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ABSTRACT: Lean has gained recognition in healthcare as a quality improvement tool. The purpose of this research was to examine the extent to which quality improvement projects in healthcare adhered to Lean's eight-step process. We analyzed 605 publications identified through a systematic literature review following PRISMA guidelines. Each publication was coded using a structured coding sheet. The most frequent type of publication reported empirical research (48.6%) and most of these (80.3%) shared the results of the Lean projects. Of the 237 publications reporting Lean projects, more than half (71.3%) used an experimental, one-site, pre/postdesign. The impact of the project was most often measured using a single metric (59.1%) that was operational (e.g., waiting time). Although most Lean project publications reported the use of tools to "break down the problem" (84.4%, Step 2) and "see countermeasures through" (70.0%, Step 6), fewer than half described using tools associated with each of the other steps. Projects completed an average of 2.77 steps and none of the projects completed all steps. Although some may perceive low adherence to the tenets of Lean as a deficiency, it may be that Lean approaches are evolving to better meet the needs of healthcare.
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Actitud del Personal de Salud , Atención a la Salud/normas , Eficiencia Organizacional/normas , Personal de Salud/psicología , Guías de Práctica Clínica como Asunto , Mejoramiento de la Calidad/normas , Adulto , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: Family responsibilities and social expectations often prompt conflict in caregivers' decision-making processes. Janis and Mann's (1977) conflict model describes vigilance as high-quality decision-making resulting in optimal outcomes. The purpose of our research was threefold: (1) to describe decision styles in a population of family caregivers of persons with dementia; (2) to examine the socio-economic characteristics associated with caregivers who are more likely to be vigilant decision-makers; and (3) to assess differences in caregiving experiences between vigilant and non-vigilant caregivers. METHOD: Our analysis was based on 639 survey respondents recruited from a university-affiliated memory disorders clinic. RESULTS: Our typical caregiver was Caucasian non-Hispanic, was currently married, and had two children. Approximately half of our sample used a 'pure vigilant' decision style. Vigilance was associated with more positive and fewer negative caregiving outcomes. CONCLUSION: Supporting caregivers to become vigilant decision-makers is a functionally viable intervention that could significantly improve the caregiving experience.
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Cuidadores/psicología , Toma de Decisiones/fisiología , Demencia/enfermería , Familia/psicología , Adulto , Anciano , Anciano de 80 o más Años , Conflicto Psicológico , Humanos , Persona de Mediana Edad , Teoría PsicológicaRESUMEN
Recent research on the decision-making abilities of older adults has shown that they use less information than young adults. One explanation ascribes this age difference to reductions in cognitive abilities with age. The article includes three experimental studies that focused on determining the conditions in which older and young adults would display dissimilar information processing characteristics. Findings from Studies 1 and 2 demonstrated that older adults are not necessarily at greater disadvantage than young adults in decision contexts that demand more information processing resources. Findings from Study 3 indicated that older adults when faced with decisions that require greater processing are likely to use a strategy that reduces the amount of information needed, whereas younger adults rely on strategies that utilize more resources. Combined the findings indicate that older adults change their decision-making strategies based on the context and information provided. Furthermore, support is provided for processing difference.
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Organizations use lean principles to increase quality and decrease costs. Lean projects require an understanding of systems-wide processes and utilize interdisciplinary teams. Most lean tools are straightforward, and the biggest barrier to successful implementation is often development of the team aspect of the lean approach. The purpose of this article is to share challenges experienced by a lean team charged with improving a hospital discharge process. Reflection on the experience provides an opportunity to highlight lessons from The Team Handbook by Peter Scholtes and colleagues. To improve the likelihood that process improvement initiatives, including lean projects, will be successful, organizations should consider providing training in organizational change principles and team building. The authors' lean team learned these lessons the hard way. Despite the challenges, the team successfully implemented changes throughout the organization that have had a positive impact. Training to understand the psychology of change might have decreased the resistance faced in implementing these changes.
