Contextual factors and mechanisms in the implementation of Value Stream Mapping in breast cancer centres - A multiple case study.

INTRODUCTION: Lean, especially Value Stream Mapping is increasingly used in hospitals to optimize processes. This method, which originated in the automotive industry, enables all staff involved in the process to make it more customer-friendly. Despite the widely reported success of Lean projects, they have failed in some cases. This study investigated the contextual factors and mechanisms that contribute to a successful implementation of Value Stream Mapping. METHODS: Value Stream Mapping was applied to the discharge process in four breast cancer centers. A mixed-method approach was used in two steps. First, to verify the successful implementation, defined as time optimization, time measurement was conducted at three points in time and analyzed using an ANOVA. Second, an analysis of contextual factors was combined with a qualitative content analysis of mechanisms based on normalization process theory, using routine data, meeting protocols, field notes, and interview transcripts as data source. RESULTS: At one of the four breast cancer centers, lead- and waiting time were significantly reduced; at the others, these reductions did not occur. Failure/success cannot be explained by the size of the hospital, the number of cases or staffing levels. The variable project team composition is evident, especially leadership involvement. DISCUSSION: A comparative analysis was conducted to identify the factors that led to success. These factors were: participation of all leaders relevant to the process, in the case of the discharge process including medical and nursing leaders; dissemination of the changes from the project team to colleagues including its sense and possibility to discuss it; joint reflection of the implementation process in regular work team meetings. CONCLUSIONS: These results confirm the important role of leadership in implementation projects. Leadership support enabled the mechanisms found. The used combination of theoretical approaches from management research and implementation science determined the interpretation and should be applied more often in implementation science.

[Hospital-based Home Care for Children with Cancer from the Parents̓ Point of View - A Qualitative Exploration of Family Members]. / Die ambulant-aufsuchende Versorgung von an Krebs erkrankten Kindern aus Sicht der Erziehungsberechtigten.

BACKGROUND: About 2,200 children and adolescents in Germany per year are diagnosed with oncological diseases. Through now, there are almost no offers for home care services for these patients. There is a pilot program offering hospital-based home care for children and adolescents with cancer in Germany. The perspective of the parents will be researched by a qualitative exploring study. PATIENTS: In this interview study parents from children with cancer will be interviewed. METHOD: A qualitative exploring interview study, seeking the subjective perspective from parents on the hospital-based home care for children with cancer. The sample was drawn criterion-guided. The interviews were transcribed verbatim and analysed using qualitative content analysis. For socio- demographic characteristics the participants respond to an online questionnaire. RESULTS: Eleven women and three men aged between 30 and 60 years participated in the interviews. The average age of the ill children was 8.43 years. Five parents state that the children's illness did not lead to a reduction in working hours or to the termination of the employment relationship. Hospital-based home care results in subjectively perceived relief in everyday family life, especially in terms of time. Furthermore, a reduction in the psychological perception of stress is described. DISCUSSION/CONCLUSION: Due to the study design, the results presented here are to be regarded as indicative. In future studies the presented results should be supplemented by quantitative representative studies.

The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis.

