Introduction
Methods
Study design and data collection
Dataset/clinical behavior | TACT-A | Sample | ||||||
---|---|---|---|---|---|---|---|---|
Target | Act | Context | Time | Actor | N = 145 | Country | Data collection dates | |
Hand hygiene | Patients | Hand hygiene | Medical and surgical wards | Before initial contact, after contact, before aseptic procedures, and after bodily fluid exposure | Physicians | 12 | Canada | Sept 2012–Feb 2013 |
Residents | 8 | |||||||
Pre-operative assessment | Patients | Completing an assessment without a routine electro-cardiography | Pre-assessment units | During pre-operative assessments | Anesthesiologist surgeons | 11 5 | Canada | Sept 2009–Oct 2009 |
Adult computerized tomography head rule | Patients | Using an adult computerized tomography head rule | Adult emergency room | During emergency room visit for a head injury | Emergency room physicians | 8 | Canada | Mar 2010–Jun 2010 |
Child computerized tomography head rule | Patients | Using a child computerized tomography head rule | Pediatric emergency room | During emergency room visit for a head injury | Physicians | 10 | Canada | Jan 2011–Jul 2011 |
Nurses | 3 | |||||||
Donation after cardio-circulatory death | Patients | Donation after cardio-circulatory death | Hospitals that perform organ donation | At circulatory death | Intensivists | 12 | Canada | Oct 2013–Jul 2014 |
ICU nurses | 8 | |||||||
Organ donation coordinators | 9 | |||||||
Fetal monitoring | Patients | Intermittent auscultation for fetal surveillance | Birthing units | During labor | Labor and delivery nurses | 12 | Canada | Apr 2010–May 2010 |
Red blood cell transfusion-2 | Patients | Watching and waiting vs. infusing red blood cells | General surgery wards | When patient has borderline hemoglobin | Orthopedic surgeons | 12 | Canada | Sept 2008–Jul 2009 |
Red blood cell transfusion-1 | Patients | Watching and waiting vs. infusing red blood cells | Intensive care units | When patient has borderline hemoglobin | Intensivists | 12 | Canada | Apr 2008–Oct 2008 |
Bone mineral density screening | Patients ≥ 50 years | Order a bone mineral density screen | Physician’s office | At next available appointment when find out about fragility fracture | Family physicians | 10 | Canada | Sept 2012–Nov 2012 |
Smoking cessation | Patients | Adherence to a guideline for smoking cessation | Primary care | During patient visit | Family physicians | 10 | Canada | Mar 2009–Oct 2009 |
Preconception care guidelines | Patients | Adherence to guidelines for preconception care | Primary care (general practitioner office) | During patient visit | Physicians | 3 | Australia | Oct 2007–Nov 2007 |
Data analysis
Results
The sample and data
Context attributes and their features
Attribute | n (%) | Attribute definition | No. of features | Example feature
Definition
|
---|---|---|---|---|
Resource Access | 145 (100) | Access to any resources. This does not necessarily imply the proximity or closeness of such resources, but only their accessibility in the broadest sense (see physical space). | 13 | Time as a resource
Time considered in economic terms: as it is required for the completion of work tasks and as it is managed by staffing and the arrangement of work.
|
Work Structure | 142 (98) | The arrangement of tasks, responsibilities, and resources within and between the various teams working in a clinical setting. This includes factors such as the delegation of tasks among supervisors and subordinates; the arrangement of schedules, shifts, and on-call duties; the order of work tasks and procedures; and the management of workloads. | 12 | Scheduling and shift work
Designated work times, the arrangement of work times among a clinical team (including shift work), and other on-call arrangements.
|
Patient Characteristics | 136 (94) | The attributes of individuals under medical care or treatment. This code refers to the characteristics of patients when considered as a group rather than as individuals; thus, all sub-codes considered for inclusion here had to be generalizable to a patient population (an attribute that could be potentially measured and aggregated). | 2 | Demographics
Quantifiable characteristics of a patient population including age, sex, weight, number of illnesses or comorbidities, patient acuity, illness severity, and medication history.
|
Professional Role | 135 (93) | A set of expectations, both formal and informal, associated with a given clinical occupation. | 7 | Clinical skill set
The technical competencies, knowledge, and abilities that typify a specific clinical role. These are directly related to, and constituted by, the professional role training received during medical training. However, the Skill Set code is differentiated from Professional Role Training code insofar as Skill Set reflects the active employment of a clinician’s particular skills, rather than their acquisition.
|
Culture | 117 (81) | The inherited ideas, beliefs, values, and attitudes of a group. | 2 | Organizational culture
The normative beliefs and shared expectations that govern the work behavior of a clinical team or employees of a healthcare facility. These values and expected behaviors are the product of interactions among system members, along with the influence of their work environment, resulting in a common social structure that exists independently and outside individual team members or workers.
