The incorporation of Māori environmental values as part of the Ruamāhanga Whaitua Implementation Programme in the Wellington Region, Aotearoa New Zealand

<p>In recent years, there has been significant efforts to create frameworks in which Māori values are incorporated as part of environmental management processes in Aotearoa New Zealand(Forster, 2014; Harmsworth et al., 2016). This research explores the factors that influence the incorporation of Māori values at the local government level, and what barriers Māori values face to being incorporated in environmental management. This research focused on a case study of the Ruamāhanga Whaitua Committe Implementation Programme process in the Wellington region. Semi-structured interviews were used to collect information on the opinions of members of the Ruamāhanga Whaitua Committee. The interviews were analysed using a critical theory approach. The research found that there was a clear discrepancy between the values and behaviours expressed by some non-Māori members of the Committee. The result of such a discrepancy was that Māori values were not sufficiently part of environmental decision making. Such a discrepancy was a result of the political structures of the Regional Council’s Whaitua Implementation Programme process. The majority of the decision-making power was found to be situated ‘higher’ up in the organisation, outside of the Committee. Overall this research found that there are important opportunities to make sure iwi values are not only included, but form the basis of decisions.</p>

The incorporation of Māori environmental values as part of the Ruamāhanga Whaitua Implementation Programme in the Wellington Region, Aotearoa New Zealand

<p>In recent years, there has been significant efforts to create frameworks in which Māori values are incorporated as part of environmental management processes in Aotearoa New Zealand(Forster, 2014; Harmsworth et al., 2016). This research explores the factors that influence the incorporation of Māori values at the local government level, and what barriers Māori values face to being incorporated in environmental management. This research focused on a case study of the Ruamāhanga Whaitua Committe Implementation Programme process in the Wellington region. Semi-structured interviews were used to collect information on the opinions of members of the Ruamāhanga Whaitua Committee. The interviews were analysed using a critical theory approach. The research found that there was a clear discrepancy between the values and behaviours expressed by some non-Māori members of the Committee. The result of such a discrepancy was that Māori values were not sufficiently part of environmental decision making. Such a discrepancy was a result of the political structures of the Regional Council’s Whaitua Implementation Programme process. The majority of the decision-making power was found to be situated ‘higher’ up in the organisation, outside of the Committee. Overall this research found that there are important opportunities to make sure iwi values are not only included, but form the basis of decisions.</p>

POS0063-PARE IMPLEMENTING SHARED DECISION MAKING TO ADVANCE PATIENT CENTRED RHEUMATOID ARTHRITIS CARE: A ROLE FOR A PATIENT ORGANISATION