BACKGROUND: Electronic medical records (EMR) are considered a key component of the health care system's digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety, and is required for big data analytics. To ensure those possibilities, the included documentation must be of high quality. In this matter, the most frequently described dimension of data quality is the completeness of documentation. In this regard, little is known about how and why the completeness of documentation might change after the implementation of an EMR. OBJECTIVE: This study aims to compare the completeness of documentation in paper-based medical records and EMRs and to discuss the possible impact of an EMR on the completeness of documentation. METHODS: A retrospective document analysis was conducted, comparing the completeness of paper-based medical records and EMRs. Data were collected before and after the implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients for a 3-week period each. Unpaired, 2-tailed t tests, chi-square tests, and relative risks were calculated to analyze and compare the mean completeness of the 2 record types in general and of 10 specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, and weight). For this purpose, each of the 10 items received a dichotomous score of 1 if it was documented on the first day of patient care on the ward; otherwise, it was scored as 0. RESULTS: The analysis consisted of 180 medical records. The average completeness was 6.25 (SD 2.15) out of 10 in the paper-based medical record, significantly rising to an average of 7.13 (SD 2.01) in the EMR (t178=-2.469; P=.01; d=-0.428). When looking at the significant changes of the 10 items in detail, the documentation of diet (P<.001), height (P<.001), and weight (P<.001) was more complete in the EMR, while the documentation of diagnosis (P<.001), excretions (P=.02), and pain (P=.008) was less complete in the EMR. The completeness remained unchanged for the documentation of pulse (P=.28), blood pressure (P=.47), body temperature (P=.497), and reanimation status (P=.73). CONCLUSIONS: Implementing EMRs can influence the completeness of documentation, with a possible change in both increased and decreased completeness. However, the mechanisms that determine those changes are often neglected. There are mechanisms that might facilitate an improved completeness of documentation and could decrease or increase the staff's burden caused by documentation tasks. Research is needed to take advantage of these mechanisms and use them for mutual profit in the interests of all stakeholders. TRIAL REGISTRATION: German Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343.

Factors facilitating the implementation of a clinical decision support system in primary care practices: a fuzzy set qualitative comparative analysis.

BACKGROUND: Understanding how to implement innovations in primary care practices is key to improve primary health care. Aiming to contribute to this understanding, we investigate the implementation of a clinical decision support system (CDSS) as part of the innovation fund project AdAM (01NVF16006). Originating from complexity theory, the practice change and development model (PCD) proposes several interdependent factors that enable organizational-level change and thus accounts for the complex settings of primary care practices. Leveraging the PCD, we seek to answer the following research questions: Which combinations of internal and external factors based on the PCD contribute to successful implementation in primary care practices? Given these results, how can implementation in the primary care setting be improved? METHODS: We analyzed the joint contributions of internal and external factors on implementation success using qualitative comparative analysis (QCA). QCA is a set-theoretic approach that allows to identify configurations of multiple factors that lead to one outcome (here: successful implementation of a CDSS in primary care practices). Using survey data, we conducted our analysis based on a sample of 224 primary care practices. RESULTS: We identified two configurations of internal and external factors that likewise enable successful implementation. The first configuration enables implementation based on a combination of Strong Inside Motivation, High Capability for Development, and Strong Outside Motivation; the second configuration based on a combination of Strong Inside Motivators, Many Options for Development and the absence of High Capability for Development. CONCLUSION: In line with the PCD, our results demonstrate the importance of the combination of internal and external factors for implementation outcomes. Moreover, the two identified configurations show that different ways exist to achieve successful implementation in primary care practices. TRIAL REGISTRATION: AdAM was registered on ClinicalTrials.gov ( NCT03430336 ) on February 6, 2018.

Speechlessness: a Conceptual Framework.

The phenomenon of speechlessness has hardly been considered in the literature from a psychological point of view. Previous research on speechlessness is limited to the fields of neurology, medicine or psychopathology. The present review aims to consider speechlessness from a psychological perspective distinct from pathology, and to highlight its observability and possible connections to existing research in the context of emotional cognition and processing. Search terms were developed and a comprehensive, systematic literature search was conducted in various databases based on previous scientific work on the understanding of non-speech, silence and speechlessness. Only results that examined the phenomenon of speechlessness from a non-pathological or non-neurological perspective were included. A total of N = 7 publications matching the inclusion criteria were identified. The results were used to develop a procedual model for the phenomenological definition of speechlessness. The developed model differentiates the observable phenomenon of speechlessness into a non-intentional, unconscious form and a intentional, conscious form. The present work suggests that meaningful emotions and their perception and processing is a core element in the emergence of speechlessness and provides a first, psychological, non-pathological explanation of speechlessness.