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Centros Médicos Académicos/organización & administración , Procesos de Grupo , Grupo de Atención al Paciente/organización & administración , Mejoramiento de la Calidad/organización & administración , Humanos , Capacitación en Servicio/organización & administración , Cultura Organizacional , Innovación Organizacional , Alta del Paciente , Garantía de la Calidad de Atención de SaludRESUMEN
While patient barriers to colorectal cancer (CRC) screening have been identified, how well this knowledge is utilized during the patient-physician interaction is not fully understood. This study aims to assess among primary care physicians the degree of consensus between perceived and actual patients' CRC screening decision-making influential factors. During 2004-2006, 30 patients were interviewed to identify factors influencing screening decisions and 66 physicians were interviewed to understand what factors they thought were important to patients. The factors were categorized using the PRECEDE-PROCEED framework, and perspectives were compared. The researchers found little consensus on CRC screening decision-making influential factors between family practitioners, general internists, and patients. The recommendations to reach consensus are provided on the individual (e.g., updating the contents of a physician's screening recommendation to proactively address patients' decision-making needs) and population (e.g., providing cross-cultural training to medical students enabling them to better understand their patients) levels.
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Neoplasias Colorrectales/diagnóstico , Toma de Decisiones , Detección Precoz del Cáncer/estadística & datos numéricos , Conocimientos, Actitudes y Práctica en Salud , Rol del Médico , Pautas de la Práctica en Medicina , Adulto , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Encuestas y CuestionariosRESUMEN
BACKGROUND: Little is known about how patients decide whether or not to undergo colorectal cancer screening. Although low screening rates evidence the outcome of these decisions, the processes patients use to balance benefits, risks, and costs with their own values and preferences are unclear. To increase screening rates, and ultimately save lives, it is important for providers to be aware of how patients make screening decisions. OBJECTIVES: The purpose of this study was to identify patterns of patient colorectal cancer screening decisions that might be supported by health care providers. POPULATION: In this study, we focused on people from Central Kentucky--a region with historically low screening rates. METHOD: We interviewed patients using a semi-structured format. Three members of the research team independently analyzed each interview transcript for factors that influenced the decision, and a pictorial representation of each decision process, based on Kurt Lewin's theory of decision making, was constructed for each participant. The individual decision processes were compared with identify patterns. RESULTS: Seventeen women and 13 men made up the sample. We discerned 7 decision patterns. CONCLUSIONS: This research documents 7 patterns and identifies common driving and restraining forces.
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Actitud Frente a la Salud , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/psicología , Toma de Decisiones , Tamizaje Masivo/psicología , Participación del Paciente/estadística & datos numéricos , Anciano , Femenino , Humanos , Kentucky , Masculino , Tamizaje Masivo/métodos , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Aceptación de la Atención de Salud/estadística & datos numéricos , Educación del Paciente como Asunto , Satisfacción del Paciente/estadística & datos numéricos , Relaciones Médico-Paciente , Encuestas y CuestionariosRESUMEN
OBJECTIVE: The purpose of this study was to identify decision heuristics utilized by primary care physicians in formulating colorectal cancer screening recommendations. DESIGN: Qualitative research using in-depth semi-structured interviews. PARTICIPANTS: We interviewed 66 primary care internists and family physicians evenly drawn from academic and community practices. A majority of physicians were male, and almost all were white, non-Hispanic. APPROACH: Three researchers independently reviewed each transcript to determine the physician's decision criteria and developed decision trees. Final trees were developed by consensus. The constant comparative methodology was used to define the categories. RESULTS: Physicians were found to use 1 of 4 heuristics ("age 50," "age 50, if family history, then earlier," "age 50, if family history, then screen at age 40," or "age 50, if family history, then adjust relative to reference case") for the timing recommendation and 5 heuristics ["fecal occult blood test" (FOBT), "colonoscopy," "if not colonoscopy, then...," "FOBT and another test," and "a choice between options"] for the type decision. No connection was found between timing and screening type heuristics. CONCLUSIONS: We found evidence of heuristic use. Further research is needed to determine the potential impact on quality of care.
