Self-reported teamwork in family health team practices in Ontario: organizational and cultural predictors of team climate

Objective

To determine the organizational predictors of higher scores on team climate measures as an indicator of the functioning of a family health team (FHT).

Design

Cross-sectional study using a mailed survey.

Setting

Family health teams in Ontario.

Participants

Twenty-one of 144 consecutively approached FHTs; 628 team members were surveyed.

Main outcome measures

Scores on the team climate inventory, which assessed organizational culture type (group, developmental, rational, or hierarchical); leadership perceptions; and organizational factors, such as use of electronic medical records (EMRs), team composition, governance of the FHT, location, meetings, and time since FHT initiation. All analyses were adjusted for clustering of respondents within the FHT using a mixed random-intercepts model.

Results

The response rate was 65.8% (413 of 628); 2 were excluded from analysis, for a total of 411 participants. At the time of survey completion, there was a median of 4 physicians, 11 other health professionals, and 4 management and clerical staff per FHT. The average team climate score was 3.8 out of a possible 5. In multivariable regression analysis, leadership score, group and developmental culture types, and use of more EMR capabilities were associated with higher team climate scores. Other organizational factors, such as number of sites and size of group, were not associated with the team climate score.

Conclusion

Culture, leadership, and EMR functionality, rather than organizational composition of the teams (eg, number of professionals on staff, practice size), were the most important factors in predicting climate in primary care teams.     

Dealing with the Archetypes Development Process for a Regional EHR System

Objectives

This paper aims to present the archetype modelling process used for the Health Department of Minas Gerais State, Brazil (SES/MG), to support building its regional EHR system, and the lessons learned during this process.

Methods

This study was undertaken within the Minas Gerais project. The EHR system architecture was built assuming the reference model from the ISO 13606 norm. The whole archetype development process took about ten months, coordinated by a clinical team co-ordinated by three health professionals and one systems analyst from the SES/MG. They were supported by around 30 health professionals from the internal SES/MG areas, and 5 systems analysts from the PRODEMGE. Based on a bottom-up approach, the project team used technical interviews and brainstorming sessions to conduct the modelling process.

Results

The main steps of the archetype modelling process were identified and described, and 20 archetypes were created.Lessons learned:

• – The set of principles established during the selection of PCS elements helped the clinical team to keep the focus in their objectives;
• – The initial focus on the archetype structural organization aspects was important;
• – The data elements identified were subjected to a rigorous analysis aimed at determining the most suitable clinical domain;
• – Levelling the concepts to accommodate them within the hierarchical levels in the reference model was definitely no easy task, and the use of a mind mapping tool facilitated the modelling process;
• – Part of the difficulty experienced by the clinical team was related to a view focused on the original forms previously used;
• – The use of worksheets facilitated the modelling process by health professionals;
• – It was important to have a health professional that knew about the domain tables and health classifications from the Brazilian Federal Government as member in the clinical team.

Conclusion

The archetypes (referencing terminology, domain tables and term lists) provided a favorable condition for the use of a controlled vocabulary between the central repository and the EMR systems and, probably, will increase the chances of preserving the semantics from the knowledge domain. Finally, the reference model from the ISO 13606 norm, along with the archetypes, proved sufficient to meet the specificities for the creation of an EHR system for basic healthcare in a Brazilian state.     

Inter-hospital transport of critically ill patients; expect surprises

Introduction

Inter-hospital transport of critically ill patients is increasing. When performed by specialized retrieval teams there are less adverse events compared to transport by ambulance. These transports are performed with technical equipment also used in an Intensive Care Unit (ICU). As a consequence technical problems may arise and have to be dealt with on the road. In this study, all technical problems encountered while transporting patients with our mobile intensive care unit service (MICU) were evaluated.

Methods

From March 2009 until August 2011 all transports were reviewed for technical problems. The cause, solution and, where relevant, its influence on protocol were stated.

Results

In this period of 30 months, 353 patients were transported. In total 55 technical problems were encountered. We provide examples of how they influenced transport and how they may be resolved.

