Use of a time series design to test effectiveness of a theory-based intervention targeting adherence of health professionals to a clinical guideline. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Improving chronic care of type 2 diabetes using teams of interprofessional learners. Identification and management of domestic violence: a randomized trial. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Does teamwork improve performance in the operating room? A multilevel evaluation. A randomized controlled trial of communication training with primary care providers to improve patient-centeredness and health risk communication. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic. Use of a consumer-led intervention to improve provider competencies. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Team training and stroke rehabilitation outcomes: a cluster randomized trial. An evaluation of a system-change training model to improve emergency department response to battered women. Using collaborative learning to improve diabetes care and outcomes: the VIDA project. Implementation and evaluation of a nursing home fall management program.
The aim of this study was to test the effectiveness of a theory of planned behaviour intervention to increase adherence of community mental health professionals to a national suicide prevention guideline.
                Routinely collected audit adherence data from an intervention and control site were collected and analysed using time series analysis to test whether the intervention significantly increased adherence. The effects of a local and national event on adherence were also examined.
                A Theory of Planned Behaviour (TPB) questionnaire, developed from interview findings, was administered to the health professionals. Subjective norms were found to be the most significant predictor of intention to adhere to the guideline, and were targeted with an interactive educational intervention. Time series analysis applied to routinely collected audit adherence data was used to test intervention effectiveness.
                The TPB accounted for 58% of the variance in intention to adhere, with subjective norms the only significant predictor. The intervention did not significantly increase adherence; however, the national and local events were found to have significantly increased adherence.
                The TPB was a useful framework for exploring barriers to adherence; however, this did not translate into an effective intervention. Future research should seek collaboration with local experts, and use this information in combination with the TPB, to develop interventions. Collaborative research with experts in pedagogy may also help to develop more effective interventions, particularly education-based interventions that require adult learning. To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery.
                A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures.
                A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (-5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03).
                Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement.
                (www.ClinicalTrials.gov), NCT00381056
                I. To improve the care and outcomes of adult patients with type 2 diabetes by teaching interprofessional teams of learners the principles and practices of the Improving Chronic Illness Care Model.
                The study population consisted of 384 adult patients with type 2 diabetes. The study design was a nonrandomized, parallel-group, clinical trial conducted during 18 months in the University of California, San Francisco internal medicine clinics. Interprofessional team care provided by primary care internal medicine residents, nurse practitioner students, and pharmacy students was compared with usual care by internal medicine residents only. Processes of care, clinical status, and health utilization were measured in both patient groups. Learner outcomes also were assessed and compared.
                At study completion, intervention patients more frequently received assessments of glycosolated hemoglobin (79% versus 67%; P=.01), LDL-C (69% versus 55%; P=.009), blood pressure (86% versus 79%; P=.08), microalbuminuria (40% versus 30%; P=.05), smoking status assessment (43% versus 31%; P=.02), and foot exams (38% versus 20%; P=.0005). Intervention patients had more planned general medicine visits (7.9+/-6.2 versus 6.2+/-5.7; P=.006) than did control patients. Interprofessional learners rated themselves significantly higher on measures of accomplishment, preparation, and success for chronic care than did the usual care learners.
                Interprofessional team care by learners was effective in improving quality of care for adult patients with diabetes treated in general medicine clinics. The chronic illness framework resulted in more appropriate health care utilization. Diagnosis of domestic violence (DV) in primary care is low compared to its prevalence. Care for patients is deficient. Over a 1-year period, we tested the effectiveness of an intensive intervention to improve asking about DV, case finding, and management in primary care. The intervention included skill training for providers, environmental orchestration (posters in clinical areas, DV questions on health questionnaires), and measurement and feedback.
                We conducted a group-randomized controlled trial in five primary care clinics of a large health maintenance organization (HMO). Outcomes were assessed at baseline and follow-up by survey, medical record review, and qualitative means.
                Improved provider self-efficacy, decreased fear of offense and safety concerns, and increased perceived asking about DV were documented at 9 months, and also at 21 months (except for perceived asking) after intervention initiation. Documented asking about DV was increased by 14.3% with a 3.9-fold relative increase at 9 months in intervention clinics compared to controls. Case finding increased 1.3-fold (95%, confidence interval 0.67-2.7).
                The intervention improved documented asking about DV in practice up to 9 months later. This was mainly because of the routine use of health questionnaires containing DV questions at physical examination visits and the placement of DV posters in clinical areas. A small increase in case finding also resulted. System changes appear to be a cost-effective method to increase DV asking and identification. Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression.
