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Monogenic disorders can present clinically heterogeneous symptoms. We hypothesized that in patients with a monogenic disorder caused by a large deletion, frequently additional loss-of-function (LOF)-intolerant genes are affected, potentially contributing to the phenotype.We investigated the LOF-intolerant gene distribution across the genome and its association with benign population and pathogenic classified deletions from individuals with presumably monogenic disorders. For people with presumably monogenic epilepsy, we compared Human Phenotype Ontology terms in people with large and small deletions.We identified LOF-intolerant gene dense regions that were enriched for ClinVar and depleted for population copy number variants. Analysis of data from143,000 individuals with a suspected monogenic disorder showed that 2.5% of haploinsufficiency disorder-associated deletions can affect at least 1 other LOF-intolerant gene. Focusing on epilepsy, we observed that 13.1% of pathogenic and likely pathogenic ClinVar deletions3 megabase pair, covering the diagnostically most relevant genes, affected at least 1 additional LOF-intolerant gene. Those patients have potentially more complex phenotypes with increasing deletion size.We could systematically show that large deletions frequently affected admditional LOF-intolerant genes in addition to the established disease gene. Further research is needed to understand how additional potential disease-relevant genes influence monogenic disorders to improve clinical care and the efficacy of targeted therapies.

To systematically review studies that evaluated the impact of employer-led efforts in the United States to improve the value of health spending, where employers have implemented changes to their health benefits to reduce costs while improving or maintaining quality.We included all studies of employer-led health benefit strategies that reported outcomes for both employer health spending and employee health outcomes.Our search returned 44 studies of employer health benefit changes that included measures of both health spending and quality. The most promising efforts were those that lowered or eliminated cost sharing for primary care or medications for chronic illnesses. High deductible health plans with a savings option appeared less promising.More research is needed on the characteristics and contexts in which these benefit changes were implemented, and on actions that address employers' current concerns.

Objectives To investigate the relationship between the closure of "anchor businesses" - manufacturing plants and distribution centers employing >1,000 workers and the daily, county-level COVID-19 rate between March 1 and May 31, 2020. Methods We conducted a comparative, interrupted time series analysis of publicly available county-level data. Our main variable of interest was closure, indicating whether one or more of the anchor businesses within the county experienced a full or partial a closure of at least 22 days (main analysis) or at least one day (sensitivity analyses). Results Closure of an anchor business was associated with 142 fewer positive COVID-19 tests per 100,000 population over a 40-day period. Even short-term and partial closures were associated with reduced spread. Conclusions Temporary closure of anchor businesses appears to have slowed, but not completely contained, the spread of COVID-19.

Anchor institutions ("anchors") are large employers, rooted in a community by reason of mission, capital, or relationships. Many anchors have encouraged coronavirus vaccination for employees and their families. Our objective was to determine whether the presence of an anchor was associated with a higher county-level vaccination rate.A cross-sectional study focused on 745 small- and mid-sized US counties. We used data from the Centers for Disease Control and Prevention, Reference USA's US Business Database, Economic Innovation Group's Distressed Communities Index database, 2021 County Health Ratings and Rankings, 2020 US Presidential Election popular vote data, and National Center for Health Statistics urban-rural classification data. We constructed 3 explanatory variables of interest: a binary variable indicating whether the county had an anchor; a continuous variable representing the number of anchors within a county; and the percent of all workers in the county who were employed by an anchor. Multivariable linear regression models were adjusted for race/ethnicity, political party allegiance, rurality, economic distress, and prevalence of smoking and adult obesity.Counties with an anchor had vaccination rates 2.31 (P.01) percentage points higher than those without an anchor. The number of anchors in a county was also significantly associated with higher vaccination rates.Efforts by anchors to encourage vaccination may have been successful, and that anchors may be well positioned to amplify public health messages. However, the influence and efforts of anchors to increase vaccination did not fully mitigate disparities in vaccination rates by race, ethnicity, and political party allegiance.

UNSTRUCTURED This is a corrigendum for MS 32174.

Objective To estimate the additional health care costs incurred by two U.S. manufacturing companies due to their policies related to shift work and long work hours. Methods We applied risk ratios from the published literature to data on 2647 workers from Company A and 1346 workers from Company B to estimate the excess cases of several chronic conditions in the worker population due to shift work and long work hours. We estimated the annual health care costs incurred by the companies by applying Medicare cost data. Results Excess annual health care costs related to shift work totaled $1,394,365 and $300,297 for Companies A and B, respectively. Excess annual costs related to long work hours totaled $231,293 and $107,902 for Companies A and B, respectively. Conclusions Excess health care costs related to shift work and long work hours is substantial, but may not be large enough to compel companies to alter their work scheduling policies.