Conclusion

The use of technical equipment is part of intensive care medicine. Wherever this kind of equipment is used, technical problems will occur. During inter-hospital transports, without extra personnel or technical assistance, the transport team is dependent on its own ability to resolve these problems. Therefore, we emphasize the importance of having some technical understanding of the equipment used and the importance of training to anticipate, prevent and resolve technical problems. Being an outstanding intensivist on the ICU does not necessarily mean being qualified for transporting the critically ill as well. Although these are lessons derived from inter-hospital transport, they may also apply to intra-hospital transport.     

Physicians’ perceptions of capacity building for managing chronic disease in seniors using integrated interprofessional care models

Objective

To explore the barriers to and facilitators of adapting and expanding a primary care memory clinic model to integrate care of additional complex chronic geriatric conditions (heart failure, falls, chronic obstructive pulmonary disease, and frailty) into care processes with the goal of improving outcomes for seniors.

Design

Mixed-methods study using quantitative (questionnaires) and qualitative (interviews) methods.

Setting

Ontario.

Participants

Family physicians currently working in primary care memory clinic teams and supporting geriatric specialists.

Methods

Family physicians currently working in memory clinic teams (n = 29) and supporting geriatric specialists (n = 9) were recruited as survey participants. Interviews were conducted with memory clinic lead physicians (n = 16). Statistical analysis was done to assess differences between family physician ratings and geriatric specialist ratings related to the capacity for managing complex chronic geriatric conditions, the role of interprofessional collaboration within primary care, and funding and staffing to support geriatric care. Results from both study methods were compared to identify common findings.

Main findings

Results indicate overall support for expanding the memory clinic model to integrate care for other complex conditions. However, the current primary care structure is challenged to support optimal management of patients with multiple comorbidities, particularly as related to limited funding and staffing resources. Structured training, interprofessional teams, and an active role of geriatric specialists within primary care were identified as important facilitators.

Conclusion

The memory clinic model, as applied to other complex chronic geriatric conditions, has the potential to build capacity for high-quality primary care, improve health outcomes, promote efficient use of health care resources, and reduce health care costs.     

Data discipline in electronic medical records: Improving smoking status documentation with a standardized intake tool and process

Objective

To evaluate the transformation in smoking status documentation after implementing a standardized intake tool as part of a primary care smoking cessation program.

Design

A before-and-after evaluation of smoking status documentation was conducted following implementation of a smoking assessment tool. To evaluate the effect of the intervention, the Canadian Primary Care Sentinel Surveillance Network was used to extract aggregate smoking data on the study cohort.

Setting

Academic primary care clinic in Kingston, Ont.

Participants

A total of 7312 primary care patients.

Interventions

As the first phase in a primary care smoking cessation program, a standardized intake tool was developed as part of a vital signs screening process.

Main outcome measures

Documented smoking status of patients before implementation of the intake tool and documented smoking status of patients in the 6 months after its implementation.

Results

Following the implementation of the standardized intake tool, there was a 55% (P < .001; 95% CI 0.53 to 0.56) increase in the proportion of patients with a completed smoking status; more than 1100 former smokers were identified and the documented smoking rate in this cohort increased from 4.4% to 16.2%.

Conclusion

This study shows that the implementation of an intake tool, integrated into existing clinical operational structures, is an effective way to standardize clinical documentation and promotes the optimization of electronic medical records.     

Mayhem on the ice: Do players’ injuries put team staff at risk of injury?

OBJECTIVE

To investigate the potential for serious injury and the nature of injuries incurred as team staff or support personnel cross ice surfaces to get to players’ benches or to attend to injured players.

DESIGN

Hybrid study, case series with survey.

MAIN OUTCOME MEASURES

Circumstances and nature of reported injuries.

RESULTS

Over 4 seasons, 988 injuries to team staff or support personnel were reported, including 94 concussions, 5 injuries to internal organs, 226 fractures, and 86 separations or dislocations. Most of the injuries were incurred by team staff or support personnel responsible for the welfare of players (managers, trainers, therapists, and emergency medical staff).

