Examining “success” in post-hip fracture care transitions: A strengths-based approach

Transitions between health care settings are a high-risk period for care quality and patient safety (; ), particularly for older patients – such as those with hip fracture – who have complex needs and may undergo multiple care transitions. We sought to understand the key elements of “success” in care transition. Using a strengths-based perspective (; ), we focused on interprofessional health care providers' perspectives of what constitutes a “good” care transition for elderly hip fracture patients. As part of a larger ethnographic field study, semi-structured interviews were conducted with 17 health providers across a number of disciplines employed across the continuum of post-hip fracture management in British Columbia, Canada. We found two hallmarks of “success” in care transitions: a focus on process – information gathering and communication, and a focus on outcomes – autonomy and care pathways. Strategies for promoting and improving success, such as using practitioner-driven ground-up solutions to address challenges in care transitions, are highlighted.     

Examining "success" in post-hip fracture care transitions: a strengths-based approach

Transitions between health care settings are a high-risk period for care quality and patient safety (Coleman, 2003; Picker Institute, 1999), particularly for older patients - such as those with hip fracture - who have complex needs and may undergo multiple care transitions. We sought to understand the key elements of "success" in care transition. Using a strengths-based perspective (Rapp, 1998; Saleebey, 2006), we focused on interprofessional health care providers' perspectives of what constitutes a "good" care transition for elderly hip fracture patients. As part of a larger ethnographic field study, semi-structured interviews were conducted with 17 health providers across a number of disciplines employed across the continuum of post-hip fracture management in British Columbia, Canada. We found two hallmarks of "success" in care transitions: a focus on process - information gathering and communication, and a focus on outcomes - autonomy and care pathways. Strategies for promoting and improving success, such as using practitioner-driven ground-up solutions to address challenges in care transitions, are highlighted.     

Measuring patient assessments of the quality of outpatient care: a systematic review

Rationale, aims and objectives The aim of the study was to answer three questions: first, what methods have been used to measure patient assessments of the quality of care? Second, how do outpatients rate their care? And third, what needs to be taken into account in measuring patient assessments of the quality of care? Methods Systematic review of the literature. Electronic searches were conducted on Medline, CINAHL and the Cochrane Database of Systematic Reviews. To be included, articles were to deal with patients’ assessments of health care in ambulatory units for somatic adult patients. They were to have been published between January 2000 and May 2005, written in English, Swedish or Finnish with an English abstract, and the research was to have been conducted in Europe. The search terms used were: ambulatory care, ambulatory care facilities, outpatient, outpatients, patient satisfaction and quality of health care. The articles were screened by two independent reviewers in three phases. Results Thirty‐five articles were included. The quality of care was measured using both quantitative and qualitative methods. Only a few studies relied on the single criterion of patient satisfaction for quality measurements. It is easy to identify common sources of dissatisfaction in different studies. Sources of satisfaction are more closely dependent on the target population, the context and research design. Conclusion Patient satisfaction is widely used as one indicator among others in assessing the quality of outpatient care. However, there is no single, universally accepted method for measuring this.     

Clinical and economic outcomes of nurse-led services in the ambulatory care setting: A systematic review

BackgroundWith the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led services have been suggested as one solution to manage increasing demand on the health system as they aim to reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction.ObjectivesThe aims of this review were to assess the clinical effectiveness, economic outcomes and key implementation characteristics of nurse-led services in the ambulatory care setting.DesignA systematic review was conducted using the standard Cochrane Collaboration methodology and was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.Data sourcesWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE EBSCO, CINAHL EBSCO, and PsycINFO Ovid (from inception to April 2016).Review methodsData were extracted and appraisal undertaken. We included randomised controlled trials; quasi-randomised controlled trials; controlled and non-controlled before-and-after studies that compared the effects of nurse-led services in the ambulatory or community care setting with an alternative model of care or standard care.ResultsTwenty-five studies of 180,308 participants were included in this review. Of the 16 studies that measured and reported on health-related quality of life outcomes, the majority of studies (n = 13) reported equivocal outcomes; with three studies demonstrating superior outcomes and one demonstrating inferior outcomes in comparison with physician-led and standard care. Nurse-led care demonstrated either equivalent or better outcomes for a number of outcomes including symptom burden, self-management and behavioural outcomes, disease-specific indicators, satisfaction and perception of quality of life, and health service use. Benefits of nurse-led services remain inconclusive in terms of economic outcomes.ConclusionsNurse-led care is a safe and feasible model of care for consideration across a number of ambulatory care settings. With appropriate training and support provided, nurse-led care is able to produce at least equivocal outcomes or at times better outcomes in terms of health-related quality of life compared to physician-led care or standard care for managing chronic conditions. There is a lack of high quality economic evaluations for nurse-led services, which is essential for guiding the decision making of health policy makers. Key factors such as education and qualification of the nurse; self-management support; resources available for the nurse; prescribing capabilities; and evaluation using appropriate outcome should be carefully considered for future planning of nurse-led services.     