Practice facilitation is an approach for advancing quality improvement (QI), but its success depends on effective relationships and communication among participants. Our goal was to identify patterns of contrasting perspectives on implementation issues between practice leaders and their practice facilitators, and factors that may contribute to them. We conducted individual interviews with practice leaders and the practice facilitators assigned to them as part of a program focused on preventive cardiology within primary care practices. We used summative content analysis to quantify the incidence of contrasting perspectives, and bivariate and qualitative analyses to explore relationships between contrasting perspectives and contextual factors. Among the 16 dyads, contrasting perspectives commonly related to the easiest or hardest QI interventions to implement (8 of 16 dyads) and the practice's success implementing interventions (5 of 16 dyads). There was a nonsignificant, inverse correlation (r = -0.19, p = .47) between the number of in-person QI visits from the facilitator and the total number of contrasting perspectives. Turnover of staff was frequently reported in dyads with contrasting perspectives. Although the impact of contrasting perspectives warrants additional study, planners of QI initiatives using practice facilitation should consider taking steps to minimize contrasting perspectives, or the potential adverse consequences of them, by addressing turnover challenges and encouraging opportunities to share perspectives.

Objective Describe manufacturing workers' perceptions of the effect of shift work, following the Framework for Worker Well-Being. Methods Eight focus groups and 43 interviews were conducted across four large manufacturing plants. Thematic analysis was used to analyze the data within each of the five domains of the Framework: physical environment and safety climate; workplace policies and culture; health status; work evaluation and experience; and home, community, and society. Results Respondents described shift work as detrimental to well-being across four of the five Framework domains. The exception was in the workplace policies and culture domain, where some respondents described shift work as necessary, fair, and financially beneficial. Conclusions Shift work negatively influences worker well-being in a holistic way. Employers could consider reconfiguring workplace wellness benefits to transcend the boundaries of the workplace and better support workers and their families.

BACKGROUND The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives. OBJECTIVE This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world case study. METHODS We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study. RESULTS The proposed framework was used to organize and analyze different stakeholders’ perspectives and key factors based on framework domains. The case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients’ social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs. CONCLUSIONS Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation–supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.

Objectives: Age is the most common predictor of hearing loss; however, many older adults are not screened. Hearing screening could improve healthcare access, participation, and outcomes. Establishing whether hearing screening in older adults is cost-effective could improve the availability and utilization of screening. Methods: We searched nine databases in January 2020. Studies with populations aged 50+ and provided data on the cost-effectiveness of hearing screening were included in the review. Results: Five studies met the inclusion criteria and all found hearing screening programs to be cost-effective compared to no hearing screening, regardless of screening method (i.e., instrument or strategy). The maximum number of repeated screenings, coupled with younger ages, was most cost-effective. Discussion: This review suggests that hearing screening in older adults is cost-effective, however, the evidence is limited. There is pressing need for research focused on economic impacts of hearing healthcare in older adults to inform research, policy and practice.

Introduction HIV self-testing (HIV-ST) is an effective means of improving HIV testing rates. Low- and middle-income countries (LMIC) are taking steps to include HIV-ST into their national HIV/AIDS programs but very few reviews have focused on implementation in LMIC. We performed a scoping review to describe and synthesize existing literature on implementation outcomes of HIV-ST in LMIC. Methods We conducted a systematic search of Medline, Embase, Global Health, Web of Science, and Scopus, supplemented by searches in HIVST.org and other grey literature databases (done 23 September 2020) and included articles if they reported at least one of the following eight implementation outcomes: acceptability, appropriateness, adoption, feasibility, fidelity, cost, penetration, or sustainability. Both quantitative and qualitative results were extracted and synthesized in a narrative manner. Results and discussion Most (75%) of the 206 included articles focused on implementation in Africa. HIV-ST was found to be acceptable and appropriate, perceived to be convenient and better at maintaining confidentiality than standard testing. The lack of counselling and linkage to care, however, was concerning to stakeholders. Peer and online distribution were found to be effective in improving adoption. The high occurrence of user errors was a common feasibility issue reported by studies, although, diagnostic accuracy remained high. HIV-ST was associated with higher program costs but can still be cost-effective if kit prices remain low and HIV detection improves. Implementation fidelity was not always reported and there were very few studies on, penetration, and sustainability. Conclusions Evidence supports the acceptability, appropriateness, and feasibility of HIV-ST in the LMIC context. Costs and user error rates are threats to successful implementation. Future research should address equity through measuring penetration and potential barriers to sustainability including distribution, cost, scale-up, and safety.