Complex implementation mechanisms in primary care: do physicians' beliefs about the effectiveness of innovation play a mediating role? Applying a realist inquiry and structural equation modeling approach in a formative evaluation study.

BACKGROUND: The adoption of digital health technologies can improve the quality of care for polypharmacy patients, if the underlying complex implementation mechanisms are better understood. Context effects play a critical role in relation to implementation mechanisms. In primary care research, evidence on the effects of context in the adoption of digital innovation for polypharmacy management is lacking. STUDY AIM: This study aims to identify contextual factors relevant to physician behavior and how they might mediate the adoption process. METHODS: The physicians who participated in this formative evaluation study (n = 218) were part of the intervention group in a cluster-randomized controlled trial (AdAM). The intervention group implemented a digital innovation for clinical decision making in polypharmacy. A three-step methodological approach was used: (1) a realist inquiry approach, which involves the description of a context-mechanism-outcome configuration for the primary care setting; (2) a belief elicitation approach, which involves qualitative content analysis and the development of a quantitative latent contextualized scale; and (3) a mediation analysis using structural equation modeling (SEM) based on quantitative survey data from physicians to assess the mediating role of the contextualized scale (n = 179). RESULTS: The key dimensions of a (1) context-mechanism-outcome model were mapped and refined. A (2) latent construct of the physicians' innovation beliefs related to the effectiveness of polypharmacy management practices was identified. Innovation beliefs play a (3) mediating role between the organizational readiness to implement change (p < 0.01) and the desired behavioral intent of physicians to adopt digital innovation (p < 0.01; R2 = 0.645). Our contextualized model estimated significant mediation, with a relative size of 38% for the mediation effect. Overall, the model demonstrated good fit indices (CFI = 0.985, RMSEA = 0.034). CONCLUSION: Physician adoption is directly affected by the readiness of primary care organizations for the implementation of change. In addition, the mediation analysis revealed that this relationship is indirectly influenced by primary care physicians' beliefs regarding the effectiveness of digital innovation. Both individual physician beliefs and practice organizational capacity could be equally prioritized in developing implementation strategies. The methodological approach used is suitable for the evaluation of complex implementation mechanisms. It has been proven to be an advantageous approach for formative evaluation. TRIAL REGISTRATION: NCT03430336 . First registration: 12/02/2018. CLINICALTRIALS: gov.

[Recommendations for a Core Curriculum for Master's Degree Programs in Health Services Research]. / Empfehlungen für ein Kerncurriculum für Masterstudiengänge der Versorgungsforschung.

The aim of the present study was to develop recommendations for a core curriculum for master's degree programs in health services research. For this purpose, a standardized online survey of university lecturers was conducted in the first step. In the second step, the curricula of the existing study programs were analyzed. In the third step, a literature search was conducted. In the last step, the resulting recommendations were discussed in a panel of experts. The final recommendations comprise 13 topics on five guiding questions with 26 subtopics. The main topics come from the areas of basic sciences in the context of health services research, the health care system and health policy, the (empirical) health services research process, and knowledge transfer. The present recommendations will serve as a basis for discussion and as a starting point. The development of recommendations should be seen as an ongoing process, as the core competencies of health services researchers will have to be continuously adapted to new research topics, new research methods and regulations.

Facilitators and barriers of vaccine uptake in patients with autoimune inflammatory rheumatic disease: a scoping review.

