Nurses in Barcelona adopt the culture of dialogue to define their professional future

5 Apr
Glòria Novel and Núria Cuxart

Asking ourselves questions, reformulating questions, rethinking the way we want to be, what we need and how we want society to know and see us. This is, without doubt, a difficult exercise to carry out as individuals but it is even more difficult to do this as a profession.

Agreeing with each other is by no means easy. Training, method and a desire to do so is needed. Having these premises clear, we initiated the RESET project at the Official College of nurses of Barcelona (COIB).

Guided by the company Diàlegs, specialised in mediation in health, we initiated an unprecedented process of participation in the nursing profession during which we went out into the territory to find out what the concerns, needs, wishes, complaints and proposals of nurses in the province of Barcelona were.

The process lasted the whole of 2017, after which our corporation was given the commission to develop the strategic lines on which the college members of Barcelona want us to work along with thousands of ideas that they would like to process.

The difficulty of the project was considerable. Apart from the geographical distances that existed and the difficulties in getting nurses involved, there was the added difficulty of coming up with a dynamic that had to be participative so as to facilitate environments of conversation, discussion and consensus among the hundreds of female and male nurses who have different professional realities and therefore varying priorities.

The Diàlegs company took on the challenge of making it possible by means of a process lasting 12 months during which participative methodologies were used to define the profession as it is today and that of the desired future. The framework for the project was based on the principles, values and methodologies of mediation, which led to a broad and necessarily inclusive view of the differences and susceptibilities of the nursing community.

The RESET project was carried out in three different stages: in the first stage, open debates were set up in circles of group discussion. The circles enabled a comprehensive collection of very valuable data which formed the basis on which to develop the following stages that consisted of two days of consensus: one to agree on the diagnosis of the situation the profession finds itself in now and another to define the future, with the aims and lines of action to be developed.

As a result of these three stages of the RESET project, 52 group discussion circles with 925 participants were set up, that is, with people who participated one or more times. 3,762 ideas were collected as well as some proposals for the future, with nine thematic areas and 65 lines of action decided on by agreement. The level of satisfaction was very high and the participants showed a high level of interest in continuing in the project, repeating participations in the three stages.

It must be said that the key to the success of the process was the large number of people that committed themselves to the project right from the start. We are referring to what we called the Driving Group made up of 208 people (with representatives from all over the territory, all positions and susceptibilities) who worked from the start both in the co-design of specific aspects as well as in the diffusion, organisation of group discussion circles and participation in the events for consensus.

Beyond the results of the RESET project, which are, in the end, a commitment to change with implications for the upcoming years, we still have much to learn and this can no doubt be extrapolated to the professional disciplines in health in which we are organised through colleges. We need to continue asking ourselves questions both in and out of the college organisations to positively drive change and development in all the aspects which bring us together as professionals. Continuity in the culture of dialogue is one of the most important challenges that came out of this fascinating process. This was the message that the nurses who worked in the Reset Project gave us. Therefore, from the COIB, this is our commitment.

Post written by Núria Cuxart Ainaud, director of programmes at the COIB, and Glòria Novel Martí, founding director of Diàlegs.

Low value clinical practices from the citizenry’s perspective

13 Oct

During the fifth edition of the international Preventing Overdiagnosis Congress, strategies for implementing solutions to avoid overdiagnosis and overuse were addressed based on the available scientific evidence.

In this year’s edition, which was held in Barcelona last year, apart from the involvement of professionals and organisations, patients had the opportunity to actively participate.

Experiences in different healthcare areas were shown in the use of best practices to communicate and to empower patients to achieve a better understanding of shared decisions.

Different world initiatives addressed the best practices to empower citizens in subjects related to low value practices, overdiagnosis and overtreatment. Experiences were shared and a debate was initiated on fundamental subjects such as the communication and participation of patients.

In recent years, the Essencial Project has studied the perspective of health professionals on low value practices, their causes and possible solutions so as to avoid them.

Essencial Project team: Cari Almazán, Johanna Caro, Liliana Arroyo and Hortènsia Aguado

For example, in a previous post, we explained the results of a survey we carried out with professionals in the field of primary care. The results of this survey highlighted the need to involve and empower the population more. Patients are also important decision makers in relation to their needs and in the demand for certain health services. Hence, the project must be accompanied by a communications strategy aimed not only at patients but also at citizens in general.