Aims To summarize evidence for the efficacy of smoking cessation interventions in low‐ and middle‐income countries (LMICs). Design Systematic review and meta‐analysis of randomized controlled trials. Setting LMICs as defined by the World Bank. Participants Adult current cigarette smokers residing in LMICs. Interventions Behavioral and/or pharmacotherapy smoking cessation interventions. Measurements PubMed MEDLINE, EMBASE (embase.com), Cochrane Central Register of Controlled Trials (Wiley), PsycINFO (Ebsco), SciELO, WHO Global Index Medicus and Scopus were searched from inception to 4 April 2018. Only studies with at least 6 months of follow‐up were included. We used the most rigorous assessment of abstinence reported by each study. Effect sizes were computed from abstracted data. Where possible, a meta‐analysis was performed using Mantel–Haenzel random‐effect models reporting odds ratios (OR) and 95% confidence intervals (CI). Findings Twenty‐four randomized controlled trials were included. Six investigated the efficacy of pharmacological agents. Four trials that compared nicotine replacement therapy (NRT) to placebo found NRT improved cessation rates (n : NRT 546, control 684, OR = 1.76, 95% CI = 1.30–2.77, P

Although better community health has long been assumed to be good for local businesses, evidence demonstrating the relationship between community health and employee performance is quite limited. Drawing on human resources data on 6103 employees from four large US manufacturing plants, we found that employees living in counties with poor community health outcomes had considerably higher rates of absenteeism and tardiness (ABT). For example, in one company, employees living in communities with high rates of children on free or reduced lunch had higher rates of ABT compared to other employees [adjusted odds ratio (OR) 2.76, 95% confidence interval (CI) 2.52–3.04], and employees living in communities with high rates of drug overdose deaths had higher rates of ABT (OR 1.51, 95% CI 1.29–1.77). In one plant, the annual value of lost wages due to ABT was over $1.3 million per year. Employees reported that poor community health (e.g., poverty, caregiving burdens, family dysfunction, drug use) resulted in “mental stress” leading to distraction, poor job performance, and more rarely, lapses in safety. These findings bolster the case for greater private sector investment in community health.

Virtually all large employers engage in corporate philanthropy, but little is known about the extent to which it is directed toward improving community health. We conducted in-depth interviews with leaders of corporate philanthropy from 13 of the largest manufacturing companies in the US to understand how giving decisions were made, the extent to which funding was directed towards improving community health, and whether companies coordinate with local public health agencies. We found that corporate giving was sizable and directed towards communities in which the manufacturers have a large presence. Giving was aligned with the social determinants of health (i.e., aimed at improving economic stability, the neighborhood and physical environment, education, food security and nutrition, the community and social context, and the health care system). However, improving public health was not often cited as a goal of corporate giving, and coordination with public health agencies was limited. Our results suggest that there may be opportunities for public health agencies to help guide corporate philanthropy, particularly by sharing community-level data and offering their measurement and evaluation expertise.

Background:Symptom management is an important component of HIV care. But symptom patterns and how they affect engagement with HIV care and treatment services have not been adequately explored in the era of increased HIV treatment scale-up. We investigated the relationship between symptom patterns among people living with HIV (PLHIV) and 12 months retention in care, within the context of other clinical and demographic characteristics.Methods:Retrospective cohort analysis of 5114 PLHIV receiving care within a large HIV treatment program in Nigeria. We assessed the prevalence and burden of baseline symptoms reported during routine clinic visits from January 2015 to December 2017. Multivariable regression was used to identify relationships between 12-month retention and symptom dimensions (prevalence and burden) while controlling for demographic and other clinical variables.Results:Increasing symptom burden was associated with higher likelihood of retention at 12 months (adjusted odds ratio [aOR] = 1.19 [95% confidence interval, CI: 1.09-1.29]; P < .001) as was the reporting of skin rashes/itching symptom (aOR = 2.59 [95% CI: 1.65-4.09]; P < .001). Likelihood of retention reduced with increasing World Health Organization (WHO) Clinical staging, with CD4 ≥500 cells/mL and self-reported heterosexual mode of HIV transmission. Conclusions: Symptom dimensions and standardized clinical/immunological measures both predicted retention in care, but effects differed in magnitude and direction. Standardized clinical/immunological measures in HIV care (eg, WHO clinical staging and CD4 count categories) can mask important differences in how PLHIVs experience symptoms and, therefore, their engagement with HIV care and treatment. Symptom management strategies are required alongside antiretroviral treatment to improve outcomes among PLHIV, including retention in care.

Aims Employers in the United States incur substantial costs associated with substance use disorders. Our goal was to examine the effectiveness of employer‐led interventions to reduce the adverse effects of drug misuse in the workplace. Methods We conducted a systematic review of studies that evaluated the effectiveness of recommended workplace interventions for opioids and related drugs: employee education, drug testing, employee assistance programs, supervisor training, written workplace drug‐free policy, and restructuring employee health benefit plans. We searched PubMed MEDLINE, EMBASE (embase.com), PsycINFO (Ebsco), ABI Inform Global, Business Source Premier, EconLit, CENTRAL, Web of Science (Thomson Reuters), Scopus (Elsevier), Proquest Dissertations, and Epistemonikos from inception through May 8, 2019, with no date or language restrictions. We included randomized controlled trials, quasi‐experimental studies, and cross‐sectional studies with no language or date restrictions. The Downs and Black questionnaire was used to assess the quality of included studies. The results were reported using the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines. Results In all, 27 studies met our inclusion criteria and were included in the systematic review. Results were mixed, with each intervention shown to be effective in at least one study, but none showing effectiveness in over 50% of studies. Studies examining the impact of interventions on workplace injuries or accidents were more commonly reported to be effective. Although four studies were randomized controlled trials, the quality of all included studies was “fair” or “poor.” Conclusions Despite the opioid epidemic, high‐quality studies evaluating the effectiveness of employer‐led interventions to prevent or reduce the adverse effects of substance use are lacking. Higher quality and mixed methods studies are needed to determine whether any of the interventions are generalizable and whether contextual adaptations are needed. In the meantime, there is a reason to believe that commonly recommended, employer‐led interventions may be effective in some environments.

