissatisfaction.

• Depersonalization in healthcare professionals, resulting from burnout, caused them to be cold and distant towards patients, compromising care quality. In some studies, no significant association was found between the occurrence of disease, medical error, infection rates, and burnout.

• High workload determined professional fatigue. External factors affected burnout and negatively impacted patient safety, while internal factors did not.

• Nurse burnout was associated with increased risk of infection in patients.

• Personnel conflict was another factor cited by nurses that increased risk of burnout. Professional and emotional exhaustion had an undesirable effect on teamwork.

Promotion: Textbook of Patient Safety and Clinical Risk Management Paperback – Import, 16 December 2021 by Liam Donaldson (Editor), Riccardo Tartaglia (Editor), Susan Sheridan (Editor), Walter Ricciardi (Editor)

  

Recommendations for a Positive Safety Culture

Researchers proposed positive measures to improve patient safety and care quality in healthcare settings.

• Safety culture must be promoted, that consists of management support, open communication, professional suitability, teamwork and mutual learning, and promotes satisfaction and productivity.

• Leadership walks during the routine were found to be important in establishing relationships between health services leaders and health delivery professionals, to identify and solve problems related to patient safety. Effective interpersonal relationships reduced fatigue and exhaustion.

• The implementation of the TeamSTEPPS (Team Strategies and Tools to Improve Patient Safety and Performance) protocol improves the psychological safety of the care team and reduces burnout.

• Researchers recommend training on clinical practice guidelines, technology use, adverse events, training on infection prevention, improving working conditions, and providing emotional and psychological support to healthcare providers.

Therefore, burnout among healthcare providers may be given due consideration with the objective of implementing a systematic plan dealing in resolving the underlying issues compromising patient safety. Patient safety processes and protocols are integral to optimal care quality, lower infection rates, reduced medical error, and increased provider and patient satisfaction.

Promotion: Patient Safety Now: Applying Concepts, Theories, and Ideas for Creating a Safe Environment Paperback – Import, 4 October 2022 by Ralph R.B. Von Frese (Author)

   

Keywotrds

patient safety, physician burnout, teamwork, occupational stress, medical error, burnout syndrome, safety culture, professional tiredness, workload, psychological support, adverse events, emotional exhaustion

References

Garcia, C., Abreu, L., Ramos, J., Castro, C., Smiderle, F., Santos, J., & Bezerra, I. (2019). Influence of burnout on patient safety: Systematic review and meta-analysis. Medicina, 55(9), 553. https://doi.org/10.3390/medicina55090553

Family Centered Care Model - Health Systems Impact

Family members play a major role as caregivers, in chronic conditions. Family members, friends, or neighbors provide unpaid care in several domains including hands-on care, assistance with daily activities, financial management, and care coordination. Deteriorating conditions may pose additional demands on caregivers as care needs of patients become complex. As a result, caregivers are often at risk of physical and mental conditions, financial instability, and adverse impact on social life. Therefore, policies and programs are required to sustain caregiving for optimal care in the home.

Geography: United States; Focus Area: Family-centered care

The Need for a Family Centered Care Model

Supporting caregivers may be in the form of a shift from long term care to home care, supported by a population-based funding model that offers social and health services to patients and caregivers. A family-centered care model addresses the needs of family members, beyond the patient. According to a definition by the Institute of Patient and Family Centered Care (IPFCC), family centered care refers to “beneficial partnerships between healthcare providers, patients, and families - in healthcare planning, delivery, and evaluation”. Family centered healthcare models have been successful in pediatrics, stroke rehabilitation, and supporting an aging population. This scenario was comprehensively evaluated by Kokorelias and colleagues (2019), who performed a scoping review to determine the key aspects of a family centered model for validity across care contexts and patient populations, and provided important recommendations for the future.

Implementing Family Centered Care (FCC) Models

The family centered models studied for the purpose considered interactions between care providers, families, and patients, and were applicable to diverse patient populations and care settings (community, rehabilitation, acute care, long-term care). Models evaluated were related to a specific healthcare or clinical context. On analyzing different family centered care (FCC) models, researchers identified the universal goal of implementing patient care plans within family contexts. Implementing such models required detailed policies and procedures, collaboration between caregivers and family members, and education for family members, patients, and caregivers.

• Care plans were intended to cover important aspects of daily home routines, patient-identified functional outcomes (such as motor skills), improved family satisfaction, reduced discharge complications, and improved caregiver support.

• For a successful implementation, it was important to understand family priority and needs, enhance family abilities to support the care plan, enhance caregiver support, define realistic outcomes, and optimize patient outcomes.

• FCC models may identify unique family strengths such as coping, resilience, motivation, and competence in providing care. Caregivers may be encouraged to identify these strengths and areas of weakness may be identified.

• Family members may devise a culturally sensitive care plan by conveying cultural priorities, values, preferences, and ideas.

• FCC models may contain detailed definitions of the nature of collaboration between family caregivers and healthcare providers across the illness trajectory, define family ability to maintain control over patient care delivery when care becomes complex, define greater decision-making authority on families and the degree of healthcare provider involvement in development of care plans.

• Communication was important for information exchange, advocacy for patient preferences and family values, promoting interdisciplinary care, and undertaking informed disease-related decisions.