That is why we, from the Essencial Project, have been interested in finding out the opinion of patients in addition to the perspective of professionals. In the international Preventing Overdiagnosis 2017 Congress we participated explaining how an exploratory first approach was made to identify the beliefs, attitudes and perceptions of patients regarding the most important elements in consultations, low value practices and the essential components of an effective dialogue between professionals and patients. The end purpose of this was to understand the position of people before initiating possible interventions in the citizenry and to determine the most effective communicative tools and channels.

In Catalonia, AQuAS carried out the first exploratory qualitative study at the end of 2016 using a focus group of parents and children assigned to a primary care team. Low value practices in paediatrics are frequently associated with an over-diagnosis regarding antibiotics, bronchodilatadors, antipyretics or imaging tests, among others. These scenarios have been transferred to the debate with patients themselves. In total, seven women, mothers and grandmother of 14 children participated.

The first point of discussion was the most important elements in a consultation with health professionals and it was found that the treatment (29%) and information received (28%) are the most important elements received by professionals (representing approximately 60% of those mentioned). The relationship with the professional comes next (15%, often related to the degree of trust), followed by the feeling that their wishes or needs are met (12%), information requested (9%) and the diagnosis (5%).

The participants did not know the concept of low value practice but did recognise situations of an excessive prescription of medication or the request of unnecessary tests, especially in emergency services and private consultations.

Regarding communication, the participants said they appreciated that professionals communicate in a simple and direct manner, explaining the reasons for decisions. Similarly, that they felt it was important to receive printed information from professionals which they could peruse later at home. They also said they would like more informative sessions or community groups where these types of subjects could be explained to them and so gain more knowledge about these types of practices.

In our context, this is the first exploratory study done to identify low value practices and the communicative strategies of the citizenry, being the start of a series of studies on the population. Nonetheless, one of the limitations with which we find ourselves was that the participation was lower than expected. Although the term ‘low value practices’ is not known, participants identify situations in which they have experienced them.

Similarly, it is important to underline how patients value the treatment and information received as well as the professional-patient relationship. In the same way, patients recognise the need for a professional’s communication skills and the need for tools to support an effective communicative exchange.

Post written by Johanna Caro Mendivelso (@jmcaro103).

The speed and relevance of assessing health products

5 Oct
Emmanuel Giménez

The European market of health products has been widely affected by the sudden emergence of a new legislative framework with the new regulations (2017/745 and 2017/746). The subtle difference between directive and regulation is paramount, they say, but we’ll leave that for another occasion. This new framework in the field of health products is characterised among other things by:

  1. A stricter control of high risk health products (for example, certain implantable products)
  2. The strengthening of rules of clinical evidence by including a coordinated procedure at a European level for the authorisation of multicentre clinical research.
  3. The reinforcement of requirements and the coordination between European countries regarding controls and after sales aspects.

In this context of important changes, the assessment community is also clearly active. Thus, on 19 June this year, there was a panel on health products at the international meeting of Health Technology Assessment HTAi, where a new and innovative Italian programme for health products was presented.

The programme, explaining the work carried out over several years in terms of definition and its pilot phase, includes three work packages: appraisal, methodology and monitoring. In another panel closely related to the previous one, in the field of methodology, the presentation of the categories to decide on what to invest in and what to disinvest win clearly stood out.

When talking about monitoring and collecting information, an example that stood out was the debate on the need for early assessments given that the life cycle of a health product tends to be short.

The significant increase in new products available and all the work objects previously mentioned are some of the things that position the importance of specific assessment in health products.

The importance of the assessment of health products is, therefore, undeniable. In the joint production work package of EUnetHTA JA3, in which AQuAS is participating, as many or more assessments of “other technologies” (health products, health interventions,…) have been planned as of the known assessments of drugs. In a sense, the numbers of one or other necessity are matched. The importance of the assessment of “other technologies” was in fact reflected in the HTAi annual meeting in a presentation by Wim Goettsch, director of EUnetHA.

The identification and prioritisation of products to be assessed (the Horizon Scanning system), as well as the balance between innovation and divestment, are also extensively discussed subjects and under continuous debate. Thus, in the REDETS network (in which the AQuAS is also actively participating) and with the leadership of Avalia-T, a public access tool was identified that helps in approaching this subject: the PriTec.

