Background
Objective
Methods
Study design
The HIS quality framework
Participants and setting
Data collection
Ethical considerations
Interview structure
Focus | Key questions | Follow-up questions |
---|---|---|
Daily care practice | Please describe your daily care practice with people on HMV as concretely as possible. | What other activities do you carry out? |
What goals define your professional behaviour? | ||
Please describe a concrete example of the care process. | ||
Quality of care | How do you perceive the quality of care for people on HMV? What is beneficial for a successful care practice? | What skills and qualifications are necessary to care for people on HMV? |
How do you implement your quality expectations in daily practice? What are barriers and facilitators? | ||
What is the role of financing? | ||
Collaboration | What are factors of a successful interprofessional (or intersectoral) collaboration? | How is interprofessional (or intersectoral) collaboration organised? Which communication channels do you use? |
What works best? Where are the biggest problems? | ||
Capacity for improvement | Where do you see a substantial need for improvement in the care for people on HMV? | Please summarise. |
Data processing and analysis
Results
Characteristics of the participants
N | 87 |
---|---|
Sex (female), n (%) | 51 (58.6) |
Age in years, M (SD) | 44.3 (11.2) |
Occupational group, n (%) | |
Nursing manager | 11 (12.6) |
Head nurse | 19 (21.8) |
Registered nurse | 20 (23.0) |
Nursing expert a | 8 (9.2) |
Equipment provider | 7 (8.0) |
Physiotherapist | 6 (6.9) |
Occupational therapist | 3 (3.4) |
Speech and language therapist | 9 (10.3) |
Physician | 4 (4.6) |
Professional experience MV in years, M (SD) | 13.6 (9.2) |
Professional experience HMV in years, M (SD) | 9.4 (6.0) |
Advanced education as respiratory therapist, n (%) | 9 (10.3) |
Analysis of the interviews
The HIS quality framework
I. Outcomes and impacts
1. Key organisational outcomes
The decrease in the quality of care already arises in the hospital. Due to the acceleration of complex processes, for example, in transition management, there is no time to promote rehabilitation and weaning from ventilation. In addition, the shortage of qualified, experienced and motivated staff (i.e., physicians, nurses and therapists) was reported as a serious problem across all healthcare sectors:[My impression in the last years is that] well-fed and clean is somehow sufficient. [...] It's about providing care that is not yet dangerous, [...] but it's no longer about providing rehabilitation and integration for these people. (Nursing expert, ID40, §40)
To counteract these problems, the HCPs recommended that the available expertise should be used in a resource-efficient manner and in line with peoples’ needs. Achieving such resource efficiency involves an urgent need for medical home visits to avoid hazardous transport and hospitalisation:So, let's start with the biggest problem: the changes in the hospital landscape. So, the staff shortage in the clinics, the short-term transfer of patients [...]. [The] patient has to leave as quickly as possible. [...] It's much faster, less detailed. (Equipment provider, ID22, §20-22)
The HCPs describe a systemic problem as the reason for the existing quality deficits. Existing legal requirements for the care of people on HMV promote a system of mismanagement in the healthcare system (e.g., accelerated and premature discharges from hospital, refusal of claims, long waiting times, and a high level of bureaucracy). A physician illustrated the impact of misaligned incentives on the facilitation of peoples’ weaning-potentials as follows:The biggest problem [is] physician care [...]. The patient can't come to the physician's practice, that would be much too complex, this transport. And that means you need a home visit. And you need someone who is competent and knows about ventilation, swallowing disorders and all that. (Physician, ID57, §25)
Finally, the HCPs criticised that the German national HMV guideline is not mandatory, and some recommendations are not feasible to implement due to structural deficits (e.g., insufficient number of weaning centres, insufficient structures for interprofessional and intersectoral collaboration). To improve key organisational outcomes the HCPs recommended the implementation of a new integrated care structure that enables networking and interprofessional collaboration.The problem is that the care services have no interest in weaning because then the customer is gone. [...] The moment the patient is recovered, they [care services] don't earn any money, and that is a very bad structure. (Physician, ID58, §33-35)
2. Impact on peoples experiencing care, carers and families
Furthermore, the HCPs highlighted shared decision making between professionals and people receiving care as a central point within the transition process and in the choice of an appropriate long-term care setting. Therefore, the assessment of rehabilitation potential is just as important as ethical considerations – especially if the ventilated patient is unable to provide consent. To support the decision-making process, the HCPs recommended interprofessional case conferences involving all stakeholders:Outpatient intensive care has a lot to do with assistance, simply understanding that someone who is fully ventilated can go to a rock concert or a restaurant or something similar, in other words, to enable participation. That is part of this service. (Nursing manager, ID34, §47)