OBJECTIVES: Patients with autoimmune inflammatory rheumatic diseases (AIRD) often have lower vaccination coverage rates compared with the general population, despite being disproportionately affected by infectious complications. We aim to systematically review the literature regarding vaccination willingness and hesitancy in AIRD. METHODS: A scoping review was conducted in PubMed, EMBASE and the Cochrane Library in June 2021. Study selection was performed by two independent reviewers and data were extracted using a standardised form. Risk of bias was assessed using instruments from McMaster University. Identified barriers were categorised into the WHO's measuring behavioural and social drivers (BeSD) of vaccination conceptual model. RESULTS: The search yielded 1644 hits of which 30 publications were included (cross-sectional studies based on interviews (n=27) and intervention studies (n=3)). The majority of studies reported barriers to influenza and pneumococcal vaccination only (n=9) or in combination with another vaccination (n=8) from the patients' perspective. Only one study assessed the view of rheumatologists. Coverage of domains matched to the BeSD model suggests a lack of awareness of infection risk by both patients and physicians. Patients mainly mentioned behavioural and social factors that negatively influenced their willingness to be vaccinated while physicians mentioned organisational deficits as major barriers. CONCLUSIONS: The view on vaccination in patients with AIRD diverges between patients and rheumatologists. Our results show that in-depth counselling on vaccines is important for patients, whereas physicians need support in implementing specific immunisation recommendations. The themes identified provide a starting point for future interventions to improve vaccine rates in patients with AIRD.

Emergency Medical Care of People with Intellectual Disabilities: A Scoping Review.

Purpose: The paper intends to do a scoping review of people with intellectual disabilities in emergency care where this group seems to face access barriers and discrimination. It analyses the conceptual and methodological framework for studies examining the former. Methods: A scoping review is conducted. The studies' quality is assessed via a checklist developed by the authors drawing on a compilation of common assessment tools for study quality. Results: Fourteen quantitative studies fulfil the inclusion criteria for further analysis. Summary measures are extracted. Results are synthesized with Andersen's Behavioral Model of Health Service Use. Studies employ a combination of variables attributable to different aspects of population characteristics and health behavior. Conclusion: Most studies seek to quantify or predict emergency care overuse by people with intellectual disabilities. Future studies should also take patients' poor health or treatment outcomes and their perspectives into account.

How is leadership behavior associated with organization-related variables? Translation and psychometric evaluation of the implementation leadership scale in German primary healthcare.

BACKGROUND: The Implementation Leadership Scale (ILS) was developed to assess leadership behavior with regard to being proactive, knowledgeable, supportive, or perseverant in implementing evidence-based practices (EBPs). As part of a study on the implementation of a digitally supported polypharmacy management application in primary care, the original ILS was translated and validated for use in the German language. RATIONALE: This study aimed to translate the original ILS into German and evaluate its psychometric properties. METHODS: The validation sample consisted of 198 primary care physicians in a cluster-randomized controlled trial in which the intervention group implemented a digitally supported clinical decision support system for polypharmacy management. The ILS was assessed using a 12-item scale. The study included a process evaluation with two evaluation waves between 2019 and 2021. The ILS was used within this process evaluation study to assess the leadership support with regard to the implementation of the polypharmacy management. The ILS was translated in a multi-step process, including pre-testing of the instrument and triple, back-and-forth translation of the instrument. We tested the reliability (Cronbach's alpha) and validity (construct and criterion-related validity) of the scale. RESULTS: The four-dimensional structure of the instrument was confirmed (comparative fit index = .97; root mean square error of approximation = .06). Convergent validity was demonstrated by correlations with organizational innovation climate, social capital, and workload, which was consistent with the proposed hypothesis. Criterion-related validity of the ILS was demonstrated by predicting the organizational readiness for change scores using structural equation modeling. The reliability of the scale was good (α = .875). CONCLUSION: The German version of the ILS created in this study is a reliable and valid measure. The original four-dimensional structure of the ILS was confirmed in a primary care setting. Further psychometric testing is needed to establish the validity and reliability of the ILS and to transfer it to other health care settings. It is a useful tool for identifying the areas for implementation leadership development. Further research is needed on how, why, and when distinct types of leadership behaviors have different effects on healthcare organizations in implementation processes.

The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review.