Among the most promising quality improvement (QI) interventions for small primary care practices are those led by practice facilitators (PFs), specially trained individuals who help practices develop capacity for continuous QI.1 2 They provide coaching on best practices for QI implementation, including using technology to improve care.3 PF-led QI initiatives are positively associated with guideline adoption,4 5 and may be cost-neutral if they reduce even a small number of high cost events (eg, admissions).6 As part of Healthy Hearts in the Heartland (H3), a programme from the Agency for Healthcare Research and Quality’s EvidenceNow initiative, PFs worked with small and medium-sized primary care practices to implement QI strategies for cardiovascular disease prevention.7 To identify lessons learnt from the programme, we interviewed practice leaders and PFs from practices that experienced the largest and smallest gains in quality scores to understand their experiences. All participating practices were assigned a primary PF for 12 months who met with practices on demand, typically once a month. PFs offered practices QI interventions related to the ABCS of heart health (Aspirin therapy, Blood pressure control, Cholesterol management, and Smoking screening and cessation) with the goal of …

Study objective We examine emergency department (ED) use and hospitalizations through the ED after Patient Protection and Affordable Care Act (ACA) health insurance expansion in Illinois, a Medicaid expansion state. Methods Using statewide hospital administrative data from 2011 through 2015 from 201 nonfederal Illinois hospitals for patients aged 18 to 64 years, mean monthly ED visits were compared before and after ACA implementation by disposition from the ED and primary payer. Visit data were combined with 2010 to 2014 census insurance estimates to compute payer-specific ED visit rates. Interrupted time-series analyses tested changes in ED visit rates and ED hospitalization rates by insurance type after ACA implementation. Results Average monthly ED visit volume increased by 14,080 visits (95% confidence interval [CI] 4,670 to 23,489), a 5.7% increase, after ACA implementation. Changes by payer were as follows: uninsured decreased by 24,158 (95% CI −27,037 to −21,279), Medicaid increased by 28,746 (95% CI 23,945 to 33,546), and private insurance increased by 9,966 (95% 6,241 to 13,690). The total monthly ED visit rate increased by 1.8 visits per 1,000 residents (95% CI 0.6 to 3.0). The monthly ED visit rate decreased by 8.7 visit per 1,000 uninsured residents (95% CI −11.1 to −6.3) and increased by 10.2 visit per 1,000 Medicaid beneficiaries (95% CI 4.4 to 16.1) and 1.3 visits per 1,000 privately insured residents (95% CI 0.6 to 1.9). After adjusting for baseline trends and season, these changes remained statistically significant. The total number of hospitalizations through the ED was unchanged. Conclusion ED visits by adults aged 18 to 64 years in Illinois increased after ACA health insurance expansion. The increase in total ED visits was driven by an increase in visits resulting in discharge from the ED. A large post-ACA increase in Medicaid visits and a modest increase in privately insured visits outpaced a large reduction in ED visits by uninsured patients. These changes are larger than can be explained by population changes alone and are significantly different from trends in ED use before ACA implementation.

Background Multi-stakeholder alliances – groups of payers, purchasers, providers, and consumers that work together to address local health goals – are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities. Methods Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 – March 2009 and January 2012—November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients’ online access to their medical records. Results Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients’ online access to medical records between AF4Q and non-AF4Q communities. Conclusion By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients’ online access to medical records. Implications Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Background Multistakeholder alliances-groups of payers, purchasers, providers, and consumers that voluntarily work together to address local health goals-have increasingly been used to improve health care quality within their communities. Under the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative, 16 multistakeholder alliances were charged with advancing payment reform as part of a larger effort to achieve dramatic and sustainable quality improvement. Methods Drawing upon key informant interviews with alliance leaders and document reviews conducted from 2010 to 2014, we describe the payment reform projects undertaken by the AF4Q alliances and the roles that the alliances played to advance them. Results The most common types of projects pursued by alliances were those that introduced supplemental payments to fee-for-service reimbursement and built upon alliances' ongoing quality improvement initiatives. Alliances advanced payment reform through 4 roles: (1) educating and advocating, (2) designing payment reform projects, (3) recruiting participants, and (4) supporting the operation of projects. However, less than half of alliances' payment reform projects were operational by 2014. Conclusions Quality improvement-focused multistakeholder alliances may play meaningful roles to advance payment reform, but they are not a panacea for overcoming well-documented barriers to reform.