The transition to the outpatient area [...] has to be managed in a completely different way in the clinic. There is a need for a medical-ethical case conference; there is a need for a serious effort to ensure that the patient experiences rehabilitation first [...]. With real information for the relatives: What is [...] possible? How ill is [...] the patient? (Nursing expert, ID41, §83)
3. Impact on staff
In contrast, the HCPs reported that a higher nursing staff-patient ratio in outpatient intensive care is related to more time and less stress. Therefore, the HCPs assumed that this time resource could be used to deliver high-quality person-centred care.Most treatments fail because of the psycho-social context. [...] The real issue is definitely dealing with family and relatives, the many conflicts between nurses and relatives. [...] A big shortcoming [...] is that there are [...] no structured offers like supervision. (Nursing expert, ID44, §21)
4. Impact on the community
The relatives should have the possibility to have a service point in the community or at a local level, where they can get their information. (Occupational therapist, ID46, §87)
II. Service delivery
5. Delivery of safe, effective, compassionate and person-centred care
Moreover, the HCPs argued that delivering person-centred care should be based on empowering ventilated patients to be completely involved in all decisions concerning their care and support:[During 24-hour emergency service], you experience [...] a lot. Well, [...] 70 to 80 % are operating errors, and the rest are technical problems. [...] Equipment is often [incorrectly] installed. [...] The handling is [...] sometimes catastrophic. (Equipment provider, ID26, §32)
Regarding barriers to a seamless journey through different settings, the HCPs reported (1) accelerated processes, (2) stressful hospital stays (e.g., as the assistance of the trusted nurse ends at the hospital door) and (3) complex and hazardous transports. The HCPs emphasised that successful collaboration between different organisations is possible if the involved stakeholders work together and share information.No two days are the same, that's for sure, because it's individual care. I also attach a lot of importance to that. The client determines his daily routine. [...] Whether he wants to be washed, whether he wants to get up, whether he would rather stay in bed, whether he wants to sleep, whether he wants to watch TV in bed, whatever his wish is. (Registered nurse, ID60, §16)
6. Policies, planning and governance
Moreover, the HCPs emphasised that planning and coordination of service delivery is a major challenge in HMV, especially when several processes run in parallel or when needs are only reimbursed at a flat rate. A quote from a head nurse illustrates the problems arising in this area:I take over the work from the medical specialist, the respiratory physician and the intensive care physician [...], but always with their supervision. The respiratory therapist [...] needs a physician who delegates this and also needs supervision. (Nursing expert, ID41, §25)
If you now need two tube extensions a day, the provider tells you to clean the tube extension. [...] I can't wash a disposable product with water that contains, for example, secretions and bacteria [...]. Then, the [patient] has pneumonia one day later. (Head nurse, ID4, §42-44)
7. Workforce management and support
In addition, the HCPs described that a high level of clinical expertise (e.g., experience and knowledge in critical care and respiratory care) is needed in caring for people on HMV, although the core competencies include monitoring, empathy, and social care. In this regard, the HCPs emphasised the importance of family-centred care, including professionally handling proximity and distance, involving the family, and being a guest in a person’s home:We [plan] a very strong and very long induction phase [...] so that everyone involved in care feels safe, i.e., the patient, relatives and, of course, the employee himself. [...] Then, we strongly focus on training and advanced education, which means that we train employees in outpatient respiratory care externally but also through regular quality trainings internally. (Head nurse, ID5, §19)
The HCPs described that in addition to nursing competence, the flexibility of the nursing team (e.g., skills mix, appropriate nurse-to-patient-ratio) is important in the care of people on HMV. Moreover, they described HMV as highly interprofessional. Therefore, the HCPs emphasised the need for effective communication among all internal and external stakeholders to ensure the achievement of common treatment goals:In the outpatient intensive care context, [...] the patient [is] not ill alone; [...] the relatives and families [must] be involved in the care [...]. And then it's a lot about the themes of proximity and distance; mindful, appreciative interaction with relatives and families; [...] feeling like a guest in the [patient's] home. (Nursing expert, ID44, §17)