                We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat.
                The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve.
                Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression. Medical care is a team effort, especially as patient cases are more complex. Communication, cooperation, and coordination are vital to effective care, especially in complex service lines such as the operating room (OR). Team training, specifically the TeamSTEPPS training program, has been touted as one methodology for optimizing teamwork among providers and increasing patient safety. Although such team-training programs have transformed the culture and outcomes of other dynamic, high-risk industries such as aviation and nuclear power, evidence of team training effectiveness in health care is still evolving. Although providers tend to react positively to many training programs, evidence that training contributes to important behavioral and patient safety outcomes is lacking.
                A multilevel evaluation of the TeamSTEPPS training program was conducted within the OR service line with a control location. The evaluation was a mixed-model design with one between-groups factor (TeamSTEPPS training versus no training) and two within-groups factors (time period, team). The groups were located at separate campuses to minimize treatment diffusion. Trainee reactions, learning, behaviors in the OR, and proxy outcome measures such as the Hospital Survey on Patient Safety Culture (HSOPS) and Operating Room Management Attitudes Questionnaire (ORMAQ) were collected.
                All levels of evaluation demonstrated positive results. The trained group demonstrated significant increases in the quantity and quality of presurgical procedure briefings and the use of quality teamwork behaviors during cases. Increases were also found in perceptions of patient safety culture and teamwork attitudes.
                The hospital system has integrated elements of TeamSTEPPS into orientation training provided to all incoming hospital employees, including nonclinical staff. to determine the efficacy and effectiveness of training to improve primary care providers' patient-centered communication skills and proficiency in discussing their patients' health risks.
                twenty-eight primary care providers participated in a baseline simulated patient interaction and were subsequently randomized into intervention and control groups. Intervention providers participated in training focused on patient-centered communication about behavioral risk factors. Immediate efficacy of training was evaluated by comparing the two groups. Over the next 3 years, all providers participated in two more sets of interactions with patients. Longer term effectiveness was assessed using the interaction data collected at 6 and 18 months post-training.
                The intervention providers significantly improved in patient-centered communication and communication proficiencies immediately post-training and at both follow-up time points.
                this study suggests that the brief training produced significant and large differences in the intervention group providers which persisted 2 years after the training.
                the results of this study suggest that primary care providers can be trained to achieve and maintain gains in patient-centered communication, communication skills and discussion of adverse childhood events as root causes of chronic disease.
                2010 Elsevier Ireland Ltd. All rights reserved. To evaluate the effectiveness of training and institutionalizing teamwork behaviors, drawn from aviation crew resource management (CRM) programs, on emergency department (ED) staff organized into caregiver teams.
                Nine teaching and community hospital EDs.
                A prospective multicenter evaluation using a quasi-experimental, untreated control group design with one pretest and two posttests of the Emergency Team Coordination Course (ETCC). The experimental group, comprised of 684 physicians, nurses, and technicians, received the ETCC and implemented formal teamwork structures and processes. Assessments occurred prior to training, and at intervals of four and eight months after training. Three outcome constructs were evaluated: team behavior, ED performance, and attitudes and opinions. Trained observers rated ED staff team behaviors and made observations of clinical errors, a measure of ED performance. Staff and patients in the EDs completed surveys measuring attitudes and opinions.
                Hospital EDs were the units of analysis for the seven outcome measures. Prior to aggregating data at the hospital level, scale properties of surveys and event-related observations were evaluated at the respondent or case level.
                A statistically significant improvement in quality of team behaviors was shown between the experimental and control groups following training (p = .012). Subjective workload was not affected by the intervention (p = .668). The clinical error rate significantly decreased from 30.9 percent to 4.4 percent in the experimental group (p = .039). In the experimental group, the ED staffs' attitudes toward teamwork increased (p = .047) and staff assessments of institutional support showed a significant increase (p = .040).
                Our findings point to the effectiveness of formal teamwork training for improving team behaviors, reducing errors, and improving staff attitudes among the ETCC-trained hospitals. Diabetes care in our inner-city primary care clinic was suboptimal, despite provider education and performance feedback targeting improved adherence to evidence-based clinical guidelines. A crew resource management (CRM) intervention (communication and teamwork, process and workflow organisation, and standardised information debriefings) was implemented to improve diabetes care and patient outcomes.
                To assess the effect of the CRM intervention on adherence to evidence-based diabetes care standards, work processes, standardised clinical communication and patient outcomes.
                Time-series analysis was used to assess the effect on the delivery of standard diabetes services and patient outcomes among medically indigent adults (n = 619).