Background:In rheumatoid arthritis (RA) care, patients and professionals face treatment decisions regularly due to the high number of treatment options, the chronic character of the disease and challenges around multi-morbidity. Recent studies have underlined the added value of shared decision making (SDM) between patients and professionals in RA care for health outcomes (i.e. disease activity, pain and joint damage) 1-4. Therefore, effort is needed to facilitate the implementation of SDM in daily clinical practice in order to advance patient centred RA care.Objectives:The aim of this implementation project was to improve SDM about treatment options for patients with RA. In addition the use of (Patient Reported) Outcome Measures in the process of SDM was taken into account.Methods:An implementation programme was developed by the National Association ReumaZorg Nederland (RZN) in co-creation with patientpartners and RMD professionals. Three hospital departments of rheumatology in the Netherlands participated in the project between January 2020 and March 2021. The implementation of SDM was supported by a project team of RZN.Results:The implementation programme started with the recording of RMD consultations in three participating departments of rheumatology. The consultations were then evaluated on the process of SDM (OPTION5) and discussed during the training of professionals that followed. Three observed improvements in SDM in RA care were: a. A more explicit introduction of choice for a patient is needed during the consultation; b. Tasks within the process of SDM should be allocated clearly among RMS specialists and nurses working together, in order to avoid unnecessary repetition of the same - or even inconsistent information; c. Besides the use of (patient reported) outcome measures in the SDM process, it is also important to include patients’ values (what matters to them?) when deciding on the best fitting treatment option. After the training, implementation support for SDM was given and aids to support the SDM process (i.e. redesign of health care processes, task allocation, hand card with explanation of the 4 steps of SDM) were developed. The implementation programme was tailored to the needs and stage of change for each hospital. Implementation materials for the hospital teams were developed in co-creation with patientpartners and the professionals. At the end of the project, a second set of consultations was recorded and evaluated on SDM. The hospital teams concluded that a continuous improvement cycle is needed to further enhance SDM.Conclusion:A continuous implementation programme on shared decision making could stimulate the enhancement of patient centred care in daily practice. Patient organisations could take a significant role in such a programme.References:[1]Pablos JL et al. Patient. 2020 Feb;13(1):57-69.[2]Fautrel B et al. Rheumatol Int. 2018 Jun;38(6):935-947. doi: 10.1007/s00296-018-4005-5.[3]Mathijssen EGE et al. RMD Open. 2020 Jan;6(1):e001121. doi: 10.1136/rmdopen-2019-001121.[4]Nota, I. 2017. Shared Decision-Making in rheumatology: What matters to patients? Thesis, University of Twente.Acknowledgements:This project of the National Association ReumaZorg Nederland (RZN) was made possible thanks to the effort of the following patientpartners, RMD specialists and researchers within the field of RMDs:Helene R Voogdt-Pruis, (AP PhD, RZN projectmanager Shared Decision Making within RMD care), Bertha Maat (RZN patient research partner), Theo Foekens (RZN patient research partner), Laura Kranenburg-van Koppen (MD, Msc, rheumatologist Erasmus and IJsselland Medical Centre), Annelieke Pasma (PhD, researcher Erasmus Medical Centre), Jos Hoes (MD PhD, rheumatologist Bravis Medical Centre), Inge Schoonen-Nuijten (RMD nurse, Bravis Medical Centre), Marijke van den Dikkenberg, (MSc, researcher Maasstad Medical Centre), Natalja Basoski (MD MSc, rheumatologist Maasstad Medical Centre), Angelique Weel-Koenders (Prof. Dr., rheumatologist Maasstad Medical Centre, Erasmus University), Gerardine Willemsen- de Mey (MSc, Chair of RZN).Disclosure of Interests:None declared.

Effect of a multilevel implementation programme on shared decision-making in breast cancer care

Background Women with newly diagnosed breast cancer face multiple treatment options. Involving them in a shared decision-making (SDM) process is essential. The aim of this study was to evaluate whether a multilevel implementation programme enhanced the level of SDM behaviour of clinicians observed in consultations. Methods This before–after study was conducted in six Dutch hospitals. Patients with breast cancer who were facing a decision on surgery or neoadjuvant systemic treatment between April 2016 and September 2017 were included, and provided informed consent. Audio recordings of consultations made before and after implementation were analysed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to assess whether clinicians adopted new behaviour needed for applying SDM. Patients scored their perceived level of SDM, using the nine-item Shared Decision-Making Questionnaire (SDM-Q-9). Hospital, duration of the consultation(s), age, and number of consultations per patient that might influence OPTION-5 scores were investigated using linear regression analysis. Results Consultations of 139 patients were audiotaped, including 80 before and 59 after implementation. Mean (s.d.) OPTION-5 scores, expressed on a 0–100 scale, increased from 38.3 (15.0) at baseline to 53.2 (14.8) 1 year after implementation (mean difference (MD) 14.9, 95 per cent c.i. 9.9 to 19.9). SDM-Q-9 scores of 105 patients (75.5 per cent) (72 before and 33 after implementation) were high and showed no significant changes (91.3 versus 87.6; MD −3.7, −9.3 to 1.9). The implementation programme had an association with OPTION-5 scores (β = 14.2, P &lt; 0.001), hospital (β = 2.2, P = 0.002), and consultation time (β = 0.2, P &lt; 0.001). Conclusion A multilevel implementation programme supporting SDM in breast cancer care increased the adoption of SDM behaviour of clinicians in consultations.