BACKGROUND: More than 100 million individuals in the USA have been diagnosed with a chronic disease, yet chronic disease care has remained fragmented and of inconsistent quality. Improving chronic disease management has been challenging for primary care and internal medicine practitioners. Practice facilitation provides a comprehensive approach to chronic disease care. The objective is to evaluate the impact of practice facilitation on chronic disease outcomes in the primary care setting. METHODS: This systematic review examined North American studies from PubMed, EMBASE, and Web of Science (database inception to August 2017). Investigators independently extracted and assessed the quality of the data on chronic disease process and clinical outcome measures. Studies implemented practice facilitation and reported quantifiable care processes and patient outcomes for chronic disease. Each study and their evidence were assessed for risk of bias and quality according to the Cochrane Collaboration and the Grade Collaboration tool. RESULTS: This systematic review included 25 studies: 12 randomized control trials and 13 prospective cohort studies. Across all studies, practices and their clinicians were aware of the implementation of practice facilitation. Improvements were observed in most studies for chronic diseases including asthma, cancer (breast, cervical, and colorectal), cardiovascular disease (cerebrovascular disease, coronary artery disease, dyslipidemia, hypertension, myocardial infarction, and peripheral vascular disease), and type 2 diabetes. Mixed results were observed for chronic kidney disease and chronic illness care. DISCUSSION: Overall, the results suggest that practice facilitation may improve chronic disease care measures. Across all studies, practices were aware of practice facilitation. These findings lend support for the potential expansion of practice facilitation in primary care. Future work will need to investigate potential opportunities for practice facilitation to improve chronic disease outcomes in other health care settings (e.g., specialty and multi-specialty practices) with standardized measures. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4581-9) contains supplementary material, which is available to authorized users.

To improve health care quality within communities, increasing numbers of multistakeholder alliances-groups of payers, purchasers, providers, and consumers-have been created. We used data from two rounds (conducted in July 2007-March 2009 and January 2012-November 2013) of a large nationally representative survey of small and medium-size physician practices. We examined whether the adoption of patient-centered medical home processes spread more rapidly in fourteen Robert Wood Johnson Foundation Aligning Forces for Quality communities, where multistakeholder health care alliances promoted their use, than in other communities. We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others. Despite the enthusiasm for quality improvement led by multistakeholder alliances, such alliances may not be a panacea for spreading patient-centered medical home processes across a community.

Although intervention dose—defined as the quality and quantity of an intervention and participation—might be key to understanding why some multisite quality improvement (QI) initiatives work and others do not, evaluations rarely consider dose, and there is no widely accepted method for measuring it. In this exploratory study, the authors examined the literature on QI dose, identified four methods for measuring QI dose, applied them to 14 communities participating in a QI initiative, examined whether the dose scores aligned with perceptions of QI dose among individuals knowledgeable of the initiative, and report on lessons learned. They conclude it is feasible to measure QI dose and found a high level of concordance between scores on a comprehensive dose measure and knowledgeable informants’ perceptions. However, measuring QI dose presents many challenges, including subjective decisions about the elements of dose to include in a measure and the need for extensive data collection.

PURPOSE Practice facilitation is a promising approach to helping practices implement quality improvements. Our purpose was to describe practice facilitators’ and practice leaders’ perspectives on implementation of a practice facilitator–supported quality improvement program and describe where their perspectives aligned and diverged. METHODS We conducted interviews with practice leaders and practice facilitators who participated in a program that included 35 improvement strategies aimed at the ABCS of heart health (aspirin use in high-risk individuals, blood pressure control, cholesterol management, and smoking cessation). Rapid qualitative analysis was used to collect, organize, and analyze the data. RESULTS We interviewed 17 of the 33 eligible practice leaders, and the 10 practice facilitators assigned to those practices. Practice leaders and practice facilitators both reported value in the program’s ability to bring needed, high-quality resources to practices. Practice leaders appreciated being able to set the schedule for facilitation and select among the 35 interventions. According to practice facilitators, however, relying on practice leaders to set the pace of the intervention resulted in a lower level of program intensity than intended. Practice leaders preferred targeted assistance, particularly electronic health record documentation guidance and linkages to state smoking cessation programs. Practice facilitators reported that the easiest interventions were those that did not alter care practices. CONCLUSIONS The dual perspectives of practice leaders and practice facilitators provide a more holistic picture of enablers and barriers to program implementation. There may be greater opportunities to assist small practices through simple, targeted practice facilitator–supported efforts rather than larger, comprehensive quality improvement projects.