The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient records (EPR) are a substantial part in this transformation, even though their influence on documentation remains often unclear. This review aims to answer the question of which effect the introduction of the EPR has on the documentation proper in hospitals. To do this, studies are reviewed that analyze the documentation itself, rather than merely conducting interviews or surveys about it. Several databases were searched in this systematic review (PubMed including PubMed, PubMed Central and Medline; PDQ Evidence; Web of Science Core Collection; CINHAL). To be included, studies needed to analyze written documentation and empirical data, be in either German or English language, published between 2010 and 2020, conducted in a hospital setting, focused on transition from paper-based to electronic patient records, and peer reviewed. Quantitative, qualitative and mixed methods studies were included. Studies were independently screened for inclusion by two researchers in three stages (title, abstract, full text) and, in case of disagreement, discussed with a third person from the research team until consensus was reached. The main outcome assessed was whether the studies indicated a negative or positive effect on documentation (e.g. changing the completeness of documentation) by introducing an EPR. Mixed Methods Appraisal Tool was used to assess the individual risk of bias in the included studies. Overall, 264 studies were found. Of these, 17 met the inclusion criteria and were included in this review. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation such as an improved completeness or guideline adherence of the documentation. Six of 17 showed a mixed effect with positive and negative or no changes. No study showed an exclusively negative effect. Most studies found a positive effect of EPR introduction on documentation. However, it is difficult to draw specific conclusions about how the EPR affects or does not affect documentation since the included studies examined a variety of outcomes. As a result, various scenarios are conceivable with higher or reduced burden for practitioners. Additionally, the impact on treatment remains unclear.

Does one size fit all? A qualitative study about the need for individualized information transfer for orthognathic patients.

AIMS: For any orthodontic-orthognathic treatment, it is crucial that patients are provided with enough and proper information in order to make evidence-based decisions- not only prior to treatment start, but also throughout the course of therapy. Thus, the objectives of this qualitative study were to identify information needs of patients undergoing combined orthodontic-orthognathic treatment. Additionally, professionals' perspectives were evaluated. METHODS: A qualitative research approach was chosen in order to determine crucial aspects of information needs before and throughout treatment. With respect to a purposive sampling strategy and thematic saturation, we conducted ten semi-structured interviews with patients who had finished their orthodontic-orthognathic surgery treatments (five women, five men; being 21 to 34 years old). The indications for the combination treatment were severe skeletal Class IIs to Class IIIs with various vertical and transverse discrepancies. In addition, a multidisciplinary focus-group with six professionals from the maxillofacial surgery and orthodontic department (three women, three men; being 30 to 38 years old) helped to reflect about the experts' point of views. After transcription, data was categorized and analyzed by Mayring's content analysis. RESULTS: We identified three key themes. During this analysis, we focused on theme (1) 'information transfer' with its corresponding categories 'information needs' - depending on different treatment stages -, 'source of information' and 'doctor-patient-communication'. The affected patients ranked individualized patient information and empathetic doctor-patient-communication high. This was mostly in line with the professionals' point of view. Verbal communication was seen as being the best way to communicate throughout treatment. The role of the internet as a source of information was seen diversely. CONCLUSION: This qualitative study highlights the need for individualized patient information and reveals both met and unmet information needs by patients. Although evidence-based written information is highly necessary for orthognathic patients and their families alike, it cannot replace an empathetic way of direct verbal doctor-patient-communication. It seems crucial to give specific individualized information at different treatment stages, starting at a thoroughly interdisciplinary screening at the very beginning.

[Educational Programmes in Health Services Research in Germany: Current State and Future Perspectives]. / Studiengänge zur Versorgungsforschung in Deutschland: aktueller Stand und zukünftige Perspektiven.

OBJECTIVE: The aim of this study was to analyse accredited study programmes of health services research in Germany at Master's degree level regarding their structural data and content. METHODS: Using a descriptive qualitative design, all included plans of study courses, module handbooks and descriptions of the Master's degree programmes were analysed. RESULTS: The Master's degree programmes were similar in their structural elements as well as in their content of education. They aim at enhancing competences related to the areas of health services research to identify health care needs and to develop, initiate, evaluate and critically assess innovative care strategies across disciplines. DISCUSSION: Although the content is similar, the study programmes focus on specific aspects that allow students to choose a certain programme depending on their preferences. A next step can be the development of a core curriculum that takes into consideration further findings and the discourse of different stakeholders.

