Encounter decision aids to facilitate shared decision-making with women experiencing heavy menstrual bleeding or symptomatic uterine fibroids: A before-after study.

OBJECTIVE: Is the level of shared decision-making (SDM) higher after introduction of a SDM package (including encounter decision aids on treatment options for heavy menstrual bleeding and training for clinicians) than before?. METHODS: This before-after study, performed in OB-GYN practice, compared consultations before and after introduction of a SDM package. The target sample size was 25 patients per group. Women seeking treatment for heavy menstrual bleeding were eligible. After their appointments, patients filled out a three-item patient-reported SDM measure. Treatment discussions were audio-recorded and rated for SDM using Observer OPTION5. Consultation transcripts in the 'after' group were checked for adherence to the steps required for intended use of decision aids. RESULTS: 16 gynaecologists participated. 25 patients participated before introduction of the decision aids and 28 after. The proportion of women reporting optimal SDM was higher after introduction (75 %) than before (50 %;p < 0.001). The mean observer-rated level of SDM was also significantly higher after than before (MD = 12.50,95 % CI 5.53-19.47). CONCLUSION: The level of SDM was higher after the introduction of the package than before. PRACTICE IMPLICATIONS: This study was conducted in a real-life setting in three clinics, both large academic and small rural, offering opportunities for implementation in different type of organizations.

COproduction VALUE creation in healthcare service (CO-VALUE): an international multicentre protocol to describe the application of a model of value creation for use in systems of coproduced healthcare services and to evaluate the initial feasibility, utility and acceptability of associated system-level value creation assessment approaches.

INTRODUCTION: Coproduction introduces a fundamental shift in how healthcare service is conceptualised. The mechanistic idea of healthcare being a 'product' generated by the healthcare system and delivered to patients is replaced by that of a service co-created by the healthcare system and the users of healthcare services. Fjeldstad et al offer an approach for conceptualising value creation in complex service contexts that we believe is applicable to coproduction of healthcare service. We have adapted Fjeldstad's value creation model based on a detailed case study of a renal haemodialysis service in Jonkoping, Sweden, which demonstrates coproduction characteristics and key elements of Fjeldstad's model. METHODS AND ANALYSIS: We propose a five-part coproduction value creation model for healthcare service: (1) value chain, characterised by a standardised set of processes that serve a commonly occurring need; (2) value shop, which offers a customised response for unique cases; (3) a facilitated value network, which involves groups of individuals struggling with similar challenges; (4) interconnection between shop, chain and network elements and (5) leadership. We will seek to articulate and assess the value creation model through the work of a community of practice comprised of a diverse international workgroup with representation from executive, financial and clinical leaders as well as other key stakeholders from multiple health systems. We then will conduct pilot studies of a qualitative self-assessment process in participating health systems, and ultimately develop and test quantitative measures for assessing coproduction value creation. ETHICS AND DISSEMINATION: This study has been approved by the Dartmouth-Hitchcock Health Institutional Review Board (D-HH IRB) as a minimal risk research study. Findings and scholarship will be disseminated broadly through continuous engagement with health system stakeholders, national and international academic presentations and publications and an internet-based electronic platform for publicly accessible study information.

Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics.

BACKGROUND: Pressures are increasing for clinicians to provide high-quality, efficient care, leading to increased concerns about staff burnout. PURPOSE: This study asks whether staff well-being can be achieved in ways that are also beneficial for the patient's experience of care. It explores whether relational coordination can contribute to both staff well-being and patient satisfaction in outpatient surgical clinics where time constraints paired with high needs for information transfer increase both the need for and the challenge of achieving timely and accurate communication. METHODOLOGY/APPROACH: We studied relational coordination among surgeons, nurses, residents, administrators, technicians, and secretaries in 11 outpatient surgical clinics. Data were combined from a staff and a patient survey to conduct a cross-sectional study. Data were analyzed using ordinary least squares and random effects regression models. RESULTS: Relational coordination among all workgroups was significantly associated with staff outcomes, including job satisfaction, work engagement, and burnout. Relational coordination was also significantly associated with patients' satisfaction with staff and their overall visit, though the association between relational coordination and patients' satisfaction with their providers did not reach statistical significance. PRACTICE IMPLICATIONS: Even when patient-staff interactions are relatively brief, as in outpatient settings, high levels of relational coordination among interdependent workgroups contribute to positive outcomes for both staff and patients, and low levels tend to have the opposite effect. Clinical leaders can increase the expectation of positive outcomes for both staff and their patients by implementing interventions to strengthen relational coordination.

