Improving quality of clinical coding of post-partum haemorrhage: the process and its effects on reported incidence rates in a NZ hospital maternity service
Galgali, G; Fong, K; Bissell, K; Armstrong, D; Humphrey, G; (2018)
NZMJ. 27 Jul 2018; 131(1479):64-71.View abstract
AIM: The Waitemata District Health Board (DHB) aimed to investigate and improve the accuracy of its reporting of post-partum haemorrhage (PPH), to understand its true incidence.
METHOD: The quality improvement project included multidisciplinary collaboration between maternity clinicians and clinical coders, substantive redesign of the Waitemata DHB's birth documentation form, systematic auditing and follow-up of clinical documentation by a dedicated quality midwife, linking of maternity clinicians to a key designated senior coder and ongoing PPH incidence monitoring and staff education.
RESULTS: The coded rate of PPH has risen dramatically and is now in line with expected Australasian incidence levels. A corresponding increase in the value of cost-weighted discharges (estimated at $544,000 for the 2015/16 financial year) was realised as a result of the more accurate reported incidence.
CONCLUSION: This case illustrates the value of coding to a clinical service and the importance of clinical leadership and engagement in achieving successful and sustainable service redesign initiatives. It provides an example of how to evaluate and update coding and a process for changing the way clinicians and coders work that could benefit other services in Waitemata DHB as well as in other New Zealand district health boards.
Effectiveness of text message based, diabetes self management support programme (SMS4BG): two arm, parallel randomised controlled trial
Dobson, R; Whittaker, R; Jiang, Y; Maddison, R; Shepherd, M; McNamara, C; Cutfield, R; Khanolkar, M; Murphy, R; (2018)
BMJ May 2018; 361:k1959. DOI:10.1136/bmj.k1959.View abstract
OBJECTIVE: To determine the effectiveness of a theoretically based and individually tailored, text message based, diabetes self management support intervention (SMS4BG) in adults with poorly controlled diabetes.
DESIGN: Nine month, two arm, parallel randomised controlled trial.
SETTING: Primary and secondary healthcare services in New Zealand.
PARTICIPANTS: 366 participants aged 16 years and over with poorly controlled type 1 or type 2 diabetes (HbA1c ≥65 mmol/mol or 8%) randomised between June 2015 and November 2016 (n=183 intervention, n=183 control).
INTERVENTIONS: The intervention group received a tailored package of text messages for up to nine months in addition to usual care. Text messages provided information, support, motivation, and reminders related to diabetes self management and lifestyle behaviours. The control group received usual care. Messages were delivered by a specifically designed automated content management system.
MAIN OUTCOME MEASURES: Primary outcome measure was change in glycaemic control (HbA1c) from baseline to nine months. Secondary outcomes included change in HbA1c at three and six months, and self efficacy, diabetes self care behaviours, diabetes distress, perceptions and beliefs about diabetes, health related quality of life, perceived support for diabetes management, and intervention engagement and satisfaction at nine months. Regression models adjusted for baseline outcome, health district category, diabetes type, and ethnicity.
RESULTS: The reduction in HbA1c at nine months was significantly greater in the intervention group (mean −8.85 mmol/mol (standard deviation 14.84)) than in the control group (−3.96 mmol/mol (17.02); adjusted mean difference −4.23 (95% confidence interval −7.30 to −1.15), P=0.007). Of 21 secondary outcomes, only four showed statistically significant improvements in favour of the intervention group at nine months. Significant improvements were seen for foot care behaviour (adjusted mean difference 0.85 (95% confidence interval 0.40 to 1.29), P<0.001), overall diabetes support (0.26 (0.03 to 0.50), P=0.03), health status on the EQ-5D visual analogue scale (4.38 (0.44 to 8.33), P=0.03), and perceptions of illness identity (−0.54 (−1.04 to −0.03), P=0.04). High levels of satisfaction with SMS4BG were found, with 161 (95%) of 169 participants reporting it to be useful, and 164 (97%) willing to recommend the programme to other people with diabetes.
CONCLUSION: A tailored, text message based, self management support programme resulted in modest improvements in glycaemic control in adults with poorly controlled diabetes. Although the clinical significance of these results is unclear, the findings support further investigation into the use of SMS4BG and other text message based support for this patient population.