|
Facility Characteristics | 104 (72) | The attributes of a building or group of buildings designated as a site for providing healthcare. These characteristics include the type of facility (i.e., a hospital, a walk-in clinic, a trauma center.), the volume of patients cared for at that location, the geographic location, the geographic catchment, and the presence or absence of medical trainees. | 6 | Type of facility
The practice setting where a team of clinicians operates. This can include private clinics, hospitals, nursing care homes, public health practices, and specialty practices.
|
System Features | 74 (51) | Distinct characteristics of a group of related parts that move or work together in order for a health care region, organization, hospital, or clinical practice to run effectively. | 3 | Record-keeping
The system by which an organization or institution organizes and maintains patient records or charts.
|
Healthcare Professional Characteristics | 72 (50) | The attributes of individuals working as providers of medical care. This code refers to the characteristics of individuals when considered as a group rather than as individuals; thus, all sub-codes considered for inclusion here had to be generalizable to a healthcare professional population (an attribute that could be potentially measured and aggregated). | 2 | Experience Having knowledge or skill in a particular field, especially a profession or job, gained over a period of time. Often used to compare groups with different experience levels (i.e., junior residents vs fellows). |
Financial | 66 (46) | Monetary receipts (income) and expenditures (costs) relating to clinical behavior or institutional standards. | 4 | Funding system
A configuration of services that varies from country to country, but in all cases consists of a financing mechanism, a paid workforce, information on which to base decisions and policies, facilities, and logistics to deliver quality medicines and technologies.
|
Collaboration | 61 (42) | To work jointly with others (including other organizations) or together especially in an intellectual endeavor | 1 | Collaboration
Informal communications between team members or other medical professionals that influence the clinical behavior of a healthcare provider.
|
Leadership | 61 (42) | The direction of a clinical team or management of a healthcare organization. | 3 | Mentorship
A relationship established between a leader or superior and a subordinate or trainee, characterized by a close, and typically enduring, pedagogical exchange, where the subordinate or trainee learns by observing and regularly communicating with the leader or superior.
|
Evaluation | 44 (30) | The systematic collection of information about the activities, characteristics, and outcomes of programs, services, policies, or processes, in order to make judgments about the program/process, improve effectiveness, and/or inform decisions about future development. | 4 | Audit
The official inspection of a division, department, or clinician group, typically by an independent body. An audit is differentiated from more conventional evaluations carried out by an organization during the normal course of operations.
|
Regulatory or Legislative Standards | 31 (21) | Statutes or principles established and enforced by an agency external to the medical profession. Regulatory or legislative standards are here distinguished from guidelines insofar as these standards are binding, often based on law or remuneration structures, and are outside the control of health organizations. | 2 | Legal
Established statutes outlining the prerogatives and responsibilities of medical professionals, organizations, and the rights of patients.
|
Societal Influences | 26 (18) | The general level of social knowledge and attitude as it regards to a particular clinical behavior or procedure. For example, widespread attitudes about organ donation, or a public reaction to a hospital audit as it has been portrayed in the media. | 1 | Societal influences
The general level of social knowledge and attitude as it regards to a particular clinical behavior or procedure. For example, widespread attitudes about organ donation, or a public reaction to a hospital audit as it has been portrayed in the media.
|
A lot of us are pretty busy though. It’s probably just a matter of not enough time in the day to follow-up with the way there is just no time.—Family physician, behavior: smoking cessation (interview #4).
The issue involves standardization right. So you want to develop a system that can easily followed by many people and applicable across a wide variety of patients.—Anesthesiologist, behavior: routine preoperative assessment (interview #A5).
… Sometimes patients are adamant that they need the CT head and that would influence [the decision to use the CT Head Rule].—Emergency room physician, behavior: using adult computerized tomography head rules (interview #4).