Scoping reviews are preliminary assessments intended to characterize the extent and nature of emerging research evidence, identify literature gaps, and offer directions for future research. We conducted a systematic scoping review to describe published scientific literature on strategies to identify and reduce opioid misuse among patients with gastrointestinal (GI) symptoms and disorders. We performed structured keyword searches to identify manuscripts published through June 2016 in the PubMed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases to extract original research articles that described healthcare practices, tools, or interventions to identify and reduce opioid misuse among GI patients. The Chronic Care Model (CCM) was used to classify the strategies presented. Twelve articles met the inclusion criteria. A majority of studies used quasi-experimental or retrospective cohort study designs. Most studies addressed the CCM’s clinical information systems element. Seven studies involved identification of opioid misuse through prescription drug monitoring and opioid misuse screening tools. Four studies discussed reductions in opioid use by harnessing drug monitoring data and individual care plans, and implementing self-management and opioid detoxification interventions. One study described drug monitoring and an audit-and-feedback intervention to both identify and reduce opioid misuse. Greatest reductions in opioid misuse were observed when drug monitoring, self-management, or audit-and-feedback interventions were used. Prescription drug monitoring and self-management interventions may be promising strategies to identify and reduce opioid misuse in GI care. Rigorous, empirical research is needed to evaluate the longer-term impact of these strategies.

Objectives Systems theory suggests that there should be relatively high correlations among quality measures within an organization. This was an examination of hospital performance across three types of quality measures included in Medicare's Hospital Inpatient Value-Based Purchasing (HVBP) program: emergency department (ED)-related clinical process measures, inpatient clinical process measures, and patient experience measures. The purpose of this analysis was to determine whether hospital achievement and improvement on the ED quality measures represent a distinct domain of quality. Methods This was an exploratory, descriptive analysis using publicly available data. Composite scores for the ED, inpatient, and patient experience measures included in the HVBP program were calculated. Correlations and frequencies were run to examine the extent to which achievement and improvement were related across the three quality domains and the number of hospitals that were in the top quartile for performance across multiple quality domains. Results Achievement scores were calculated for 2,927 hospitals, and improvement scores were calculated for 2,842 hospitals. There was a positive, moderate correlation between ED and inpatient achievement scores (correlation coefficient of 0.50, 95% confidence interval [CI] = 0.47 to 0.53), but all other correlations were weak (0.16 or less). Only 96 hospitals (3.3%) scored in the top quartile for achievement across the three quality domains; 73 (2.6%) scored in the top quartile for improvement across all three quality domains. Conclusions Little consistency was found in achievement or improvement across the three quality domains, suggesting that the ED performance represents a distinct domain of quality. Implications include the following: 1) there are broad opportunities for hospitals to improve, 2) patients may not experience consistent quality levels throughout their hospital visit, 3) quality improvement interventions may need to be tailored specifically to the department, and 4) consumers and policy-makers may not be able to draw conclusions on overall facility quality based on information about one domain. Resumen Objetivos La teoria de sistemas indica que deberia haber correlaciones relativamente altas entre las medidas de calidad dentro una organizacion. Se trata de una evaluacion del rendimiento hospitalario a traves de tres tipos de medidas de calidad incluidas en el programa Hospital Inpatient Value-Based Purchasing (HVBP) de Medicare: medidas del proceso clinico relativo al servicio de urgencias (SU), medidas del proceso clinico del paciente hospitalizado y medidas de la experiencia del paciente. El proposito de este analisis fue determinar si las medidas de calidad en el logro y la mejora del SU y del hospital representan un dominio distinto de la calidad. Metodologia Se trata de un analisis descriptivo y exploratorio que utilizo los datos disponibles de dominio publico. Se calcularon las puntuaciones compuestas para el SU, el paciente hospitalizado y las medidas de la experiencia del paciente incluidas en el programa HVBP. Se calcularon las frecuencias y correlaciones para examinar el grado en el que el logro y la mejora se relacionaban a traves de los tres dominios de calidad, y el numero de hospitales que estuvieron en el cuartil superior de rendimiento de multiples dominios de calidad. Resultados Se asignaron las puntuaciones del logro a 2.927 hospitales y 2.842 recibieron puntuaciones de la mejora bajo el programa HVBP. Hubo una correlacion positiva moderada entre las puntuaciones de los logros entre el SU y el paciente hospitalizado (coeficiente de correlacion de 0,50, intervalo de confianza [IC] 95% = 0,47 a 0,53), pero el resto de las correlaciones fueron debiles (0,16 o menos). Solo 96 hospitales (3,3%) puntuaron en el cuartil superior para el logro de los objetivos a traves de las tres dimensiones de calidad; 73 (2,6%) puntuaron en el cuartil superior para la mejora a traves de las tres dimensiones de la calidad. Conclusiones Se encontro poca consistencia en el logro o la mejora a traves de los tres dominios de calidad, lo que indica que el rendimiento del SU representa un dominio distinto de calidad. Esto supone las siguientes implicaciones: 1) existen amplias oportunidades para que los hospitales mejoren, 2) los pacientes pueden no experimentar grados de calidad consistentes a lo largo su visita hospitalaria, 3) se pueden necesitar intervenciones en mejora de calidad para ser especificamente adaptadas al servicio, y 4) los responsables politicos y los usuarios pueden no ser capaces de sacar conclusiones sobre la calidad general de las instalaciones si se basan en la informacion de un solo dominio.