Co-Creating Quality in Health Care Through Learning and Dissemination.

For most of the 20th century the predominant focus of medical education across the professional continuum was the dissemination and acquisition of medical knowledge and procedural skills. Today it is now clear that new areas of focus, such as interprofessional teamwork, care coordination, quality improvement, system science, health information technology, patient safety, assessment of clinical practice, and effective use of clinical decision supports are essential to 21st century medical practice. These areas of need helped to spawn an intense interest in competency-based models of professional education at the turn of this century. However, many of today's practicing health professionals were never educated in these newer competencies during their own training. Co-production and co-creation of learning among interprofessional health care professionals across the continuum can help close the gap in acquiring needed competencies for health care today and tomorrow. Co-learning may be a particularly effective strategy to help organizations achieve the triple aim of better population health, better health care, and lower costs. Structured frameworks, such as the Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, provide guidance in the design, planning, and dissemination of interventions designed to improve care through co-production and co-learning strategies.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature.

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.

What matters most? The content and concordance of patients' and providers' information priorities for contraceptive decision making.

OBJECTIVE(S): The objective of this study was to identify women's and health care providers' information priorities for contraceptive decision making and counseling, respectively. STUDY DESIGN: Cross-sectional surveys were administered online to convenience samples of 417 women and 188 contraceptive care providers residing in the United States. Participants were provided with a list of 34 questions related to the features of contraceptive options and rated the importance of each. Participants also ranked the questions in descending order of importance. For both women and providers, we calculated the mean importance rating for each question and the proportion that ranked each question in their three most important questions. RESULTS: The average importance ratings given by women and providers were similar for 18 questions, but dissimilar for the remaining 16 questions. The question rated most important for women was "How does it work to prevent pregnancy?" whereas, for providers, "How often does a patient need to remember to use it?" and "How is it used?" were rated equally. The eight questions most frequently selected in the top three by women and/or providers were related to the safety of the method, mechanism of action, mode of use, side effects, typical- and perfect-use effectiveness, frequency of administration and when it begins to prevent pregnancy. CONCLUSION(S): Although we found considerable concordance between women's and provider's information priorities, the presence of some inconsistencies highlights the importance of patient-centered contraceptive counseling and, in particular, shared contraceptive decision making. IMPLICATIONS: This study provides insights into the information priorities of women for their contraceptive decision making and health care providers for contraceptive counseling. These insights are critical both to inform the development of decision support tools for implementation in contraceptive care and to guide the delivery of patient-centered care.

Collaborative maternity care: three decades of success at Dartmouth-Hitchcock Medical Center.

This article describes the development of our collaborative practice, discusses the barriers and challenges presented by the current health care environment, and identifies factors that would encourage the initiation and strengthening of a successful collaborative model in similar settings. Successful collaborative practice is more than just a practice model, or a set of items that, once checked off, will guarantee success. It is a process that is inextricably linked to the focus and dedication of all our clinicians to provide the best care possible for women.

Incorporating population medicine into primary care residency training.

BACKGROUND AND OBJECTIVES: Expanded competencies in population health and systems-based medicine have been identified as a need for primary care physicians. Incorporating formal training in preventive medicine is one method of accomplishing this objective. METHODS: We identified three family medicine residencies that have developed formal integrated pathways for residents to also complete preventive medicine residency requirements during their training period. Although there are differences, each pathway incorporates a structured approach to dual residency training and includes formal curriculum that expands resident competencies in population health and systems-based medicine. RESULTS: A total of 26 graduates have completed the formally combined family and preventive medicine residencies. All are board certified in family medicine, and 22 are board certified in preventive medicine. Graduates work in a variety of academic, quality improvement, community, and international settings utilizing their clinical skills as well as their population medicine competencies. Dual training has been beneficial in job acquisition and satisfaction. CONCLUSIONS: Incorporation of formal preventive medicine training into family medicine education is a viable way to use a structured format to expand competencies in population medicine for primary care physicians. This type of training, or modifications of it, should be part of the debate in primary care residency redesign.