Does positive affect mediate the association of multimorbidity on depressive symptoms?

Objectives Multimorbidity poses various challenges, and previous research has indicated a causal relation with depression. As multimorbidity is not curable, the underlying mechanisms are of great interest. Positive affect is a major resource for coping with chronic conditions and for the prevention of depression. Long-term multimorbidity, however, may deplete positive affect. The purpose of this paper is to investigate the role of positive affect in the association between multimorbidity and depressive symptoms.Method We used four consecutive waves (2008, 2011, 2014, 2017) of the nationally representative German Ageing Survey (DEAS) with a total of 1,558 older adults aged 40 and over. To account for time-varying confounding, exposure-induced mediator-outcome confounding, and reciprocities, we applied the mediational g-formula with inverse-probability weighting techniques. We also tested for exposure-mediator interaction to adjust for differences in mediation across the duration of multimorbidity.Results We confirmed a positive longitudinal relation between multimorbidity and depressive symptoms, both of which were negatively associated with while positive affect. The model without interaction indicated a share mediated of ca. 18.3% on the total effect of multimorbidity on depressive symptoms. Addition of interaction led to substantial differences for multimorbidity duration and levels of positive affect. Associations for long-term multimorbidity (at least two survey waves) were more substantial, and the share mediated doubled (>40%). Additionally, the direct effect of multimorbidity on depressive symptoms diminished for short-term multimorbidity.Conclusion Strengthening positive affect could reduce depressive symptoms in those facing multimorbidity. This study also discusses methodological challenges in performing longitudinal mediation analysis. We advise researchers to consider the mediational g-formula and exposure-mediator interaction.

When do physicians perceive the success of a new care model differently?

BACKGROUND: The health care innovation "MamBo - people with multimorbidity in outpatient care: patient-focused and needs-oriented healthcare management" aims to improve the efficiency and quality of care for multimorbid patients by delegating tasks (e.g. taking over house calls or coordinating specialist appointments) to a monitoring and coordination assistant (MoniKa). Participating physicians are very important for the success of the health care innovation due to their direct involvement as practitioners and their task of enrolling patients. The aim of this part of the evaluation study is therefore to identify the physicians' personal values, which influence the individual perception of the project's advantages and thus possibly the acceptance and sustainable implementation of new care structures. METHODS: Two Focus groups (n = 4; n = 6) and three individual interviews with general practitioners and specialists who decided to implement the health care innovation within the first year were conducted. The semi-structured guidelines were developed by the research team. The interviews were analysed according to the content analysis by Mayring. We used the learning model of operant conditioning to place our study results in a theoretical context. RESULT: Two central personal values of the participants, which determine the desired advantages of the health care innovation were identified: More patient-oriented and more economic-oriented values. Participants with more patient-oriented values quickly perceived advantages, which seems to be beneficial for the acceptance of the new care structures. Economic-oriented participants tended to be more critical. The benefits of the health care innovation, which was expressed, for example, in an improvement of the practice routine, has not yet been perceived by this group, or only to a limited extent. CONCLUSIONS: The results suggest that the respective values of the participants define the individual perceived advantages and thus, the assessment of the success of the health care innovation in general. These findings could be used in the implementation process by increasing the motivation of the project participants through typified supervision. TRIAL REGISTRATION: The study has been registered in the German Clinical Trials Register ( DRKS00014047 ).

Effectiveness of the application of an electronic medication management support system in patients with polypharmacy in general practice: a study protocol of cluster-randomised controlled trial (AdAM).