Background Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally. Objectives The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer. Methods We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I2 was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot. Results Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk. Conclusion Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women’s participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

This was an evaluation of the efforts of five hospitals that participated in a collaborative aimed at improving patient flow and reducing emergency department (ED) crowding. Interviews with hospital implementation team members were conducted at two separate times, and multivariate linear regression models and bivariate logistic models were constructed to assess changes in ED length of stay (LOS) and left without being seen (LWBS). By the end of the collaborative, four of the five hospitals had at least one fully implemented improvement strategy. Those hospitals experienced modest improvements in patient flow: a hospital that implemented front-end improvements and devoted additional resources to fast track had a 51-min reduction in ED LOS, another that implemented only front-end improvements had a 9-min reduction in LOS, a third hospital that improved communication between the ED and inpatient units to facilitate admissions decreased LWBS from 0.6% to 0.4%, and a fourth hospital reduced LOS by 59 min for mid-acuity patients by establishing a new care process for them. Results suggest that relatively small changes may lead to improvements in measures of patient flow that are modest, at best.

The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed.A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided.The summative research design employed by the evaluation team is discussed.The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program.The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

Aligning Forces for Quality (AF4Q) was the Robert Wood Johnson Foundation's nearly 10-year, multicomponent initiative to create meaningful and sustainable change in 16 communities. Our purpose was to describe the likely legacy of the care delivery component of AF4Q among participating communities and the factors that influenced the legacy.We used a multiple-case study approach. Our analysis relied on 3 key documents for each community, based on key informant interviews conducted between 2006 and 2015: (1) a summary of the community's care delivery activities under AF4Q, (2) a summary of the community's experience in the AF4Q program, and (3) a summary of the characteristics of each community and the multi-stakeholder alliance that led local efforts under AF4Q. We used a team-based consensual approach to analysis.We identified 3 types of legacies: (1) in 3 communities, there appear to be sustained infrastructures or wide-reaching activities attributable to AF4Q; (2) in 5 communities, AF4Q participation was used to advance preexisting activities; and (3) in 8 communities, the care delivery legacy is likely to be limited, because the local alliance focused on performance measurement instead of care delivery or the care delivery activities had limited reach and sustainability. Community contextual factors (eg, availability of other grant support) and alliance characteristics (eg, areas of expertise) greatly influenced the AF4Q care delivery legacy.AF4Q appears to have created meaningful and sustained change in care delivery in half of the participating communities. Among the other communities, the considerable financial support and technical assistance provided by RWJF was not enough to overcome some of the contextual barriers that often hamper quality-improvement efforts.

To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015.This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities.Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances.Descriptive overview of a multi-site, community-based quality improvement initiative.We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders.The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives.The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative.Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care.Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

There is growing appreciation that significant improvements in healthcare quality cannot be achieved by organizations working in isolation. To that end, the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative provides multistakeholder alliances-groups of payers, purchasers, providers, and consumers that work together-with funding and technical assistance to improve healthcare community wide. Reducing readmissions was one of the several AF4Q goals. Alliances crafted their own interventions, tailored to address the communities' unique needs, and took advantage of local resources. Our objective was to determine whether readmission rates declined more in AF4Q communities than in non-AF4Q communities by year 7 of the 10-year initiative. We conducted a quasiexperimental study using zip code-level demographics and 30-day readmission rates for all medical and surgical discharges using Medicare claims data for 2008 through 2012. This interim analysis found that AF4Q was not associated with significant reductions in medical or surgical readmissions, suggesting that AF4Q's multistakeholder approach was no more effective at reducing readmissions than other national efforts, such as the Hospital Reduction Program under the Affordable Care Act.

Introduction: The Emergency Nurses Association and other groups have encouraged the adoption of patient flow improvement strategies to reduce ED crowding, but little is known about time and expenses associated with implementation. The purpose of this study was to estimate the time spent and expenses incurred as 6 Urgent Matters hospitals planned and implemented strategies to improve patient flow and reduce crowding. Methods: We conducted key informant interviews with members of the hospitals’ patient flow improvement teams at 2 points in time: immediately after strategy implementation and approximately 6 months later. A total of 129 interviews were conducted using a semistructured interview protocol. Interviews were recorded, transcribed, and coded for analysis. Results: Eight strategies were implemented. The time spent planning and implementing the strategies ranged from 40 to 1,017 hours per strategy. The strategies were largely led by nurses, and collectively, nurses spent more time planning and implementing strategies than others. The most time-consuming strategies were those that involved extensive staff training, large implementation teams, or complex process changes. Only 3 strategies involved sizable expenditures, ranging from $32,850 to $490,000. Construction and the addition of new personnel represented the most costly expenditures. Discussion: The time and expenses involved in the adoption of patient flow improvement strategies are highly variable. Nurses play an important role in leading and implementing these efforts. Hospital, ED, and nurse leaders should set realistic expectations for the time and expenses needed to support patient flow improvement.