As a key problem, the HCPs emphasised that existing structures hamper communication with external stakeholders. Case conferences are not remunerated, and communication therefore often occurs only in written format or via third parties:The great thing is [...] the interprofessional team; everyone contributes something new and says, “Watch out, we can take a look at that.” [...] I as a physiotherapist [...], the speech and language therapist [...], as well as the nursing staff [...] who are much closer to the patient, [...] you can involve [...] them as co-therapists. (Physiotherapist, ID52, §19)
If you want a round table, it's really very hard to organise. Physicians are self-employed, we are self-employed, [and] everyone wants this time to be paid, of course. [...] The only contact is sometimes a short phone call or [...] via our written reports [...] and that is often not enough. (Speech and language therapist, ID85, §39)
8. Partnerships and resources
Another key issue concerns financing. The HCPs described the fragile situation between reducing costs and delivering high-quality care for people receiving HMV. In this regard, the HCPs criticised the point that cost reduction strategies (e.g., flat-rate payments for respiratory equipment or insufficient remuneration of medical home visits) can decrease quality of care and even increase long-term costs (e.g., due to preventable infections, unnecessary transport or hospital stays).[It is not enough] if the physiotherapist comes three times a week for 20 minutes. These are also things that the nursing staff can – and perhaps must be able to – take over. [...] All other professionals provide treatment on a temporary basis, and the nurse is on site 24 hours a day. (Head nurse, ID7, §73-75)
III. Vision and leadership
9. Quality improvement-focused leadership
The HCPs stated the necessity of motivating and empowering staff to share a common vision of delivering person-centred care. Therefore, the HCPs recommended leadership that supports staff in learning and developing competencies needed for highly specialised care in HMV. Moreover, the HCPs defined successful leadership as being well-known, visible, open to new ideas, and encouraging. The following quote from a nursing manager illustrates how staff can be invited to be an active part of improvement:[My] focus is on ensuring that patients receive the best possible care according to their wishes and needs. I put a lot of emphasis on staff maintaining resources as well. (Head nurse, ID9, §23)
We have [...] very flat hierarchies. [...] It is also important to me that I have a good relationship [...] with the employees. I want to work transparently with them [...]. I want to involve them [...] in many things, because I believe there is nothing worse than people who actually have nothing to do with the matter making the decisions. (Nursing manager, ID36, §29)
Capacities for improvement and relationships among the domains
Key Areas | Recommendations |
---|---|
I. Outcomes and impact | • Eliminate financial disincentives to support transition management, the exploitation of rehabilitation and weaning potential, and the independent choice of long-term care setting. • Decelerate complex processes (e.g., support guideline-based transition management). • Support home visits and avoid hazardous transport and hospitalisation whenever possible. • Promote person-centred attitude and focus on the needs of patients on HMV and their families. • Provide clear information and involve all stakeholders to support shared-decision making. • Ensure staff wellbeing and support staff via supervision. • Support integrated care structures to enable interprofessional networking and collaboration. • Engage the local community, build networking structures, and implement independent counselling. • Establish mandatory quality criteria and support guideline implementation. |
II. Service delivery | • Enable ventilated patients to be an active part of the care process. • Accompany ventilated patients on the journey through different settings (e.g., case management). • Be involved in interprofessional networks. • Implement quality insurance systems and review processes. • Ensure a supporting infrastructure to implement recognised standards and agreed-upon best practices. • Implement safety policies and support proactive risk management. • Cooperate with highly qualified nursing experts to close gaps in the provision of medical care (e.g., delegation of medical services). • Ensure that planning is flexible enough to respond to individual needs (e.g., anticipated needs for respiratory equipment). • Qualify staff to deliver safe care and ensure effective introduction, training and supervision to support staff. • Support training in family-centred care and ensure empathy and respect for the individual. • Ensure skill mixes to allow staff to learn from each other and improve internal processes. • Support interprofessional teamwork and communication (e.g., case conferences). • Ensure collaboration and develop common treatment plans to improve collaboration and outcomes. |
III. Vision and leadership | • Share a clear vision and understandable strategy to support person-centred care. • Motivate and empower staff to be an active part of the intensive care service. • Support staff to develop competencies needed for expertise in HMV. • Encourage staff to be an active part of improvement through a visible, participatory, and open leadership. |