It was kind of drilled into me when I was a resident and I see minor head injuries frequently, so it just becomes part of your practice pattern. When you spit out the rules all the time with our residents so it’s just there.—Emergency room physician, behavior: using adult computerized tomography head rules (interview #3)
Setting
Primary care
Hospital: medical-surgical
Hospital: emergency room
Hospital: critical care
Professional role
Attribute and Feature | Total N = 143* n (%) | Physicians and residents N = 111 n (%) | Nurses and organ donor coord. N = 32 n (%) |
---|---|---|---|
Attribute: Resource Access | 143 (100) | 111 (100) | 32 (100) |
Time as a resource | 112 (78) | 88 (79) | 24 (75) |
Guidelines | 84 (59) | 59 (53) | 25 (78) |
Documentation | 79 (55) | 59 (53) | 20 (63) |
Proximity | 72 (50) | 52 (47) | 20 (63) |
Resource quality | 69 (48) | 56 (50) | 13 (41) |
Formal communication | 58 (41) | 45 (41) | 13 (41) |
Organizational training and education | 50 (35) | 28 (25) | 22 (69) |
Staff | 42 (29) | 22 (20) | 20 (63) |
Space as a resource | 29 (20) | 17 (15) | 12 (38) |
Technology | 28 (20) | 18 (16) | 10 (31) |
Expert support | 22 (15) | 13 (12) | 9 (28) |
Programs | 12 (8) | 9 (8) | 3 (9) |
Online resources | 8 (6) | 7 (6) | 1 (3) |
Team educator | 4 (3) | 3 (3) | 1 (3) |
Attribute: Work Structure | 140 (98) | 108 (97) | 32 (100) |
Timeframe | 90 (63) | 67 (60) | 23 (72) |
Continuity of care | 84 (59) | 65 (59) | 19 (59) |
Standardization of care | 80 (56) | 56 (50) | 24 (75) |
Team work | 68 (48) | 48 (43) | 20 (63) |
Reminders | 58 (41) | 52 (47) | 6 (19) |
Work load | 36 (25) | 22 (20) | 14 (44) |
Delegation of tasks | 36 (25) | 25 (23) | 11 (34) |
Order of work tasks | 35 (24) | 27 (24) | 8 (25) |
Work tempo | 25 (17) | 13 (12) | 12 (38) |
Scheduling and shift work | 21 (15) | 12 (11) | 9 (28) |
Patient wait times | 19 (13) | 17 (15) | 2 (6) |
Attribute: Patient Characteristics | 134 (94) | 103 (93) | 31 (97) |
Patient demographics | 111 (78) | 84 (76) | 27 (84) |
Patient expectations and preferences | 90 (63) | 61 (55) | 29 (91) |
Attribute: Professional Role | 133 (93) | 104 (94) | 29 (91) |
Clinical skill set | 73 (51) | 49 (44) | 24 (75) |
Professional role training | 53 (37) | 38 (34) | 15 (47) |
Job autonomy | 48 (34) | 38 (34) | 10 (31) |
Conflict | 47 (33) | 29 (26) | 18 (56) |
Professional development | 43 (30) | 27 (24) | 16 (50) |
Accountability | 36 (25) | 28 (25) | 8 (25) |
Code of ethics | 30 (21) | 15 (14) | 15 (47) |
Attribute: Culture | 115 (80) | 86 (77) | 29 (91) |
Organizational culture | 93 (65) | 65 (59) | 28 (88) |
Culture (general) | 13 (9) | 7 (6) | 6 (19) |
Attribute: Facility Characteristics | 102 (71) | 76 (68) | 26 (81) |
Type of facility | 75 (52) | 57 (51) | 18 (56) |
Geography | 45 (31) | 29 (26) | 16 (50) |
Size | 17 (12) | 9 (8) | 8 (25) |
Volume | 14 (10) | 12 (11) | 2 (6) |
Atmosphere | 13 (10) | 7 (6) | 6 (19) |
Facility characteristics (general) | 10 (7) | 7 (6) | 3 (9) |
Religious affiliation | 1 (1) | 1 (1) | 0 (0) |
Attribute: System Features | 72 (50) | 58 (52) | 14 (44) |
Resource waste | 35 (24) | 31 (28) | 4 (13) |
Logistics and coordination | 25 (17) | 22 (20) | 3 (9) |
Record-keeping | 24 (17) | 14 (13) | 10 (31) |
Attribute: Healthcare Professional Characteristics | 70 (49) | 44 (40) | 26 (81) |
Experience | 53 (37) | 38 (34) | 15 (47) |
Group makeup | 36 (25) | 16 (14) | 20 (63) |
Attribute: Financial | 65 (45) | 58 (52) | 7 (22) |
Costs | 58 (41) | 52 (47) | 6 (19) |
Financial incentives | 18 (13) | 16 (14) | 2 (6) |
Funding system | 12 (8) | 12 (11) | 0 (0) |
Financial (general) | 11 (8) | 8 (7) | 3 (9) |
Attribute: Leadership | 60 (42) | 43 (39) | 17 (53) |
Role modeling | 21 (15) | 17 (15) | 4 (13) |
Mentorship | 8 (6) | 5 (5) | 3 (9) |
Champion | 6 (4) | 5 (5) | 1 (3) |
Attribute: Collaboration | 59 (41) | 39 (35) | 20 (63) |
Social interactions | 59 (41) | 39 (35) | 20 (63) |
Attribute: Evaluation | 43 (30) | 35 (32) | 8 (25) |
Evaluation (general) | 21 (15) | 17 (15) | 4 (13) |
Audit | 20 (14) | 20 (18) | 0 (0) |
Organizational evaluation | 14 (10) | 12 (11) | 2 (6) |
Patient evaluation | 5 (3) | 3 (3) | 2 (6) |
Attribute: Regulatory or Legislative Standards | 30 (21) | 23 (21) | 7 (22) |
Legal | 20 (14) | 13 (12) | 7 (22) |
Standard of practice or care | 13 (9) | 11 (10) | 2 (6) |
Attribute: Societal Influences | 25 (17) | 13 (12) | 12 (38) |
Societal influences (general) | 25 (17) | 13 (12) | 12 (38) |