                The CRM principles were translated into useful process redesign and standardised care approaches. Significant improvements in microalbumin testing and associated patient outcome measures were attributed to the intervention.
                The CRM approach provided tools for management that, in the short term, enabled reorganisation and prevention of service omissions and, in the long term, can produce change in the organisational culture for continuous improvement. Client-centered care is a major aim of health care. In mental health, new client-centered treatment approaches that emphasize recovery, rehabilitation, and empowerment can improve outcomes for people with severe and persistent mental illness. However, these approaches are not widely used, in part because many clinicians lack the necessary competencies. The objective of this study was to evaluate the effectiveness of an innovative, consumer-led intervention, Staff Supporting Skills for Self-Help, which was designed to improve provider quality, empower mental health consumers, and promote mutual support.
                The study was conducted at five large community mental health provider organizations in two western states. One organization in each state received the intervention. The intervention included education, clinician-client dialogues, ongoing technical assistance, and support of self-help. It focused on client-centered care, rehabilitation, and recovery. A one-year controlled trial evaluated the effect of the intervention on clinicians' competencies, care processes, and the formation of mutual support groups. Outcomes were assessed by using competency assessment survey instruments and semistructured interviews with clinicians and managers.
                A total of 269 clinicians participated in the study: 151 in the intervention group and 118 in the control group. Compared with clinicians at the control organizations, clinicians at intervention organizations showed significantly greater improvement in education about care, rehabilitation methods, natural supports, holistic approaches, teamwork, overall competency, and recovery orientation.
                A feasible, consumer-led intervention improves provider competencies in domains that are necessary for the provision of high-quality care. Although substantial resources have been invested in communication skills training for clinicians, little research has been done to test the actual effect of such training on patient satisfaction.
                To determine whether clinicians' exposure to a widely used communication skills training program increased patient satisfaction with ambulatory medical care visits.
                Randomized, controlled trial.
                A not-for-profit group-model health maintenance organization in Portland, Oregon.
                69 primary care physicians, surgeons, medical subspecialists, physician assistants, and nurse practitioners from the Permanente Medical Group of the Northwest.
                "Thriving in a Busy Practice: Physician-Patient Communication," a communication skills training program consisting of two 4-hour interactive workshops. Between workshops, participants audiotaped office visits and studied the audiotapes.
                Change in mean overall score on the Art of Medicine survey (HealthCare Research, Inc., Denver, Colorado), which measures patients' satisfaction with clinicians' communication behaviors, and global visit satisfaction.
                Although participating clinicians' self-reported ratings of their communication skills moderately improved, communication skills training did not improve patient satisfaction scores. The mean score on the Art of Medicine survey improved more in the control group (0.072 [95% CI, -0.010 to 0.154]) than in the intervention group (0.030 [CI, -0.060 to 0.1201).
                "Thriving in a Busy Practice: Physician-Patient Communication," a typical continuing medical education program geared toward developing clinicians' communication skills, is not effective in improving general patient satisfaction. To improve global visit satisfaction, communication skills training programs may need to be longer and more intensive, teach a broader range of skills, and provide ongoing performance feedback. To test whether a team training intervention in stroke rehabilitation is associated with improved patient outcomes.
                A cluster randomized trial of 31 rehabilitation units comparing stroke outcomes between intervention and control groups.
                Thirty-one Veterans Affairs medical centers.
                A total of 237 clinical staff on 16 control teams and 227 staff on 15 intervention teams. Stroke patients (N=487) treated by these teams before and after the intervention.
                The intervention consisted of a multiphase, staff training program delivered over 6 months, including: an off-site workshop emphasizing team dynamics, problem solving, and the use of performance feedback data; and action plans for process improvement; and telephone and videoconference consultations. Control and intervention teams received site-specific team performance profiles with recommendations to use this information to modify team process.
                Three patient outcomes: functional improvement as measured by the change in motor items of the FIM instrument, community discharge, and length of stay (LOS).
                For both the primary (stroke only) and secondary analyses (all patients), there was a significant difference in improvement of functional outcome between the 2 groups, with the percentage of stroke patients gaining more than a median FIM gain of 23 points increasing significantly more in the intervention group (difference in increase, 13.6%; P=.032). There was no significant difference in LOS or rates of community discharge.
                Stroke patients treated by staff who participated in a team training program were more likely to make functional gains than those treated by staff receiving information only. Team based clinicians are encouraged to examine their own team. (ClinicalTrials.gov identifier NCT00237757). To evaluate a system-change model of training from the Family Violence Prevention Fund and the Pennsylvania Coalition Against Domestic Violence for improving the effectiveness of emergency department (ED) response to intimate partner violence (IPV).
