Clinical practice guidelines (CPGs) for Attention Deficit Hyperactivity Disorder (ADHD) recommend documentation of symptom scales and comorbidity screenings at the time of diagnosis and routinely throughout care. Rates of documentation for these tools in pediatric primary care are consistently low, creating a gap in care that impairs diagnosis, management, and patient outcomes. The purpose of this quality improvement project was to implement an online ADHD portal that emails, collects and scores these tools. The aims of the project are to improve utilization of CPGs by increasing documentation rates of symptom scales and comorbidity screenings for pediatric patients with ADHD. One primary care pediatrician located in Middle Tennessee piloted the project, with the goal to expand this practice change to additional partners in the future. Following submission to the IRB, the committee determined this type of quality improvement project to not require their oversight. A six-month retrospective chart review was conducted to determine baseline rates of documentation for the two outcomes. During the ten-week project, the portal was activated and evaluation tools were sent. A second chart review will be conducted at the conclusion of the project to determine if utilization of CPGs for the two outcomes has improved. Limitations included small sample size and accessibility barriers. The expected outcomes of this project include successful implementation of the online portal with improved rates of documentation for symptom scales and comorbidity assessments. This project could potentially improve CPG utilization and ultimately impact the quality of care for pediatric patients with ADHD.

Background: Health information system (HIS) performance has been defined as “data quality and the continuous use of information †. The quality of data, as well as the culture of data use in an organisation has been shown to shape the way data is used. In order to fully understand data use practices with the aim of strengthening the HIS, one needs to first understand whether the context and “culture†in the organisation is conducive to data use. Are the policies, structures, processes and people within the organisation aiding data use? In what ways do managers view and use data? Aim: In this study, we sought to explore the culture of health information use on a district and sub district management level. The aim was to contribute to the wider knowledge on information use by exploring the data use practices and factors that shape its use among these managers. What is the culture of data use in the district management structures? When, why and in what way does data get brought into the management discussion? Do managers feel that the information produced are useful in aiding their decision making, and what do they recommend be changed? What are the key factors that affect data use practices? Methods: This thesis comprises a literature review of published articles, conducted in order to provide context for the study of the culture of data use, whilst defining the problem to be investigated. The full thesis comprises the literature review, the original study protocol, a full manuscript in the format of a publishable article and a set of appendices. The study was granted ethical approval and permission from the provincial department of health. Given the exploratory purpose of the study, we conducted a mini ethnographic case study using qualitative research methods in a rural health district of the Western Cape Province of South Africa. The researcher employed ethnographic methods that included participant observation, in depth key informant interviews, document reviews as well as informal conversations to collect data. We used the PRISM framework as a guide for analysing our findings. Findings: Our findings suggest that there is a strong focus in this district on reporting requirements and technical aspects of producing good quality data. The drive to achieve excellence in production of quality data may be in tension with another important organisational value, which is the need of managers, for ease of access to relevant data, to facilitate decision-making and improvement of health service delivery. Managers’ overall experience is of not receiving the health information support they require. Instead, they experienced an organisational culture of using health information to narrowly measure targets and performance, which left them feeling unsupported and frustrated. Managers were resilient in managing these challenges and created alternative ways of accessing the data they needed for decision-making. Conclusion: We conclude that in our setting where the technical component of producing good data was well performed, this was not sufficient to guarantee effective use of data for quality improvements. Behavioural and organisational factors were found to play an important role as both obstacles and facilitators in shaping the culture of data use, information that is useful to inform design of interventions for health information strengthening.

