PURPOSEThe Using Learning Teams for Refl ective Adaptation (ULTRA) study used facilitated refl ective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show signifi cant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. METHODSWe analyzed fi eld notes and interviews from a multimethod practice assessment, as well as fi eld notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach.RESULTS Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practicewide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines.CONCLUSION Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence. Ann Fam Med 2010;8:425-432. doi:10.1370/afm.1159. INTRODUCTIONThe quality of care in the United States is substandard, 1 and the early promise of improving care by translating research into practice has been disappointing. 2,3 Initial efforts to improve quality often target improving knowledge, attitudes, and behaviors of individual health professionals by using such strategies as audit and feedback, reminder systems, continuing medical education, and educational outreach. 4 These strategies have been found to produce modest change. 2,3,[5][6][7][8] Even when improvement changes are adopted, they are often not sustained over time 7 and may deteriorate after practice members' attention shifts elsewhere.8 Sustaining change appears to be an active process that requires continual attention as innovations are adapted to fi t continually evolving environments.9,10 Additionally, small, independent primary care practices often lack the resources 426T E A M -BA SED CHANGE M A NAGEMENT or motivation needed to develop quality improvement strategies that can address multiple clinical issues. 11The substantial, broad improvements required for optimal primary care cannot be achieved by focusing improvement efforts on specifi c diseases or on individual professional behavior. In fact, primary care pract...
Objective To examine the influence of patient and physician communication factors on diagnostic delay (DD). Methods 242 patients diagnosed with colorectal cancer (CRC) in the past 6 months who experienced symptoms prior to diagnosis were administered a 2-hour semi-structured qualitative interview to assess communication with health care provider and ease of access to care, among other factors. Patient-provided information was verified via review of medical records. Results The factors associated with DD > 2 months included lower income (OR=0.56, p=0.03), having regular physician prior to receiving a cancer diagnosis (OR=2.52, p=0.03), having a physician who used temporizing communication strategies during the consultation (OR=2.41, p=0.02), receiving an initial alternate diagnosis (OR=3.36, p=0.02), experiencing referral delay (OR=3.61, p=<0.001), and experiencing follow-up delay of any kind (OR=3.32, p=0.01). Conclusion Excellent communication skills that appropriately probe for relevant social and economic patient information, assist patients in distinguishing and elaborating on symptoms, and provide clear rationale and instructions for future steps, will speed along the diagnosis process and could be the difference between early and late stage CRC. Practice Implications Increased understanding of physician communication and practice styles that contribute to DD could have a positive impact on decreasing the morbidity and mortality from this disease.
The ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the MetS, despite their more favorable metabolic profiles. This was particularly true for black participants.
Objective-This paper provides an overview of the implementation of using Unannounced Standardized Patients (USPs) to conduct health communication research in clinical settings.Methods-Certain types of health communication situations are difficult to capture because of their rarity or unpredictable nature. In primary care the real reasons for a visit are frequently unknown until the consultation is well under way. Therefore, it is logistically difficult for communication studies to capture many real-time communications between patients and their physicians. Although the USP methodology is ideal for capturing these communication behaviors, challenges to using this method include developing collaborative relationships with clinical practices, logistical issues such as safeguarding the identity of the USP, training USPs and creating their identities, maintaining fidelity to the role, and analyzing the resultant data.Results-This paper discusses the challenges and solutions to USP implementation. We provide an example of how to implement a USP study using an on-going study being conducted in primary care practices.Conclusion-This paper explores the advantages and challenges as well as strategies to overcome obstacles to implementing a USP study. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Practice Implications-Despite the challenges, USP methodology can contribute much to our understanding of health communication and practice. NIH Public Access
Background Few valid and reliable measures exist for health care professionals interested in determining their levels of cultural and linguistic competence. Objective To evaluate the measurement properties of the Cultural Competence Health Practitioner Assessment (CCHPA-129). Methods The CCHPA-129 is a 129-item web-based instrument, developed by the National Center for Cultural Competence (NCCC). Responses on the CCHPA -129 were examined using factor analysis; Rasch modeling; and Differential Item Functioning (DIF) across race, ethnicity, gender, and profession. Subjects 2504 practitioners, including 1864 nurses (RN/LPN,/BSN); 341 clinicians (PA/NP); and 299 physicians (MD/DO), who completed the CCHPA-129 online between 2005 and 2008. Results Three factors representing domains of knowledge, adapting practice, and promoting health for culturally and linguistically diverse populations accounted for 46% of the variance. Among Knowledge factor items, 53% (23/43) fit the Rasch model, item difficulties ranged from −1.01 logits (least difficult) to +1.11 logits (most difficult), separation index (SI) 13.82, and Cronbach’s α 0.92. Forty-seven percent (21/44) Adapting Practice factor items fit the model, item difficulties −0.07 to +1.11 logits, SI 11.59, Cronbach’s α 0.88; and 58% (23/39). Promoting Health factor items fit the model, item difficulties −1.01 to +1.38 logits, SI 22.64, Cronbach’s α 0.92. Early evidence of validity was established by known groups having statistically different scores. Conclusion The 67-item CCHPA-67 is psychometrically sound. This shorted instrument can be used to establish associations between practitioners’ cultural and linguistic competence and health outcomes as well as to evaluate interventions to increase practitioners’ cultural and linguistic competence.
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