INTRODUCTION: Clinically complex patients often require multiple medications. Polypharmacy is associated with inappropriate prescriptions, which may lead to negative outcomes. Few effective tools are available to help physicians optimise patient medication. This study assesses whether an electronic medication management support system (eMMa) reduces hospitalisation and mortality and improves prescription quality/safety in patients with polypharmacy. METHODS AND ANALYSIS: Planned design: pragmatic, parallel cluster-randomised controlled trial; general practices as randomisation unit; patients as analysis unit. As practice recruitment was poor, we included additional data to our primary endpoint analysis for practices and quarters from October 2017 to March 2021. Since randomisation was performed in waves, final study design corresponds to a stepped-wedge design with open cohort and step-length of one quarter. SCOPE: general practices, Westphalia-Lippe (Germany), caring for BARMER health fund-covered patients. POPULATION: patients (≥18 years) with polypharmacy (≥5 prescriptions). SAMPLE SIZE: initially, 32 patients from each of 539 practices were required for each study arm (17 200 patients/arm), but only 688 practices were randomised after 2 years of recruitment. Design change ensures that 80% power is nonetheless achieved. INTERVENTION: complex intervention eMMa. FOLLOW-UP: at least five quarters/cluster (practice). recruitment: practices recruited/randomised at different times; after follow-up, control group practices may access eMMa. OUTCOMES: primary endpoint is all-cause mortality and hospitalisation; secondary endpoints are number of potentially inappropriate medications, cause-specific hospitalisation preceded by high-risk prescribing and medication underuse. STATISTICAL ANALYSIS: primary and secondary outcomes are measured quarterly at patient level. A generalised linear mixed-effect model and repeated patient measurements are used to consider patient clusters within practices. Time and intervention group are considered fixed factors; variation between practices and patients is fitted as random effects. Intention-to-treat principle is used to analyse primary and key secondary endpoints. ETHICS AND DISSEMINATION: Trial approved by Ethics Commission of North-Rhine Medical Association. Results will be disseminated through workshops, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION: NCT03430336. ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03430336).

A qualitative study of the adoption of Value Stream Mapping in breast cancer centers.

PURPOSE: In order to design a patient-centered discharge process, the entire process is visualized in Value Stream Mapping. The duration of the process steps and waiting times are measured and presented. As a team, health professionals discuss problems and agree on suitable solutions. METHODS: After applying Value Stream Mapping, we conducted eight interviews in 2018, four with physicians and four with breast care nurses. We used the Consolidated Framework for Implementation Research to develop the interview guide and to identify categories for content analysis. To identify the differences in attitude and experience between the occupational groups, we conducted a framework analysis. RESULTS: Each team of health professionals developed action steps to optimize the discharge process. Obstacles became apparent in the implementation of these action steps. The lack of adequate staff and complex structures were identified as the main factors. These hierarchical structures also prevented a patient-centered discharge process independent of patient-centered care by health professionals. Self-efficacy varied more among breast care nurses than physicians. The group of physicians perceives standardization in the discharge process critically and therefore assumes limitations in transferring Value Stream Mapping to hospitals. The breast care nurses were open in their attitude. Financial incentives contribute to the acceptance of the method. CONCLUSION: Value Stream Mapping is a simple way to uncover waste and develop applicable action steps. Since the implementation of the action steps was hindered by hierarchical problems and a lack of resources, management involvement and a hospital-wide approach could be beneficial.

"I must, and I can live with that": a thematic analysis of patients' perspectives on polypharmacy and a digital decision support system for GPs.

BACKGROUND: To investigate patients' perspectives on polypharmacy and the use of a digital decision support system to assist general practitioners (GPs) in performing medication reviews. METHODS: Qualitative interviews with patients or informal caregivers recruited from participants in a cluster-randomized controlled clinical trial (cRCT). The interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS: We conducted 13 interviews and identified the following seven themes: the patients successfully integrated medication use in their everyday lives, used medication plans, had both good and bad personal experiences with their drugs, regarded their healthcare providers as the main source of medication-related information, discussed medication changes with their GPs, had trusting relationships with them, and viewed the use of digital decision support tools for medication reviews positively. No unwanted adverse effects were reported. CONCLUSIONS: Despite drug-related problems, patients appeared to cope well with their medications. They also trusted their GPs, despite acknowledging polypharmacy to be a complex field for them. The use of a digital support system was appreciated and linked to the hope that reasons for selecting specific medication regimens would become more comprehensible. Further research with a more diverse sampling might add more patient perspectives. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03430336 . Registered on February 6, 2018.