Visiting Fellow on Patient Engagement - After-Visit Report & Plan
De Bronkart, D; (2018)View abstract
The Revera i3 visting fellowship on patient engagement was a jointly sponsored opportunity to raise Revera's profile and commitment to "digital health to unleash the potential for all New Zealanders", in partnership with high-profile allies from Waitemata EDHB and the HINZ technical society.
OPPORTUNITY, PURPOSE & ACTIVITIES
New Zealand is uniquely positioned to benefit from, and participate in developing, the potential value of combining e-health innovations with patient engagement. The country’s evolving demographics, expanding infrastructure and widely dispersed population combine to set the stage for relevant innovations.
Aptly, this fellowship was a partnership between private sector infrastructure / innovation (Revera), government (Waitemata DHB and i3), and technical workforce (HINZ). Revera’s infrastructure is enhanced by it’s cloud platform for integration of data from diverse sources. Waitemata DHB is at the forefront of Digital Health and patient engagement in NZ, and HINZ is New Zealand’s meeting place for digital health, providing a neutral and constructive environment for information sharing. Never in my travels have I encountered such a relevant partnership.
Evaluating Fundamentals of Care: The Development of a Unit Level Quality Measurement and Improvement Programme
Parr, J; Bell, J; Koziol-McLain, J; (2018)
Journal of Clinical Nursing (JCN). DOI: 10.111/jocn.14250. 2018;00:1-13. Feb 2018.View abstract
AIMS/OBJECTIVES: The project aimed to develop a unit level quality measurement and improvement programme using evidence based fundamentals of care.
BACKGROUND: Feedback from patients, families, whānau, staff, and audit data in 2014 indicated variability in the delivery of fundamental aspects of care such as monitoring, nutrition, pain management and environmental cleanliness at a New Zealand District Health Board.
DESIGN: A general inductive approach was used to explore the fundamentals of care and design a measurement and improvement programme, the Patient and Whānau Centred Care Standards (PWCCS), focused on fundamental care.
METHODS: Five phases were used to explore the evidence, and design and test a measurement and improvement framework. Results Nine identified fundamental elements of care were used to define expected standards of care and develop and test a measurement and improvement framework. Four six-monthly peer reviews have been undertaken since June 2015. Charge Nurse Managers used results to identify quality improvements. Significant improvement was demonstrated overall, in six of the 27 units, in seven of the nine standards and three of the four measures. In all, 89% (n=24) of units improved their overall result.
CONCLUSION: The PWCCS measurement and improvement framework makes visible nursing fundamentals of care in line with continuous quality improvement to increase quality of care.
RELEVANCE TO CLINICAL PRACTICE: Delivering fundamentals of care is described by nurses as getting ?back to basics'. Patient and family feedback supports the centrality of fundamentals of care to their hospital experience. Implementing a unit-level fundamentals of care quality measurement and improvement programme clarifies expected standards of care, highlights the contribution of fundamentals of care to quality and provides a mechanism for ongoing improvements.
Co-designing an mHealth Tool in the New Zealand Māori Community with a "Kaupapa Māori" Approach
Te Morenga, L; Pekepo, C; Corrigan, C; Matoe, L; Mules, R; Goodwin, D; Dymus, J; Tunks, M; Grey, J; Humphrey, G; Jull, A; Whittaker, R; Verbiest, M; Firestone, R; Ni Mhurchu, C; (2018)
AlterNative: An International Journal of Indigenous Peoples Jan 2018. DOI:10.1177/1177180117753169. Epub Jan 2018View abstract
Obesity rates in Aotearoa/New Zealand continue to rise, and there is an urgent need for effective interventions. However, interventions designed for the general population tend to be less effective for Māori communities and may contribute to increased health inequities. We describe the integration of co-design and kaupapa Māori research approaches to design a mobile-phone delivered (mHealth) healthy lifestyle app that supports the health aspirations of Māori communities. The co-design approach empowered our communities to take an active role in the research. They described a holistic vision of health centred on family well-being and maintaining connections to people and place. Our resultant prototype app, OL@-OR@, includes content that would not have been readily envisaged by academic researchers used to adapting international research on behaviour change techniques to develop health interventions. We argue that this research approach should be considered best practice for developing health interventions targeting Māori communities in future.
Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial
Hatcher, S; Whittaker, R; Patton, M; Sylvester, W; Ralph, N; Kercher, K; Sharon, C; (2018)
JMIR Mental Health 2018; 5(1):e5. DOI: 10.2196/mental.8510. PMID: 29362207.View abstract
BACKGROUND: The evidence for the effectiveness of Web-based therapies comes mainly from nonclinical populations, with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. Adherence to Web-based therapies is often poor. One way to increase this is to create a new health service role of a coach to guide people through the therapy.
OBJECTIVE: This study aimed to test in people referred to secondary care with depression if a Web-based therapy (The Journal) supported by a coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about Web-based resources after 12 weeks.
METHODS: We conducted a randomized controlled trial with two parallel arms and a process evaluation that included structured qualitative interviews analyzed using thematic analysis. The coach had a background in occupational therapy. Participants were recruited face-to-face at community mental health centers.
RESULTS: We recruited 63 people into the trial (intervention 35, control 28). There were no statistically significant differences in the change from baseline in Patient Health Questionnaire-9 (PHQ-9) scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group, t41=1.05, P=.30; mean difference=2.3, 95% CI −2.1 to 6.7). People who were offered The Journal attended on average about one less outpatient appointment compared with usual care, although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group, t45=−0.80, P=.43; mean difference=1.3, 95% CI −4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 (SD=1.9; range=0-6) and the number of contacts with the coach was a mean of 8.1 (SD=4.4; range=0-17). The qualitative interviews highlighted the problem of engaging clinicians in research and their resistance to recruitment: technical difficulties with The Journal, which prevented people logging in easily; difficulty accessing The Journal as it was not available on mobile devices; participants finding some lessons difficult; and participants saying they were too busy to complete the sessions.
CONCLUSIONS: The study demonstrated that it is feasible to use a coach in this setting, that people found it helpful, and that it did not conflict with other care that participants were receiving. Future trials need to engage clinicians at an early stage to articulate where Web-based therapies fit into existing clinical pathways; Web-based therapies should be available on mobile devices, and logging in should be easy. The role of the coach should be explored in larger trials.
Stakeholder Views Do Matter: A Conceptual Framework for Medication Safety Measurement
Ng, J; Scahill, S; Harrison, J; (2017)
Journal of Pharmaceutical Health Services Research Sep 2017; DOI; 10.1111/jphs.12203View abstract
Many patients are harmed by medications intended to help them. Significant efforts have been directed toward the improvement of medication safety. Policymakers, clinicians, researchers and consumers are interested in knowing the progress of medication safety but it is unclear whether it is safer than before.
Part of the challenge has been the achievement of a common understanding of what medication safety means to multi-stakeholders, and then developing a measurement framework. Existing approaches to measurement have been narrow and piecemeal, failing to encompass diverse stakeholder beliefs and preferences.
A multi-stakeholder derived conceptual framework for medication safety measurement was required. The interview method was used to elicit and explore stakeholder views in-depth. Stakeholders were selected by purposive sampling on the basis of their job role or expertise in the area of medication safety in the New Zealand public hospital setting. Snowball sampling was also used and data collection was continued until data saturation which occurred after interviewing 30 people.
Transcripts were thematically analysed and interpreted with the aid of NVivo and mind maps using a general inductive approach. The developed multi-stakeholder derived conceptual framework for medication safety measurement consists of seven key dimensions meaningful to multi-stakeholders in the New Zealand public hospital setting. These are:
1) Outcome goals of medication safety;
2) Financial costs and effectiveness;
3) Medications available for and their use;
4) Safety culture;
5) Technical components of the medication use system;
6) Factors affecting medication use by patients; and
7) Staff competency.
The contribution to knowledge has been the development of a multi-stakeholder derived conceptual framework for medication safety measurement. As a consequence of this research, the measurement of medication safety should change from one which has been narrow and fragmented, to one which is multi-dimensional and holistic.
The developed framework incorporates diverse multi-stakeholder views and preferences increasing its relevance in the local context and is important for engagement and buy-in. It draws together all meaningful dimensions and facets providing a necessary and robust single theoretical frame to measure medication safety. Understanding stakeholders’ priorities and beliefs for medication safety can also be used to facilitate improvement programmes.