CONCLUSION

Team staff and support personnel incur serious injuries as a result of falls on the ice. Several preventive strategies can be put in place: changes in rink design, policies restricting access to the ice surface, and encouraging team staff and support personnel who must cross the ice surface to attend to injured players to wear gait-stabilizing devices.     

Women’s views on reminder letters for screening mammography: Mixed methods study of women from 23 family health networks

OBJECTIVE

To explore women’s perspectives on the acceptability and content of reminder letters for screening mammography from their family physicians, as well as such letters’ effect on screening intentions.

DESIGN

Cross-sectional mailed survey followed by focus groups with a subgroup of respondents.

SETTING

Ontario.

PARTICIPANTS

One family physician was randomly selected from each of 23 family health networks and primary care networks participating in a demonstration project to increase the delivery of preventive services. From the practice roster of each physician, up to 35 randomly selected women aged 50 to 69 years who were due or overdue for screening mammograms and who had received reminder letters from their family physicians within the past 6 months were surveyed.

MAIN OUTCOME MEASURES

Recall of having received reminder letters and of their content, influence of the letters on decisions to have mammograms, and interest in receiving future reminder letters. Focus group interviews with survey respondents explored the survey findings in greater depth using a standardized interview guide.

RESULTS

The response rate to the survey was 55.7% (384 of 689), and 45.1% (173 of 384) of responding women reported having mammograms in the past 6 months. Among women who recalled receiving letters and either making appointments for or having mammograms, 74.8% (122 of 163) indicated that the letters substantially influenced their decisions. Most respondents (77.1% [296 of 384]) indicated that they would like to continue to receive reminders, and 28.9% (111 of 384) indicated that they would like to receive additional information about mammograms. Participants in 2 focus groups (n = 3 and n = 5) indicated that they thought letters reflected a positive attitude of physicians toward mammography screening. They also commented that newly eligible women had different information needs than women who had had mammograms done in the past.

CONCLUSION

Reminder letters were considered by participants to be useful and appeared to influence women’s decisions to undergo mammography screening.     

Improving Bridging from Informatics Theory to Practice

Background

In 1962, Methods of Information in Medicine (MIM) began to publish papers on the methodology and scientific fundamentals of managing data, information, and knowledge in biomedicine and health care. Meeting an increasing demand for research about practical implementation of health information systems, the journal Applied Clinical Informatics (ACI) was launched in 2009. Both journals are official journals of the International Medical Informatics Association (IMIA).

Objectives

Based on prior analyses, we aimed to describe major topics published in MIM during 2014 and to explore whether theory of MIM influenced practice of ACI. Our objectives were further to describe lessons learned and to discuss possible editorial policies to improve bridging from theory to practice.

Methods

We conducted a retrospective, observational study reviewing MIM articles published during 2014 (N=61) and analyzing reference lists of ACI articles from 2014 (N=70). Lessons learned and opinions about MIM editorial policies were developed in consensus by the two authors. These have been influenced by discussions with the journal’s associate editors and editorial board members.

Results

The publication topics of MIM in 2014 were broad, covering biomedical and health informatics, medical biometry and epidemiology. Important topics discussed were biosignal interpretation, boosting methodologies, citation analysis, health-enabling and ambient assistive technologies, health record banking, safety, and standards. Nine ACI practice articles from 2014 cited eighteen MIM theory papers from any year. These nine ACI articles covered mainly the areas of clinical documentation and medication-related decision support. The methodological basis they cited from was almost exclusively related to evaluation. We could show some direct links where theory impacted practice. These links are however few in relation to the total amount of papers published.

Conclusions

Editorial policies such as publishing systematic methodological reviews and clarification of possible practical impact of theory-focused articles may improve bridging.     

A Framework for (Tele-) Monitoring of the Rehabilitation Progress in Stroke Patients: eHealth 2015 Special Issue

Background

Preservation of mobility in conjunction with an independent life style is one of the major goals of rehabilitation after stroke.

Objectives

The Rehab@Home framework shall support the continuation of rehabilitation at home.