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Neoplasias Colorrectales/prevención & control , Toma de Decisiones , Tamizaje Masivo/métodos , Médicos de Familia , Adulto , Actitud Frente a la Salud , Competencia Clínica , Colonoscopía/estadística & datos numéricos , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Sangre Oculta , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/tendencias , Sensibilidad y Especificidad , Encuestas y CuestionariosRESUMEN
OBJECTIVE: The purpose of this research was to examine the content of physicians' colorectal cancer screening recommendations. More specifically, using the framework of informed decision making synthesized by Braddock and colleagues, we conducted a qualitative study of the content of recommendations to describe how physicians are currently presenting this information to patients. METHODS: We conducted semi-structured interviews with 65 primary care physicians. We analyzed responses to a question designed to elicit how the physicians typically communicate their recommendation. RESULTS: Almost all of the physicians (98.5%) addressed the "nature of decision" element. A majority of physicians discussed "uncertainties associated with the decision" (67.7%). Fewer physicians covered "the patient's role in decision making" (33.8%), "risks and benefits" (16.9%), "alternatives" (10.8%), "assessment of patient understanding" (6.2%), or "exploration of patient's preferences" (1.5%). CONCLUSION: We propose that the content of the colorectal screening recommendation is a critical determinant to whether a patient undergoes screening. Our examination of physician recommendations yielded mixed results, and the deficiencies identified opportunities for improvement. PRACTICE IMPLICATIONS: We suggest primary care physicians clarify that screening is meant for those who are asymptotic, present tangible and intangible benefits and risks, as well as make a primary recommendation, and, if needed, a "compromise" recommendation, in order to increase screening utilization.
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Neoplasias Colorrectales/diagnóstico , Comunicación , Toma de Decisiones , Tamizaje Masivo , Educación del Paciente como Asunto/organización & administración , Médicos de Familia/psicología , Adulto , Actitud del Personal de Salud , Actitud Frente a la Salud , Femenino , Conocimientos, Actitudes y Práctica en Salud , Directrices para la Planificación en Salud , Humanos , Consentimiento Informado , Kentucky , Masculino , Tamizaje Masivo/métodos , Tamizaje Masivo/normas , Persona de Mediana Edad , Participación del Paciente/métodos , Participación del Paciente/psicología , Selección de Paciente , Relaciones Médico-Paciente , Médicos de Familia/organización & administración , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Encuestas y Cuestionarios , IncertidumbreRESUMEN
The lifetime risk of developing colorectal cancer is 2.5 to 5% in the general population. Colorectal screening can prevent mortality, and there are a number of screening methods, ranging from noninvasive to highly invasive. Although recommendations have been widely disseminated in the media and scientific journals, screening usage is low. In this project, the authors examine the factors that influence individuals' decisions regarding colorectal screening. They conducted semistructured interviews with 30 people (13 men and 17 women) selected to provide a maximum variation sample. They categorized factors into the following themes: concern for one's personal well-being, competing demands, preparing for the procedure, the screening process, gender concerns, fear of having cancer, feeling healthy, cost, the experiences of others, and turning 50 years old.
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Neoplasias Colorrectales/diagnóstico , Toma de Decisiones , Examen Físico/estadística & datos numéricos , Femenino , Humanos , Entrevistas como Asunto , Kentucky , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Research has shown that dementia often goes unrecognized, and diagnostic assessment is often further delayed. Understanding families' decision to seek care at memory clinics is relevant to efforts to facilitate early diagnosis. OBJECTIVE: To examine the population seeking care at two memory clinics and the triggers causing caregivers to seek diagnostic assessment for a family member. METHOD: We surveyed a consecutive sample of caregivers who accompanied a patient to an assessment at two university memory disorders clinics. Caregivers (n=416) described events that led them to seek a memory assessment for the patient, as well as who first suggested an assessment and diagnosis received. RESULTS: Changes in the patient (cognitive, personality/behavioral, physical, or unspecified) accounted for 81% of 903 trigger events reported. Nearly half of the caregivers noting specific patient changes recorded some combination, rather than cognitive changes alone. Of the 338 respondents who noted a change in the patient as a trigger, 85% specified at least one cognitive change, while 40% specified at least one personality/behavioral change. Memory loss was most frequent trigger reported, followed by disorientation and recommendations (lay or professional). Caregivers themselves and non-specialist physicians were the most frequent sources of recommendations noted by all respondents. CONCLUSION: A broad range of trigger events, beyond cognitive or symptomatic changes, caused caregivers to seek diagnosis at a memory clinic. Awareness of triggers significant to families may help physicians reduce the number and severity of events needed to convince caregivers a memory assessment is indicated.