An Organisational Study into the Impact of Mobile Devices on Clinician and Patient Experience in Auckland, New Zealand
Bohot, Kelly L.; Hammond, Rebecca C.; and Stanbrook, Teresa A (2017)
Patient Experience Journal 2017; 4(1):9View abstract
Mobile technology has potential to improve workflow, patient safety and quality of care, and has been identified as an important enabler of community services. However, little is known about the impact of mobile device use on clinician and patient experiences. Eleven community allied health clinicians were provided with live access to electronic health records, their email and electronic calendar, peer reviewed education and therapy mobile applications via a mobile device.
Three data measures were collected over 19-weeks. First, quantitative time and motion data was gathered at baseline and follow-up to enable longitudinal analysis of clinician workflow. Second, a questionnaire consisting of rateable statements, multi-choice and open questions was completed at baseline and follow-up to enable analysis of clinician experience. Third, a short questionnaire was completed with a convenience sample of 101 patients who experienced mobile device use in their home. Clinicians and patients reported positive experiences associated with access to electronic health information at the point of care and the use of pictures, diagrams and videos to support clinical interactions. There was a significant reduction in time spent on patient related administration (p<0.0001) and a significant increase in direct patient contact time (p<0.0001) following 15 weeks of mobile device use.
This study indicates that mobile device use has potential to improve clinician and patient experiences of community allied health through improvements in workflow and efficiency, improved clinician-patient interactions and improvements in health information flow.
Development of a Culturally Tailored Text Message Maternal Health Programme (TextMATCH)
Dobson, R; Whittaker, R; Bartley, H; Connor, A; Chen, R; Ross, M; McCool, J (2017)
JMIR mHealth & uHealth Apr 2017; 5(4):e49. DOI:10.2196/mhealth.7205View abstract
BACKGROUND: Mobile phones are increasingly being used to deliver health information and health services globally. Mobile health (mHealth) interventions may be well-suited for minority groups with greater barriers to accessing traditional health services. However, little has been written about the process of culturally adapting interventions for multiple ethnic and cultural minorities within a population.
OBJECTIVE: This study describes the process of developing a culturally tailored text message-based maternal health program (TextMATCH: Text for MATernal and Child Health) for Māori, Pacific, Asian, and South Asian families living in New Zealand. We report on engagement and acceptability of the TextMATCH program.
METHODS: Program data was examined to describe engagement with the program 18 months after implementation. Telephone interviews were conducted with a sample of participants who consented to provide feedback on acceptability and relevance of the program.
RESULTS: A total of 1404 participants enrolled in TextMATCH over 18 months, with 18.52% (260) actively opting out at some point (after 0 to 17 months of messages). It was found that 356 (70.9%) of the 502 eligible participants actively switched from the initial pregnancy program to the baby program after delivery. Phone interviews were conducted with 29 participants including 6 who had withdrawn (duration of program from 3 to 16 months). Only 2 participants reported that the program was not useful, with the remainder rating the usefulness of messages positively (average 4.24 out of 5). All participants stated that the messages were relevant, culturally appropriate, and easy to understand. Most were happy with the specific advice and the language options provided.
CONCLUSIONS: We have demonstrated the importance of an intensive approach to the development of a culturally adapted and tailored mHealth program for multiple different cultural minority groups within our population.
Getting the Foundations Right for the Measurement of Medication Safety: the Need for a Meaningful Conceptual Frame
Ng, J; Scahill, S; Harrison, J (2017)
NZ Medical Journal 2017; 130(1452):54-62View abstract
A number of initiatives aimed at improving medication safety in and across New Zealand public hospitals have been introduced over recent years. Clinicians, policymakers and patients now want to know whether patients are safer today from medicine use than they have been in the past.
The challenge has been determining exactly what should be measured. In this viewpoint, we critically examine the suitability of adverse drug events (ADE) as a primary metric for assessing the progress of medication safety improvement. We provide an overview of contemporary dialogue on medication safety measurement and highlight the emergent challenges.
Finally, we reflect on how New Zealand has approached medication safety measurement so far and argue the need for a multi-stakeholder informed conceptual framework with a view to further enhancing meaningful assessment of medication safety.