Prospective multicentre multifaceted before-after implementation study of ICU delirium guidelines: a process evaluation

ObjectiveWe aimed to explore: the exposure of healthcare workers to a delirium guidelines implementation programme; effects on guideline adherence at intensive care unit (ICU) level; impact on knowledge and barriers, and experiences with the implementation.DesignA mixed-methods process evaluation of a prospective multicentre implementation study.SettingSix ICUs.Participants4449 adult ICU patients and 500 ICU professionals approximately.InterventionA tailored implementation programme.Main outcome measureAdherence to delirium guidelines recommendations at ICU level before, during and after implementation; knowledge and perceived barriers; and experiences with the implementation.ResultsFive of six ICUs were exposed to all implementation strategies as planned. More than 85% followed the required e-learnings; 92% of the nurses attended the clinical classroom lessons; five ICUs used all available implementation strategies and perceived to have implemented all guideline recommendations (>90%). Adherence to predefined performance indicators (PIs) at ICU level was only above the preset target (>85%) for delirium screening. For all other PIs, the inter-ICU variability was between 34% and 72%. The implementation of delirium guidelines was feasible and successful in resolving the majority of barriers found before the implementation. The improvement was well sustained 6 months after full guideline implementation. Knowledge about delirium was improved (from 61% to 65%). The implementation programme was experienced as very successful.ConclusionsMultifaceted implementation can improve and sustain adherence to delirium guidelines, is feasible and can largely be performed as planned. However, variability in delirium guideline adherence at individual ICUs remains a challenge, indicating the need for more tailoring at centre level.

Evaluating an implementation programme for medication review with follow-up in community pharmacy using a hybrid effectiveness study design: translating evidence into practice

ObjectivesTo evaluate an implementation programme of a community pharmacy medication review with follow-up (MRF) service using a hybrid effectiveness-implementation study design, and to compare the clinical and humanistic outcomes with those in a previously conducted cluster randomised controlled trial (cRCT).SettingCommunity pharmacies in Spain.Participants135 community pharmacies and 222 pharmacists providing MRF to polymedicated patients aged 65 or over.InterventionThe intervention was an implementation programme for the MRF service. A national level group was established, mirrored with a provincial level group. A series of interventions were defined (1) to engage pharmacy owners with the implementation model and (2) to provide training to pharmacists consisting of clinical case studies, process of MRF, communication skills and data collection methods and (3) practice change facilitators.Primary and secondary outcome measuresThe primary outcomes for the implementation programme were progress, reach, fidelity and integration. The secondary outcomes were number of medications, non-controlled health problems, emergency visits, hospitalisations and health-related quality of life, which were compared with a previous 6-month cluster RCT.Results55% of pharmacies reached the implementation phase and 35.6% remained in the testing phase at 12 months. A reach of 89.3% (n=844) was achieved. Fidelity average score was 8.45 (min: 6.2, max: 9.3) out of 10. The integration mean score was 3.39 (SD: 0.72) out of 5. MRF service outcomes were similar to the cluster RCT study; however, the magnitude of the outcomes was delayed.ConclusionsThe implementation of pharmacy services is a complex multifactorial process, conditioned by numerous implementation factors. In the absence of remuneration, the implementation of the MRF service is a slow process, taking at least 12 months to complete.Trial registration numberCGFTRA-2017-01.

De-implementing wisely: developing the evidence base to reduce low-value care

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey

Background Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption. Methods Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption. Results The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients’ treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care. Conclusions HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient’s preferences in the care process – preferably before starting treatment through discussions in a multidisciplinary meeting.