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Cuidadores , Demencia/diagnóstico , Aceptación de la Atención de Salud , Anciano , Atención Ambulatoria , Trastornos del Conocimiento/complicaciones , Toma de Decisiones , Demencia/psicología , Evaluación Geriátrica , Humanos , Trastornos de la Memoria/diagnóstico , Persona de Mediana Edad , Trastornos del Movimiento/complicaciones , Trastornos de la Personalidad/complicaciones , Accidente Cerebrovascular/complicacionesRESUMEN
This study examined the characteristics of entry into the caregiving role for family and friends of older adults suffering from dementia. Using data from a large community survey of informal caregivers of patients who visited the University of Kentucky's Alzheimer's Disease Research Center (n = 1055), respondents were classified into one of four onset sequences: recognition-diagnosis, care provision, recognition-care, and diagnosis dependent. A multinomial logistic regression identified several characteristics (i.e., caregiver income, time since onset, care recipient gender, care recipient living status, and primary caregiver identification) that were significantly associated with various caregiving onset patterns. The findings describe the complexity of the entry process and its potential association with health-related transitions in the caregiving career.
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Enfermedad de Alzheimer/terapia , Cuidadores/psicología , Anciano , Enfermedad de Alzheimer/psicología , Cuidadores/estadística & datos numéricos , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Modelos de Enfermería , Factores Socioeconómicos , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
The goals of this study were to identify the benefits and barriers perceived by family caregivers of persons who have been through a diagnostic assessment for dementia symptoms and to determine which caregivers experience more benefits and barriers associated with assessments. A survey was mailed to caregivers involved in the decision to seek a diagnostic assessment for a family member at a University of Kentucky memory disorders clinic. A total of 528 family caregivers (response rate 71.7%) returned a 4-page survey designed to elicit benefits, barriers, and demographic information. Respondents delayed the diagnostic assessment for an average of 22.4 months after noticing symptoms. Perceived benefits involved confirmation of a medical condition, access to treatment, and help preparing for the caregiving role. Barriers were both emotional and pragmatic in nature. Respondents who were younger, visited the rural assessment clinic, and had less education experienced more barriers. All groups reported receiving the same number of benefits from the assessment. By incorporating these benefits and barriers, interventions can be designed to increase the likelihood of early diagnostic assessments.
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Cuidadores , Demencia/diagnóstico , Accesibilidad a los Servicios de Salud , Trastornos de la Memoria/diagnóstico , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Toma de Decisiones , Escolaridad , Emociones , Relaciones Familiares , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Población Rural , Factores de TiempoRESUMEN
The usefulness of qualitative methodologies to augment and enrich quantitative studies is often overlooked. The authors' goals are to describe the qualitative process employed to generate survey items and to compare the results to those of studies that used different methodologies for item generation. The study identified barriers to and benefits of memory assessments. The survey item generation methodology, which involved 24 key informant interviews and 3 focus groups, resulted in the identification of 31 barrier and 28 benefit items. The 34 unique items were rated among the most important by survey respondents. The authors, therefore, present a strong case for generating survey items using informant interviews as groundwork for focus groups.
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Enfermedad de Alzheimer/diagnóstico , Actitud Frente a la Salud , Cuidadores/psicología , Familia/psicología , Evaluación Geriátrica , Encuestas de Atención de la Salud/métodos , Anciano , Toma de Decisiones , Grupos Focales , Humanos , Entrevistas como Asunto , Kentucky , Memoria , Proyectos de InvestigaciónRESUMEN
The purpose of this study was to identify essential information and support needs of family caregivers for individuals with Alzheimer's disease or a related dementia, and to examine the relationship between caregiver characteristics and needs. Caregivers (n=128, response rate=49.4%) returned a survey detailing information needs, support needs, and personal information. The need for information concerning diagnosis/treatment and legal/financial issues was more important than general information about the disease. Specifically, information about health plan coverage was most important. Experienced caregivers also needed legal/financial information, as well as support. Female caregivers rated needs related to support as significantly more important than male caregivers. Practitioners should realize that caregivers may have different information and support needs and these needs may change throughout the caregiving experience.