Methods

The framework consists of instrumented insoles, connected wirelessly to a 3G ready tablet PC, a server, and a web-interface for medical experts. The rehabilitation progress is estimated via automated analysis of movement data from standardized assessment tests which are designed according to the needs of stroke patients and executed via the tablet PC application.

Results

The Rehab@Home framework’s implementation is finished and ready for the field trial (at five patients’ homes). Initial testing of the automated evaluation of the standardized mobility tests shows reproducible results.

Conclusions

Therefore it is assumed that the Rehab@Home framework is applicable as monitoring tool for the gait rehabilitation progress in stroke patients.     

THE PREPARTICIPATION EVALUATION FOR ATHLETES WITH DISABILITY

Background:

Athletes are routinely assessed medically prior to competition. Although standardized preparticipation examinations (PPEs) are available for able‐bodied athletes, the literature lacks any validated equivalent for the athlete with disability (AWD). Since participation and level of competition is increasing in this population, evidence‐based tools such as a standardized PPE form should be available for health professionals to assess AWD health and safety.

Aim of the study:

To develop an AWD‐targeted standardized preparticipation history evaluation (PPE history) using consensus‐based expert recommendations.

Methods:

Researchers developed a PPE history for critical evaluation of its content validity. Structured Delphi method for collecting and interpreting contributions from an expert panel using a series of questionnaires with controlled feedback was performed. Opinions based on the experience of related experts ‐ physiotherapists, sports medicine physicians and physiatrists ‐ were studied during each of the three survey rounds. The process was terminated once adequate consensus relating to the proposed PPE history document was reached.

Results:

Majority consensus was reached for forty‐nine of fifty‐four items to create a refined ten section AWD‐specific document to supplement the current standardized PPE. Modifications were made by researchers to accommodate the five items that did not reach statistical consensus.

Conclusion:

Consensus was reached on a variety of AWD‐specific PPE items, including the disability‐related history and functional review. Equipment issues represent a complex area of evaluation, worthy of future research and discussion. The current proposed PPE history tool is considered comprehensive and ready for application in a clinical setting as an adjunct to existing PPE tools. Injury research in the AWD population will provide guidance for refinement and further validation of this PPE history document.

Level of evidence:

5     

Integrating Physician Services in the Home: evaluation of an innovative program

OBJECTIVE

To evaluate a new program, Integrating Physician Services in the Home (IPSITH), to integrate family practice and home care for acutely ill patients.

DESIGN

Causal model, mixed-method, multi-measures design including comparison of IPSITH and non-IPSITH patients. Data were collected through chart reviews and through surveys of IPSITH and non-IPSITH patients, caregivers, family physicians, and community nurses.

SETTING

London, Ont, and surrounding communities, where home care is coordinated through the Community Care Access Centre.

PARTICIPANTS

A total of 82 patients receiving the new IPSITH program of care (including 29 family physicians and 1 nurse practitioner), 82 non-randomized matched patients receiving usual care (and their physicians), community nurses, and caregivers.

MAIN OUTCOME MEASURES

Emergency department (ED) visits and satisfaction with care. Analysis included a process evaluation of the IPSITH program and an outcomes evaluation comparing IPSITH and non-IPSITH patients.

RESULTS

Patients and family physicians were very satisfied with the addition of a nurse practitioner to the IPSITH team. Controlling for symptom severity, a significantly smaller proportion of IPSITH patients had ED visits (3.7% versus 20.7%; P = .002), and IPSITH patients and their caregivers, family physicians, and community nurses had significantly higher levels of satisfaction (P < .05). There was no difference in caregiver burden between groups.

CONCLUSION

Family physicians can be integrated into acute home care when appropriately supported by a team including a nurse practitioner. This integrated team was associated with better patient and system outcomes. The gains for the health system are reduced strain on hospital EDs and more satisfied patients.     

Patient satisfaction with access and continuity of care in a multidisciplinary academic family medicine clinic

Objective

To determine patient satisfaction with care provided at a family medicine teaching clinic.

Design

Mailed survey.

Setting

Victoria Family Medical Centre in London, Ont.

Participants

Stratified random sample of 600 regular patients of the clinic aged 18 years or older; 301 responses were received.