• Education on disease and care planning increased control of patients and family members and reduced anxiety. Education could be provided in a written form, but may be presented in a language level that is understandable by the patient and family, with minimal medical jargon. Education is an ongoing process, beyond inpatient care, to improve trusting relationships between care providers and patients and families, empower family caregivers with knowledge, and facilitate independent treatment decisions. Peer sharing of resources is encouraged and also enhances emotional support. In addition, support groups, retreats, and workshops may be encouraged.

• Agreement of all stakeholders is important for commencement of care delivery.

• Family members communicate issues and priorities to care providers and are involved in discharge planning (for inpatient care).

• Care plans may be monitored to achieve additional goals such as minimizing duplication of resources, bridging service gaps, and optimizing service utilization.

• FCC models are designed to support caregivers through mental health services, financing, homecare, transportation, vocational services, public health, housing, social services, and education.

Therefore, patient-centered care is a key component of FCC models. Partnerships among stakeholders in the care delivery plan is integral to the implementation of illness-specific models. In future, models may be developed with due consideration to patient preferences for permission to access medical records, evaluating cognitive capacity for decision making, and improvement in caregiver burnout and efficient use of services. Finally the models need to be evaluated for outcome measures such as improvement in family and patient satisfaction, overall health outcomes, health services utilization, increase in efficiency, cost effectiveness, and community reintegration.

Promotion: Person and Family Centered Care Paperback – Import, 29 May 2014 by R.N. Barnsteiner, Jane H., P.D. (Author), R. N. Disch, Joanne, Ph. D. (Author), R.N. Walton, Mary K. (Author)

   

Keywords

health education, health systems, health policy, care plans, patient-centered care, care model, healthcare delivery, healthcare communication, family-centered care, FCC models, culture-sensitive care

References

Kokorelias, K. M., Gignac, M. A. M., Naglie, G., & Cameron, J. I. (2019). Towards a Universal Model of Family Centered care: a Scoping Review. BMC Health Services Research, 19(1), 1–11. https://doi.org/10.1186/s12913-019-4394-5

Conceptional and Methodological Rigor in Quality of Life (QoL) Research

Recent measurements of Quality of Life (QoL) and Health-Related Quality of Life (HR QoL) have been inadequate in terms of conceptual and methodological rigor. More comprehensive measures are required to assess its impact on health, disease, therapy, and medical decision-making for individuals and populations.

Geography: United States; Focus Area: Measuring healthcare quality of life

According to the definition by World Health Organization (WHO), QoL relates to the perception of an individual about the position in life in context of their culture and in relation to expectations, goals, concerns, and standards. HR-QoL refers to the measure of a duration of life that is influenced by functional states, impairments, disease, injury, treatment, opportunities, perceptions, and policy. 

Why QoL Assessment is Important

An assessment of QoL measure is important as the focus on outcomes has recently shifted from biomedical to QoL outcomes in the context of health, care delivery, and rehabilitation of patients. Self-reported QoL can show problems affecting patients, improvements in treatment, and efficacy of therapies. QoL measures disability status and daily functioning. It can help understand the consequences of disease and treatment of patient populations. Other important implications of QoL include understanding problems occurring later on, prognosis, and medical decision-making. Therefore, it makes sense to assess QoL on a routine basis in clinical trials. Besides, what exactly is measured by QoL must be determined.

Systematic Review Snapshot of QoL Research

Haraldstad and team (2019) explored research related to Quality of Life (QoL) in the research and health sciences domains. Most research studies in the recent years have focus on Quality of Life (QoL) and Health Related Quality of Life (HR QoL). However, these studies have not been evaluated for methodological and conceptual rigor. In their systematic review, researchers used the Gill and Feinstein criteria to evaluate QoL research. 

The studies included in the systematic review focused on heart disease, mental illness, cancer, chronic obstructive pulmonary disease (COPD), asthma, and gastrointestinal disease. A number of patient groups, QoL measures, and research designs (descriptive, experimental, longitudinal) were used in the studies included. The studies represented a global sample, mostly from developed countries.

Final Thoughts

Scientists found that inconsistencies in QoL research were due to a lack of conceptual clarity, and absence of a uniform definition of QoL. They indicated that theories and theoretical frameworks improve QoL understanding and develop new knowledge. Theoretical thinking also forms the basis of hypothesis generation. However, researchers indicated several limitations such as the snapshot not being fully representative of QoL research, studies evaluated limited only to the English language, and the criteria developed to assess rigor not being recent, making its validity questionable. In effect, researchers must invest greater time and effort in planning conceptual and methodological issues when designing QoL studies. 

Promotion: Health-related quality of life in cardiovascular patients Paperback – Import, 20 September 2014 by Kalina Kawecka-Jaszcz (Editor), Marek Klocek (Editor), Beata Tobiasz-Adamczyk (Editor), Christopher J. Bulpitt (Editor)

     

Keywords

treatment, disease, population health, methodological rigor, functional state, medical decision-making, conceptual rigor, HR QoL, quality of life, QoL research, QoL, health related Quality of Life

References

Haraldstad, K., Wahl, A., Andenæs, R., Andersen, J. R., Andersen, M. H., Beisland, E., Borge, C. R., Engebretsen, E., Eisemann, M., Halvorsrud, L., Hanssen, T. A., Haugstvedt, A., Haugland, T., Johansen, V. A., Larsen, M. H., Løvereide, L., Løyland, B., Kvarme, L. G., Moons, P., & Norekvål, T. M. (2019). A systematic review of quality of life research in medicine and health sciences. Quality of Life Research, 28(10), 2641–2650. https://doi.org/10.1007/s11136-019-02214-9