I Can’t Read That! Improving Perioperative Literacy for Ambulatory Surgical Patients

Low literacy and low health literacy are surprisingly rampant problems facing health care providers. Patient educators in all settings should consider the need for improved patient education materials that are easy to read and understand for the majority of patients. In the ambulatory surgery setting, patients often have time to prepare for scheduled outpatient surgery, yet education is provided primarily in the postoperative period. This article highlights the need for incorporating education into all phases of the perioperative process, beginning in the preoperative period. Perioperative educators should address all learning styles that provide education in a simple and cost-effective way to appeal to all patients and help to reduce postoperative complications and increase patient satisfaction in the ambulatory surgery setting.     

Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure

BACKGROUND: Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to expand. Performance measurement is one potential strategy towards improving the quality of transitional care. A valid and reliable self-report measure of the quality of care transitions is needed that is both consistent with the concept of patient-centeredness and useful for the purpose of performance measurement and quality improvement. OBJECTIVE: We sought to develop and test a self-report measure of the quality of care transitions that captures the patient's perspective and has demonstrated utility for quality improvement. SUBJECTS: Patients aged 18 years and older discharged from one of the 3 hospitals of a vertically integrated health system were included. RESEARCH DESIGN: Cross-sectional assessment of factor structure, dimensionality, and construct validity. RESULTS: The Care Transitions Measure (CTM), a 15-item uni-dimensional measure of the quality of preparation for care transitions, was found to have high internal consistency, reliability, and reflect 4 focus group-derived content domains. The measure was shown to discriminate between patients discharged from the hospital who did and did not have a subsequent emergency department visit or rehospitalization for their index condition. CTM scores were significantly different between health care facilities known to vary in level of system integration. CONCLUSIONS: The CTM not only provides meaningful, patient-centered insight into the quality of care transitions, but because of the association between CTM scores and undesirable utilization outcomes, it also provides information that may be useful to clinicians, hospital administrators, quality improvement entities, and third party payers.     

Promoting patient-centred fundamental care in acute healthcare systems

Meeting patients’ fundamental care needs is essential for optimal safety and recovery and positive experiences within any healthcare setting. There is growing international evidence, however, that these fundamentals are often poorly executed in acute care settings, resulting in patient safety threats, poorer and costly care outcomes, and dehumanising experiences for patients and families. Whilst care standards and policy initiatives are attempting to address these issues, their impact has been limited. This discussion paper explores, through a series of propositions, why fundamental care can be overlooked in sophisticated, high technology acute care settings. We argue that the central problem lies in the invisibility and subsequent devaluing of fundamental care. Such care is perceived to involve simple tasks that require little skill to execute and have minimal impact on patient outcomes. The propositions explore the potential origins of this prevailing perception, focusing upon the impact of the biomedical model, the consequences of managerial approaches that drive healthcare cultures, and the devaluing of fundamental care by nurses themselves. These multiple sources of invisibility and devaluing surrounding fundamental care have rendered the concept underdeveloped and misunderstood both conceptually and theoretically. Likewise, there remains minimal role clarification around who should be responsible for and deliver such care, and a dearth of empirical evidence and evidence-based metrics. In explicating these propositions, we argue that key to transforming the delivery of acute healthcare is a substantial shift in the conceptualisation of fundamental care. The propositions present a cogent argument that counters the prevailing perception that fundamental care is basic and does not require systematic investigation. We conclude by calling for the explicit valuing and embedding of fundamental care in healthcare education, research, practice and policy. Without this re-conceptualisation and subsequent action, poor quality, depersonalised fundamental care will prevail.     

Investigating the safety of medication administration in adult critical care settings

Background: Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high‐risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings. Purpose: This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. Search strategies (inclusion and exclusion criteria): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer‐reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant. Conclusion: The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.     