BACKGROUND: There is continued attention towards using patient demographic and clinical characteristics available in health administrative data when case mix adjusting the measurement of length of stay (LOS) for hospitalized children. However, little is known about what proportion of children’s LOS is explained by these characteristics. OBJECTIVES: The objectives of the study were to quantify the amount of variation in LOS within and across hospitals that is explained by demographic and clinical factors of hospitalized pediatric patients. METHODS: A retrospective cohort analysis was completed of 818,848 hospitalizations for any reason occurring from 1/1/2014 to 12/31/2014 in one of 44 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. A generalized linear model was derived to simultaneously regress demographic factors [age, race/ethnicity, payer, rural residence, health professional shortage area (HPSA) residence, income, and distance traveled], and clinical factors (severity of illness, type and number of chronic conditions) on LOS. The percentage of LOS attributable to each characteristic within each hospital was quantified using the covariance test of the hospital random effect. RESULTS: The factors with the greatest impact on LOS were severity of illness and chronic condition type and number, with a median (interquartile range) of 16.8% (IQR 15.0%-19.4%) and 4.0% (IQR 2.9%-4.5%) of LOS, respectively, explained by these characteristics across hospitals. LOS varied significantly (p<0.05) with both severity of illness and chronic condition type and number for all 44 hospitals in the cohort. All patient demographic factors, (age, race/ethnicity, payer, rural residence, HSPA residence, income, and distance traveled) had minimal impact on LOS, with <0.1% of LOS explained by each characteristic. Across hospitals, 78.3% (IQR 75.8-80.2%)] of LOS remained unexplained by the patient characteristics under study. CONCLUSIONS: Patients’ clinical characteristics ascertained from administrative data account for approximately one-fifth of LOS whereas their demographic characteristics account for a negligible amount. Efforts to optimize the efficiency of inpatient care for hospitalized children might benefit from uncovering how much of the vast amount of unexplained LOS is due to modifiable aspects of care quality. / 2018-06-16T00:00:00Z

Nurses are expected to perform evidence-based practice (EBP) at the point of care (POC) to promote positive outcomes through the quality and safety of patient care. The struggle for nurses on the surgical digestive unit in a hospital to adopt EBP is the lack of access and knowledge to evidence-based research at the POC. The utilization of information technology is an innovated approach to providing access and knowledge for EBP at the POC to improve patient outcomes. The project was to develop a quality improvement program to improve nursing access and knowledge of EBP resources. The program was to identify the type of e-nursing resources and necessary education to provide nurses access to evidence-based resources and the knowledge to utilize these resources in nursing practice. The purpose of the doctoral project was set to identify necessary resources to develop an evidence-based program for staff nurses to access evidence-based resources and improve nursing knowledge on EBP at the POC. The use of the Stevens's star model of knowledge transformation was the framework for the project, and use of the logic model guided the structure for program evaluation. The quantitative project used a 1 group pre- and post-survey design using a convenience sample (n =10). A final statistical analysis to determine effectiveness of the educational intervention was inconclusive. Quantitative descriptive data from pre- and post-survey results were used to summarize recommendations for the future development of an EBP quality improvement project with the use of information technology tools. The further dissemination of the findings could promote new methods to implement quality improvement programs to improve the quality and safety of patient care to promote positive health outcomes.

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13004号 / 論社医博第8号 / 新制||社医||9(附属図書館) / 32932 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 木原 正博, 教授 黒田 知宏 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

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The purpose of this thesis was to explore the literature regarding physicians’ prescriptions of opioid analgesics before and after The Joint Commission Pain Standards for 2001. Opioids are a last resort treatment for chronic pain due to their high potential for tolerance, dependency, and misuse. The establishment of The Joint Commission Pain Standards for 2001 was the culmination of several movements to address the underassessment and undertreatment of pain. The Joint Commission Pain Standards for 2001 focused on improving pain assessment, management, and treatment through a systematic approach. The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is the largest accrediting body for healthcare organizations in the United States and affects thousands of medical care facilities and physicians. Although many physicians were hesitant to prescribe opioids due to addiction concerns, opioid prescriptions rose due to pressures to meet the TJC’s accreditation requirements and maintain patient satisfaction. Pain management seemed to improve for a short period before adverse reactions and unintended consequences emerged. Confusing language within the TJC Pain Standards for 2001 and its supplemental materials and misleading information from researchers and pharmaceutical companies led to unnecessary pain measurement, problematic pain treatment algorithms, and excessive opioid analgesic use. As patient safety concerns emerged, the TJC continuously amended the TJC Pain Standards for 2001. They were revised in 2017 as the opioid epidemic became a national public health emergency. The TJC has since called for better evaluation of research validity, more vigilant examination for conflicts of interest, and more detailed instructions on interpreting and implementing future standards. The medical community, pharmaceutical industry, government, and the public need to coordinate future strategies to combat the opioid epidemic.

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