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Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

Background: Research to date has focused on strategies and resources used by effective champions of healthcare change efforts, rather than personal characteristics that contribute to their success. We sought to identify and describe champion attributes influencing outcomes of healthcare change efforts. To examine attributes of champions, we used postpartum contraceptive care as a case study, because recommended services are largely unavailable, and implementation requires significant effort. Methods: We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 U.S. maternity hospitals in 2017-18. We conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research (CFIR). Phase one analysis (qualitative content analysis using a priori CFIR codes and cross-case synthesis) showed that implementation leaders ("champions") strongly influenced outcomes across sites. To understand champion effects, phase two inductive analysis included (1) identifying and elaborating key attributes of champions; (2) rating the presence or absence of each attribute in champions; and 3) cross-case synthesis to identify patterns among attributes, context, and implementation outcomes. Results: We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. All identified champions were obstetrician-gynecologists. Six key attributes of champions emerged: influence, ownership, physical presence at the point of change, persuasiveness, grit, and participative leadership style. These attributes promoted success by enabling champions to overcome institutional siloing, build and leverage professional networks, create tension for change, cultivate a positive learning climate, optimize compatibility with existing workflow, and engage key stakeholders. Not all champion attributes were required for success, and having all attributes did not guarantee success. Conclusions: Effective champions appear to leverage six key attributes to facilitate healthcare change efforts. Prospective evaluations of the interactions among champion attributes, context, and outcomes may further elucidate how champions exert their effects.

BackgroundIdentifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.MethodsSystematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.ResultsThirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.ConclusionsStruggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.Systematic review registrationPROSPERO: CRD42017067367.

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The types and numbers of champions varied with the type of practice implemented and the effectiveness of champions was affected by the quality of organisational networks.

Background Specific ways community health worker (CHW) programs affect participants’ health care behaviors and interactions with their health care providers, as well as mechanisms by which CHW programs influence these outcomes, are poorly understood. Through a qualitative descriptive study of participants in a successful CHW diabetes self-management program, we sought to answer: 1) What gaps in diabetes care, with a focus on patient-doctor interactions, do participants identify? And 2) How does the program influence participants’ diabetes care and interactions with health care providers, and what gaps, if any, does it address? Methods From 2005-2007, we conducted semi-structured interviews with 40 African American and Latino adults with diabetes who had completed or were active in a CHW-led diabetes self-management program developed and implemented using community-based participatory research (CBPR) principles in Detroit. Interviews were audiotaped, transcribed, and coded through a consensual and iterative process. Results Participants reported that before participating in the intervention they had received inadequate information from health care providers for effective diabetes self-management, had had low expectations for help from their providers, and had not felt comfortable asking questions or making requests of their health care providers. Key ways participants reported that the program improved their ability to manage their diabetes were by providing 1) clear and detailed information on diabetes and diabetes care that they had not known before REACH; 2) education and training on specific strategies to meet diabetes care goals; 3) sustained and non-judgmental assistance to increase their motivation and confidence to improve their diabetes self-management; and 4) social and peer support that enabled them to better manage their diabetes. The knowledge and confidence gained through the CHW intervention increased participants’ assertiveness in asking questions to and requesting necessary tests and results from their providers. Conclusions Our interview findings suggest ways that CHW programs that provide both one-on-one support and group self-management training sessions may be effective in promoting more effective diabetes care and patient-doctor relationships among Latino and African American adults with diabetes. Through these mechanisms, such interventions may help to mitigate racial and ethnic disparities in diabetes care and outcomes.