The current state of nursing performance measurement, public reporting, and value-based purchasing

Over the last decade, there has been a substantial investment in holding health care providers accountable for the quality of care provided in hospitals and other settings of care. This investment has been realized through the proliferation of national policies that address performance measurement, public reporting, and value-based purchasing. Although nurses represent the largest segment of the health care workforce and despite their acknowledged role in patient safety and health care outcomes, they have been largely absent from policy setting in these areas. This article provides an analysis of current nursing performance measurement and public reporting initiatives and presents a summary of emerging trends in value-based purchasing, with an emphasis on activities in the United States. The article synthesizes issues of relevance to advancing the current climate for nursing quality and concludes with key issues for future policy setting.     

Heart failure management across the continuum: a communication link

Patients with heart failure often become lost in the ambulatory healthcare maze on hospital discharge. This causes fragmentation of care due to a lack of a communication link with the ambulatory setting. This article discusses a quality improvement project and addresses the use of a communication tool that helps to transition the plan of care for the heart failure patient from acute care to the ambulatory care setting. The key points focus on the continuance of the plan of care that began during hospitalization and is then extended into the ambulatory setting through care management services.     

Quality and safety in home and ambulatory settings

Much of the work in quality and patient safety has been based in hospitals and other acute care settings, yet it has become increasingly apparent that there are errors in delivery of care in other settings, all of which require attention. This article reviews sources of errors in 3 nonacute settings: the home, children's day care, and ambulatory surgery centers. Also described are standards that have been developed to guide practice, as well as specific regulatory agencies that are involved and some of the safeguards that have been instituted in each of the settings to protect against errors.     

Impact of place on people and process: the integration of research on the built environment in the planning and design of critical care areas

What is the role of the built environment in healing? What aspects of the built environment promote healing, staff efficiency, and patient safety? How can we know if these assertions hold true? Can scientific research help us validate these assumptions? These questions are important to explore, especially for our most vulnerable patients-those in critical care settings. This article explores the historical influences on health care design, reveals how the current health care transformation movement has accelerated the incorporation of elements of the built environment into patient safety and quality improvement effort, discusses how healing environments are constructed, and examines how the literature of health care and health care design organizations have incorporated the impact of the built environment on patient, family, and staff outcomes and satisfaction. Finally, a case study of applying "design hypotheses" and a scientific method to the design of an intensive care unit setting is offered. This article will help critical care nurses understand the role the built environment has in creating optimal healing environments.     

“Acute caring” in the emergency department

The aim of this essay was to discuss the ways in which the dynamics of interprofessional communication and collaboration among healthcare providers ultimately affect patient quality of care in the acute setting. Interprofessionalism describes a care model whereby health providers use complementary skills, knowledge and competencies to provide quality care to a group of patients. These interactions are characterized by trust, respect and an understanding of each other's skill and knowledge. At its best, the interprofessional care model has made great strides in the amelioration of patient outcomes, including reduction in negative outcomes, decreased health access needs and increased patient satisfaction. However, challenges with regard to communication and implementation have translated to a steep learning curve for healthcare providers. As such, a new-found emphasis has been placed on interprofessional education for today's healthcare students with the goal of promoting a more efficient and collaborative philosophy for tomorrow's healthcare teams.     

Introducing Interprofessional Education in Nursing Curricula

Promoting positive outcomes is a primary focus of providers when treating patients in all health care settings. Interprofessional education is an integral and necessary practice that must take place to ensure that positive outcomes are achieved and to promote patient safety. The American Association of Colleges of Nursing, the Institute of Medicine, and the National League of Nursing have prioritized interprofessional collaboration as a crucial component of education necessary to improve the quality of health care in the United States. Curricular development in nursing is a principle setting where interprofessional education can be developed.     

Clinical leadership: using observations of care to focus risk management and quality improvement activities in the clinical setting

In an era when patient safety and quality of care are a daily concern for health care professionals, it is important for nurse managers and other clinical leaders to have a repertoire of skills and interventions that can be used to motivate and engage clinical teams in risk assessment and continuous quality improvement at the level of patient care delivery. This paper describes how a cohort of clinical leaders who were undertaking a leadership development program used a relatively simple, patient-focused intervention called the 'observation of care' to help focus the clinical team's attention on areas for improvement within the clinical setting. The main quality and safety themes arising out of the observations that were undertaken by the Clinical Leaders (CLs) were related to the environment, occupational health and safety, communication and team function, clinical practice and patient care. The observations of care also provided the CLs with many opportunities to acknowledge and celebrate exemplary practice as it was observed as a means of enhancing the development of a quality and safety culture within the clinical setting. The 'observation of care' intervention can be used by Clinical Leader's to engage and motivate clinical teams to focus on continuously improving the safety and quality of their own work environment and the care delivered to patients within that environment.     