                An experimental design with outcomes measured at baseline, 9-12, and 18-24 months post-intervention. Twelve hospitals in Pennsylvania and California with 20,000-40,000 annual ED visits were randomly selected and randomly assigned to experimental and control conditions. Emergency department teams (physician, nurse, social worker) from each experimental hospital and a local domestic violence advocate participated in a two-day didactic information and team planning intervention.
                The experimental hospitals were significantly higher than the control hospitals on a staff knowledge and attitude measure (F = 5.57, p = 0.019), on all components of the "culture of the ED" system-change indicator (F = 5.72, p = 0.04), and in patient satisfaction (F = 15.43, p < 0.001) after the intervention. There was no significant difference in the identification rates of battered women (F = 0.411, p = 0.52) (although the linear comparison was in the expected direction) in the medical records of the experimental and control hospitals.
                A system-change model of IPV ED training was effective in improving staff attitudes and knowledge about battered women and in protocols and staff training, as well as patient information and satisfaction. However, change in actual clinical practice was more difficult to achieve and may be influenced by institutional policy. The prevalence of diabetes in Mexico among those 20-64 years of age has increased from 7.2% in 1993 to 10.7% in 2000. National population-based surveys in Mexico demonstrated that 50% of the total population with diabetes had blood glucose levels of 200mg/dl or higher. Thus, diabetes care has become one of the most important public health challenges in this country. The aim of the study was to improve the quality of diabetes care in primary health care centers using the chronic care model and the breakthrough series (BTS) collaborative methodology.
                Ten public health centers in the cities of Xalapa and Veracruz were randomly selected to participate in the project. Five of the health centers were randomly assigned to receive the intervention (intervention group) and the other five followed usual care (usual care group). The intervention was evaluated by A1c test before and after the intervention in both groups of patients. Patients were followed for 18 months from November 2002 to May 2004. Results were adjusted for the clustering of patients within practices and baseline measure.
                The proportion of people with good glycemic control (A1c<7%) among those in the intervention group increased from 28% before the intervention to 39% after the intervention. The proportion of patients achieving three or more quality improvement goals increased from 16.6% to 69.7% (p<0.001) among the intervention group while the usual care group experienced a non-significant decrease from 12.4% to 5.9% (p=0.118). The focus on the primary care team and the participation of people with diabetes were strategic elements incorporated into the methodology, expected to ensure sustainability of continued improvement of health outcomes.
                The intervention introduced modifications to solve problems identified by health teams in their practice and improved process and outcome measures of quality diabetes care. Most of the actions were directed at four components of the chronic care model: self-management support, decision support, delivery system design, and clinical information systems.
                Copyright © 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved. To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs).
                A quality improvement project with data collection throughout FMP implementation.
                NHs in Georgia owned and operated by a single nonprofit organization.
                All residents of participating NHs.
                A convenience sample of 19 NHs implemented the FMP. The FMP is a multifaceted quality improvement and culture change intervention. Key components included organizational leadership buy-in and support, a designated facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management.
                Process-of-care documentation using a detailed 24-item audit tool and fall and physical restraint use rates derived from quality improvement software currently used in all Georgia NHs (MyInnerView).
                Care process documentation related to the assessment and management of fall risk improved significantly during implementation of the FMP. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention NHs (a relative reduction of 44%), and decreased in the nonintervention NHs from 7.0% to 4.9% (a relative reduction of 30%). Fall rates remained stable in the intervention NHs (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end), whereas fall rates increased 26% in the NHs not implementing the FMP (from 15.0 falls/100 residents/per month to 18.9 falls/100 residents per month).
                Implementation was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in the use of physical restraints. In contrast, fall rates increased in NHs owned by the same organization that did not implement the FMP. The FMP may be a helpful tool for NHs to manage fall risk while attempting to reduce physical restraint use in response to the Centers for Medicare and Medicaid Services quality initiatives.
This updated review reports on 15 studies that met the inclusion criteria (nine studies from this update and six studies from the 2008 update). Although these studies reported some positive outcomes, due to the small number of studies and the heterogeneity of interventions and outcome measures, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. To improve the quality of evidence relating to IPE and patient outcomes or healthcare process outcomes, the following three gaps will need to be filled: first, studies that assess the effectiveness of IPE interventions compared to separate, profession-specific interventions; second, RCT, CBA or ITS studies with qualitative strands examining processes relating to the IPE and practice changes; third, cost-benefit analyses.