Main outcome measures

Patient satisfaction with overall care, wait times for appointments, contact with physicians, and associated demographic factors. Logistic regression analysis and analysis were used to determine the significance of factors associated with satisfaction.

Results

The response rate was 50%. Overall, 88% of respondents were fairly, very, or completely satisfied with care. Older patients tended to be more satisfied. Patients who were less satisfied had longer wait times for appointments (P < .001) and reduced continuity with specific doctors (P = .004). More satisfied patients also felt connected through other members of the health care team.

Conclusion

Patients were generally satisfied with the care provided at the family medicine teaching clinic. Older patients tended to be more satisfied than younger patients. Points of dissatisfaction were related to wait times for appointments and continuity with patients’ usual doctors. These findings support the adoption of practices that reduce wait times and facilitate continuity with patients’ usual doctors and other regular members of the health care team.     

ColonCancerCheck Primary Care Invitation Pilot project: Family physician perceptions

Objective

To determine family physician perspectives regarding the acceptability and effectiveness of 2 interventions—a targeted, mailed invitation for screening to patients, and family physician audit-feedback reports—and on the colorectal cancer (CRC) screening program generally. This information will be used to guide program strategies for increasing screening uptake.

Design

Qualitative study.

Setting

Ontario.

Participants

Family physicians (n = 65).

Methods

Seven 1-hour focus groups were conducted with family physicians using teleconferencing and Web-based technologies. Responses were elicited regarding family physicians’ perspectives on the mailing of invitations to patients, the content and design of the audit-feedback reports, the effect of participation in the pilot project on daily practice, and overall CRC screening program function.

Main findings

Key themes included strong support for both interventions and for the CRC screening program generally. Moderate support was found for direct mailing of fecal occult blood testing (FOBT) kits. Participants identified potential pitfalls if interventions were implemented outside of patient enrolment model practices. Participants expressed relatively strong support for colonoscopy as a CRC screening test but relatively weak support for FOBT.

Conclusion

Although the proposed interventions to increase the uptake of CRC screening were highly endorsed, concerns about their applicability to non–patient enrolment model practices and the current lack of physician support for FOBT will need to be addressed to optimize intervention and program effectiveness. Our study is highly relevant to other public health programs planning organized CRC screening programs.     

Factors associated with delays to medical assessment and diagnosis for patients with colorectal cancer

Objective

To identify factors associated with delays to medical assessment and diagnosis for patients with colorectal cancer (CRC).

Design

Data were collected through a standardized questionnaire. Clinical records were also reviewed. When necessary, patients were contacted by a member of the study team to collect missing data and confirm information.

Setting

Cross Cancer Institute in Edmonton, Alta.

Participants

Patients newly diagnosed with a histologically proven colorectal adenocarcinoma were identified and eligible for the study.

Main outcome measures

Associations between symptoms, tumour stage at operation, symptom duration, and tumour location were sought to identify factors associated with a delay in diagnosis of CRC.

Results

Surveys were completed by 93 patients. A total of 49% of patients had symptoms of CRC present for 1 month or less before seeing a physician, and 51% had symptoms for longer than 1 month. Seventy-five (86%) patients initially presented to family physicians for assessment, while 12 (14%) patients presented to the emergency department for their first physician encounters. Only 33 (38%) patients had digital rectal examinations during their first visits. Women were more likely to present to physicians with longer than 1 month of symptoms, while men were more likely to present with less than 1 month of symptoms (P = .03). Abdominal pain, blood in the stool, and change in stool size were the most frequent symptoms encountered. Twenty-two (26%) patients delayed seeking treatment because they thought their symptoms were not serious and 12 (14%) believed that their family physicians had taken inappropriate action. Fifteen (18%) patients attributed their delays to waiting too long for specialist referral and diagnostic tests.

Conclusion

This study highlights the important role patients and physicians both play in delays in the diagnosis of CRC. Efforts to diminish future delays must focus on educating the public and practising physicians about important symptoms and signs of CRC. Additionally, the value of a digital rectal examination must be emphasized, along with continued promotion of CRC screening.