Ambulatory emergency oncology: A key tenet of future emergency oncology care

Ambulatory emergency oncology

The challenges of emergency oncology alongside its increasing financial burden have led to an interest in developing optimal care models for meeting patients’ needs. Ambulatory care is recognised as a key tenet in ensuring the safety and sustainability of acute care services. Increased access to ambulatory care has successfully reduced ED utilisation and improved clinical outcomes in high‐risk non‐oncological populations. Individualised management of acute cancer presentations is a key challenge for emergency oncology services so that it can mirror routine cancer care. There are an increasing number of acute cancer presentations, such as low‐risk febrile neutropenia and incidental pulmonary embolism, that can be risk assessed for care in an emergency ambulatory setting. Modelling of ambulatory emergency oncology services will be dependent on local service deliveries and pathways, but are key for providing high quality, personalised and sustainable emergency oncology care. These services will also be at the forefront of much needed emergency oncology to define the optimal management of ambulatory‐sensitive presentations.     

An interdisciplinary approach to the rehabilitation of open-heart surgical patients.

Quite often nurses in environments other than the immediate postoperative setting are responsible for the well-being of patients who have had open-heart surgery (OHS). These patients may be admitted to rehabilitation or home healthcare settings as early as 1 week after surgery. They may be deconditioned because of postoperative complications such as a cerebrovascular accident or cardiopulmonary compromise. Rehabilitation nurses in inpatient or home health environments are key members of the interdisciplinary team in terms of establishing standards of care for OHS patients after surgery. Coordinating care within an interdisciplinary team reduces fragmentation of care, improves patient outcomes, and enhances patient, family, staff, and physician satisfaction. This article focuses on empowering rehabilitation nurses as leaders and members of interdisciplinary teams as they establish standards for coordinating the postoperative care of OHS patients.     

Ambulatory care pharmacy services: the incomplete agenda.

OBJECTIVE: To review studies that document the impact of clinical pharmacy services in ambulatory care settings and to propose standards of practice and resource allocation needs in ambulatory care. DATA SOURCES: English-language literature from 1970 through 1991 was reviewed and the representative literature is described. STUDY SELECTION: Studies were selected that examined the impact of clinical pharmacy services on patient outcomes and costs. Studies that evaluated pharmacist consultations by blind peer-review panels were also evaluated. DATA EXTRACTION: Trials were assessed based on their methodologies and ability to assess the value of clinical pharmacy services on patient outcomes. DATA SYNTHESIS: Numerous studies from the past 20 years are described illustrating the impact that ambulatory care pharmacy practitioners have made on patient care. These studies demonstrate that clinical pharmacists in ambulatory care not only serve as consultants on pharmacotherapy issues, but also can improve the quality of care for individual patients. CONCLUSIONS: Based on the studies cited and the needs of ambulatory patients, this article highlights the authors' views on what the standards of practice should be for ambulatory care practitioners and where resources should be allocated as ambulatory programs are expanded.     

Telephone Administered Cognitive-behavioral Therapy for the Treatment of Depression in a Rural Primary Care Clinic

The purpose of this study was to pilot a telephonically delivered cognitive-behavioral therapy to treat moderate to severe depression in patients from rural primary care settings where specialized mental health care is scarce. The goal was to obtain preliminary evidence of safety and efficacy. Depression is treated principally in primary care, however the outcomes are poor. Outcomes for depression in rural primary care settings are worse than in urban settings in part due to lack of access to specialized mental health care. This study examined the potential utility and safety of telephone-administered Cognitive-Behavior Therapy (T-CBT) for the treatment of depression in a rural primary care setting. Eight patients from a rural primary care clinic with significant depression were enrolled in 8 weeks of T-CBT administered by trained psychologists. Patients showed significant improvements in diagnostic status, as well as reductions in depression based the Beck Depression Inventory-II and the Hamilton Rating Scale for Depression, and there were no adverse events or problems with patient safety.