Purpose This report reviews the diagnosis and management of patients with Class III skeletal patterns and discusses the stability of a bilateral sagittal split to set back the mandible using 2 fixed bicortical screws and a monocortical plate. Materials and Methods The database of the University of Kentucky was searched for code 524.02 of the International Classification of Diseases, Ninth Revision and 21,196 cases from 2006 through 2010. Of these, cases with large anterior posterior discrepancies were identified that required maxillary advancement and mandibular setback. Two representative cases were chosen to illustrate the stability of the mandibular setback. Results The 2 patients had good esthetic results and were debanded before their 6-month postoperative appointment. The case in which the mandible was set back the least showed the greatest skeletal stability. Conclusions Patients with Class III occlusal patterns often have maxillary and mandibular skeletal components to their malocclusions. A bilateral sagittal split that is rigidly fixed with 2 bicortical screws and a monocortical plate will produce excellent occlusal and skeletal results when the 2 components of the deformity are addressed.

ACADEMIC EMERGENCY MEDICINE 2012; 19:106–109 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Patient acuity triage systems can play an important role in supporting patient safety and emergency department (ED) operations. In 2003, the boards of the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) approved a joint statement calling for hospitals to adopt a reliable, valid, five-level triage scale such as the Emergency Severity Index (ESI). Still, there appears to be considerable variation in use of triage acuity systems in the United States, with many hospitals using three- and four-level systems that have not been validated. The purpose of this effort was to measure the use of various triage acuity systems in U.S. hospitals. Methods: The authors conducted a cross-sectional analysis of secondary data. Data were obtained from the 2009 American Hospital Association (AHA) Annual Survey—an intensive questionnaire mailed to all U.S. general medical and surgical hospitals. In 2009, a question was added to the survey about hospitals’ use of triage systems in EDs. Descriptive statistics were used to explore various triage acuity systems used by different types of hospitals. Results: Of the 4,897 hospitals surveyed, 82% responded, and 62% (3,024 hospitals) provided information on their ED triage system. The 2009 data revealed that the most commonly used triage system types were the five-level ESI (56.9% of responding hospitals) and three-level triage systems (25.2%). More than 70% of large hospitals and teaching hospitals use the ESI, and the unvalidated three-level systems were more common in small hospitals, public hospitals, nonteaching hospitals, and hospitals in the Midwest. The majority (72.1%) of all ED patient visits to hospitals in our sample were assessed using ESI; only 13.1% of visits were assessed using a three-level system. Conclusions: Among our sample of more than 3,000 hospitals, the ESI was the most commonly used triage system, and more patients were triaged using the ESI than any other triage acuity system. Still, there is an opportunity to further promote the adoption of validated, reliable triage systems.

Background : Although management practices are recognized as important factors in improving health care quality and efficiency, most research thus far has focused on individual practices, ignoring or underspecifying the contexts within which these practices are operating. Research from other industries, which has increasingly focused on systems rather than individual practices, has yielded results that may benefit health services management. Purpose : Our goal was to develop a conceptual model on the basis of prior research from health care as well as other industries that could be used to inform important contextual considerations within health care. Methodology/approach : Using theoretical frameworks from A. Donabedian (1966), P. M. Wright, T. M. Gardner, and L. M. Moynihan (2003), and B. Schneider, D. B. Smith, and H. W. Goldstein (2000) and review methods adapted from R. Pawson (2006b), we reviewed relevant research from peer-reviewed and other industry-relevant sources to inform our model. The model we developed was then reviewed with a panel of practitioners, including experts in quality and human resource management, to assess the applicability of the model to health care settings. Findings : The resulting conceptual model identified four practice bundles, comprising 14 management practices as well as nine factors influencing adoption and perceived sustainability of these practices. The mechanisms by which these practices influence care outcomes are illustrated using the example of hospital-acquired infections. In addition, limitations of the current evidence base are discussed, and an agenda for future research in health care settings is outlined. Practice implications : Results may help practitioners better conceptualize management practices as part of a broader system of work practices. This may, in turn, help practitioners to prioritize management improvement efforts more systematically.

Patient flow improvement strategies have been effective in reducing emergency department (ED) crowding, but little guidance is available on the implementation process. By using a qualitative research design, our objective was to identify common facilitators and barriers to the implementation of patient flow improvement strategies and successful approaches for mitigating barriers. Six hospitals participated in an 18-month Urgent Matters learning network launched in October 2008. The hospitals selected strategies to improve patient flow that could be implemented within 3 months with measurable impact. Across 6 hospitals, 8 strategies were implemented. We conducted 2 rounds of key informant interviews with improvement teams, for a total of 129 interviews. Interviews were recorded, transcribed, and coded by using a grounded theory approach to identify common themes. Factors facilitating implementation included participation in the learning network and strategic selection of team members. Common challenges included staff resistance and entrenched organizational culture. Some of the challenges were mitigated through approaches such as staff education and department leaders' constant reinforcement. Our findings indicate that several facilitators and barriers are common to the implementation of different strategies. Leveraging facilitators and developing a strategy to address common barriers may leave hospital and ED leaders better prepared to implement patient flow improvement strategies.