Assessment, therefore, can help directly in the use, management and sustainability of different health systems. In conclusion, new opportunities are provided for improving decision making in the area of health products and some of them will come through demonstrating efficiency by means of the adequate use and definition of health technology assessments (HTA).

Post written by Emmanuel Giménez.

Methodological innovations in Central de Resultats 2014

1 Dec

OLYMPUS DIGITAL CAMERAJosep Maria Argimon, AQuAS Director

Central de Resultats’ reports consolidate some data and some analysis based on: patient-centered care, appropriateness, patient safety, efficiency, economic sustainability and training. This is thus a repository of knowledge tuned each year by counting on experience and innovation.

Regarding the issue of the Central de Resultats for 2014 (based on data 2013) the following methodological developments are the most remarkable:

  1. Primary care report’s innovations. The most highlighted technical novelty for primary care is that for the first time the data from Central de Resultats feed from minimum basic data set (EHR), which opens a new range of possibilities for future processes. Another novelty is the incorporation in this report of the segmentation based on Clinical Risk Group differentiated for the population assigned to each of the 369 primary care teams of the public network.
  2. Monograph report of diabetes. Since 1993, when the program of continuous improvement of the care quality was initiated from the indicators of “Group study of diabetes in primary care” (GEDAPS), there has been a gradual improvement in diabetes care, both of process indicators and of outcome. For this reason, this year it has been convenient to entrust a monograph report to “Diabetes Epidemiological Research Group from Primary Care – IDIAP J. Gol”, in order to confirm that the strategy of enhancing competency among teams of primary care in this clinical process is the most appropriate.
  3. Hospital activity’s synthetic appropriateness index. The appropriate use of hospitals, the most expensive resource of all health care systems is key to the overall sustainability for the health sector. After a couple years of internal testing, now a monograph on this new synthetic indicator is presented which consists of 10 specific indicators that reflect: a) ambulatory care sensitive conditions for 5 chronic diseases, b) appropriate use of hospital emergencies, c) excessive consumption of hospital stays for femur fractures and ictus, and d) surgical overacting (caesarean section rate). The results of the synthetic adequacy index are shown both for hospitals as well as for each territory.
  4. Mortality at 30 days from hospital admission. The traditional way to measure hospital mortality is the one that emerges from the hospital minimum basic data set (MBDS), when the circumstance of hospital admission records the “death”. Clearly, this is a very limited source for the analysis of mortality, since after hospitalization for certain severe diseases, people can die in a geriatric home, at home or in another hospital admission that differs from the first. Motivated by this limitation of traditional indicators of mortality, several agencies, most notably Medicare in the US and Dr. Foster Intelligence in the UK, have promoted the intersection of databases to detect mortality at 30 days from the hospital admission, regardless of the place of death. Following this same hint, this Central de Resultats edition, after crossing, from MSIQ – CatSalut, the MBDS with the central registry of insured, offers the novelty of hospital mortality at 30 days of admission duly adjusted for age, sex and morbidity, for a group of selected diseases, but also, specifically, for 5 conditons.
  5. New specific indicators for 3 clinical processes: myocardial infarction code, stroke code and hip fractures. From the heart attack and stroke codes sources and from the arthroplasty (RACat) data, this year the Central de Resultats incorporates circuits’ efficacy data (time to effective clinical intervention: angioplasty, fibrinolysis or surgery).
  6. Information technology and communication trends map. The hospitals report includes, this year, the TICSalut map of trends in information technology and communication. The indicator consisting of eHealth Benchmarking IC-EU27, which puts Catalan hospitals on a high level of development of these technologies and, specifically, the electronic health record, is notable.
  7. Novelties in the report for chronic care area. This second report for the chronic care area is more dynamic and functional than the first, in the sense that not only performance data and sustainability of suppliers are provided, but also the lines of analysis that make sense for groups of well defined patients has been open: the end of life period, dementia and neurological diseases with disabilities. The report also contains a section for older people with chronic conditions, that provides a significant methodological innovation due to the fact that it combines the hospital and chronic care stays for patients with hip fracture and stroke.

Acknowledgments. The Central de Resultats’ exercise of transparency emanates from a political decision of the Department of Health, but to make this possible, the innovative cleverness of professionals working in the different information systems from the Department of Health, CAtSalut, AQuas Observatori de Salut and specific directory plans, has been essential. To all of them, I want to express my appreciation and my plea not to lose the drive which is indispensable to consolidating the experience, while continuing to refine the proposed analysis.