Using a Malcolm Baldrige framework to understand high-performing clinical microsystems.

UNLABELLED: BACKGROUND, OBJECTIVES AND METHOD: The Malcolm Baldrige National Quality Award (MBNQA) provides a set of criteria for organisational quality assessment and improvement that has been used by thousands of business, healthcare and educational organisations for more than a decade. The criteria can be used as a tool for self-evaluation, and are widely recognised as a robust framework for design and evaluation of healthcare systems. The clinical microsystem, as an organisational construct, is a systems approach for providing clinical care based on theories from organisational development, leadership and improvement. This study compared the MBNQA criteria for healthcare and the success factors of high-performing clinical microsystems to (1) determine whether microsystem success characteristics cover the same range of issues addressed by the Baldrige criteria and (2) examine whether this comparison might better inform our understanding of either framework. RESULTS AND CONCLUSIONS: Both Baldrige criteria and microsystem success characteristics cover a wide range of areas crucial to high performance. Those particularly called out by this analysis are organisational leadership, work systems and service processes from a Baldrige standpoint, and leadership, performance results, process improvement, and information and information technology from the microsystem success characteristics view. Although in many cases the relationship between Baldrige criteria and microsystem success characteristics are obvious, in others the analysis points to ways in which the Baldrige criteria might be better understood and worked with by a microsystem through the design of work systems and a deep understanding of processes. Several tools are available for those who wish to engage in self-assessment based on MBNQA criteria and microsystem characteristics.

Publicly reporting comprehensive quality and cost data: a health care system's transparency initiative.

BACKGROUND: Transparency in health care, including the public reporting of health care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measures, and (3) use public reporting to foster process of care and outcome improvement initiatives. An overview is provided of the first 22 months of a transparency initiative at Dartmouth-Hitchcock Medical Center (DHMC). LAUNCHING THE TRANSPARENCY INITIATIVE: An interdisciplinary operations group works with the various clinical programs--both providers and patients--to identify what quality and cost measures are most desired by patients and what measures are the focus of the clinical program's internal measurement and reporting processes. The measures are presented on the DHMC Web site, with access to additional resources, such as clinical decision aids. DISCUSSION: A variety of factors are important to the transparency initiative--senior leaders' perceptions, risk management issues, resources required for the design and maintenance of the initiative, and developing both methodological protocols and technical systems.

Potentially avoidable maternity complications: an indicator of access to prenatal and primary care during pregnancy.

OBJECTIVE: We identified Potentially Avoidable Maternity Complications (PAMCs). Used with hospital discharge data, PAMCs may indicate lack of prenatal care access. METHODS: A research team of two obstetrician/gynecologists and three health services researchers developed the PAMC indicator, which was verified by external review. AIM 1 used the National Maternal and Infant Health Survey, with prenatal care information and 8,661 pregnancy hospitalizations, to examine associations between prenatal care, risk factors, and PAMCs. AIM 2 used the 1997 Nationwide Inpatient Sample (NIS), with 895,259 pregnancy-related hospitalizations, to examine PAMC risks for groups likely to have prenatal care access problems. RESULTS: In AIM 1, adequate prenatal care reduced PAMC risks by 57% (p < .01). Compared to nonsmokers, the odds of a PAMC for smokers were 86% higher (p < .01). Cocaine use increased PAMC risk notably (odds ratio 3.35, p < .0001). In the multivariate analyses of AIM 2, African Americans, the uninsured, and Medicaid beneficiaries had high PAMC risks (all p < .0001). CONCLUSIONS: Findings suggest adequate prenatal care may reduce PAMC risks. Results for groups with less prenatal care access were consistent with previous research using less refined indicators, such as low birth weight. PAMCs improve on earlier measures, and readily permit adjustments for mothers' ages and comorbidities.