Electronic patient record and its effects on social aspects of interprofessional collaboration and clinical workflows in hospitals (eCoCo): a mixed methods study protocol.

BACKGROUND: The need for and usage of electronic patient records within hospitals has steadily increased over the last decade for economic reasons as well as the proceeding digitalization. While there are numerous benefits from this system, the potential risks of using electronic patient records for hospitals, patients and healthcare professionals must also be discussed. There is a lack in research, particularly regarding effects on healthcare professionals and their daily work in health services. The study eCoCo aims to gain insight into changes in interprofessional collaboration and clinical workflows resulting from introducing electronic patient records. METHODS: eCoCo is a multi-center case study integrating mixed methods from qualitative and quantitative social research. The case studies include three hospitals that undergo the process of introducing electronic patient records. Data are collected before and after the introduction of electronic patient records using participant observation, interviews, focus groups, time measurement, patient and employee questionnaires and a questionnaire to measure the level of digitalization. Furthermore, documents (patient records) as well as structural and administrative data are gathered. To analyze the interprofessional collaboration qualitative network analyses, reconstructive-hermeneutic analyses and document analyses are conducted. The workflow analyses, patient and employee assessment analyses and classification within the clinical adoption meta-model are conducted to provide insights into clinical workflows. DISCUSSION: This study will be the first to investigate the effects of introducing electronic patient records on interprofessional collaboration and clinical workflows from the perspective of healthcare professionals. Thereby, it will consider patients' safety, legal and ethical concerns and quality of care. The results will help to understand the organization and thereby improve the performance of health services working with electronic patient records. TRIAL REGISTRATION: The study was registered at the German clinical trials register (DRKS00023343, Pre-Results) on November 17, 2020.

Associations between hospital structures, processes and patient experiences of preparation for discharge in breast cancer centers: A multilevel analysis.

BACKGROUND: Discharge management is a central task in hospital management. Mitchell's quality health outcomes model offers a contextual framework to derive expectations about the relationship between indicators of hospital structures and processes with patient experiences of preparation for discharge. PURPOSE: The aim is to analyze the association between hospital structures and processes with patient experiences of preparation for discharge in breast cancer centers. METHODOLOGY: The data were collected between February 1 and July 31, 2014-2016, with annual cross-sectional postal surveys on patient experiences of preparation for discharge in breast cancer center hospitals in Germany. These data were combined with secondary data on hospital structures, obtained from structured quality reports 2014 and the accreditation institution certifying breast cancer centers, constituting a hierarchical data structure. A total of 10,750 newly diagnosed breast cancer patients from 67 hospitals were analyzed. Following listwise deletion, 9,762 patients could be included in linear hierarchical regression analyses. RESULTS: Patients felt better prepared for discharge in hospitals that communicate the discharge date timely to patients, with good coordinative processes, and which cooperate with two other breast cancer center hospitals. Hospital structures, size, teaching status, and ownership were not associated with the patient experiences of preparation for discharge. CONCLUSION: The results suggest that timely and informative communication, well-organized care processes, and the network structure of centers allow for an improvement of preparation for discharge. Current and future approaches for the improvement of hospital discharge should consider the identified hospital resources. PRACTICE IMPLICATIONS: Hospital management should increase the focus on structured communication and coordination processes to improve the discharge process. Cooperating networks should be expanded to increase expertise and resources. Results can be generalized to other care domains with caution. Patients' characteristics should further be assessed in order to use resources efficiently.