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Table 1 Evidence table

From: Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits

Study ID
Country
Topica
Setting
N hospitals
N providers
N patients
Study design
Toolkit name and components
Other intervention evaluated in the study
Results
Uptake
Feasibility
Provider
Procedures
Patient
Ashiru-Oredope 2016 [56]
UK
Antimicrobial stewardship (AMS)
Primary care and acute trusts
# hospitals: 211 cinical commissioning groups (primary care), 146 acute trusts
# providers: NR
# patients: NR
Post-only
Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) (primary care) and Start Smart Then Focus (SSTF) (trusts)
Implementation: TARGET: Guidance (local/national antibiotic treatment recommendations), suggested antibiotic practice audits. SSTF: Written materials
Provider: TARGET: Educational materials and tools for providers to share with patients. SSTF: Examples of audit tools, review stickers, and drug charts
Patient: Patient leaflets (Treating Your Infection), resources for clinical and waiting areas
Other intervention: None
Uptake: Of the 82 responding groups, 60% had formally or informally reviewed TARGET and 13% had an action plan to implement AMS interventions recommended by TARGET. Fifty percent had implemented use of the patient information leaflet, 59% were using the TARGET educational presentation, 58% promoted TARGET during practice prescribing visits, 46% promoted the use of TARGET to GPs for use in CPD/revalidation. Groups that had reviewed TARGET were more likely to have implemented an action plan (OR 8.68, CI 1.06, 71.48, p = .044), and more likely to have implemented the use of the patient information leaflet (OR 4.38, CI 1.70, 11.27, p = .002). Of 100 responding trusts, 87% had reviewed national AMS toolkits, and 46% had implemented an action plan to deliver national toolkit AMS interventions. Acute trusts that had undertaken a review of SSTF were more likely to have implemented an action plan (OR 3.33, CI 1.00, 11.06, p = .050).
Feasibility: NR
Providers: NR
Procedures: Few groups had implemented suggested audits or collated data in prevalence surveys; however, 69% groups had used local antibiotic audits within the past 2 years. The most frequent recommended audits in trust-wide point prevalence surveys included: adherence to guidelines of dose, route and duration (82%); clinical indication and treatment duration documented on drug chart (82%); and intravenous to oral switch at 48 h (49%). Other audits, such as review of prescription/evidence of documenting decision at 48 h and time to first dose in severe sepsis, were less commonly implemented (42% and 40% of acute trusts).
Patients: NR
Jones 2017 [69]
UK
Antimicrobial stewardship (AMS)
Primary care
# hospitals: 56
# providers: 269 (surveys), 24 (focus groups), 29 (interviews)
# patients: NA
Post-only
TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics Toolkit
Implementation: see Ashiru-Oredope, 2016
Provider: see Ashiru-Oredope, 2016
Patient: see Ashiru-Oredope, 2016
Other intervention: 1 h workshop covering AMR, guidance, how to optimize antibiotic prescribing, use of resources in the Toolkit, reflection on their own antibiotic prescribing data and some action planning. Workshop participants completed a five-point Likert scale eval
Uptake: Around half of GPs reported using the TARGET resources to varying degrees.
Feasibility: Most GP staff and stakeholders described the TARGET Antibiotics Toolkit as a useful resource, which addressed their own prescribing behavior and patient expectations. They felt that it complemented existing efforts and was relevant to all practice staff in developing a consistent approach to patient enquiries about antimicrobials.
Providers: 88% responded that the workshop helped them understand how to optimize antimicrobial prescribing, 88% responded that the workshop helped them to understand why responsible antimicrobial prescribing is important. All stakeholders were promoting its use.
Procedures: The self-assessment checklist is a key resource that can be used for monitoring but was infrequently mentioned by participants.
Patients: NR
Bender 2011 [19]
US
Asthma management
Primary care
# hospitals: 58
# providers: 372
# patients: ~15,508
Pre-post
Colorado Asthma Toolkit
Implementation: Training manual
Provider: Spirometer
Patient: Toolkit for patients, peak flow meter, guide for self-management support, telephone outreach enrollment form, asthma action plan, "understanding asthma" booklet, other educational materials
Other intervention: On-site training/coaching, optional interactive voice response program for patients
Uptake: 98% of practices offered the toolkit took it up; median action plan use increased from 0% to 20% after coaching (53% of practices increased)
Utility: NR
Providers: NR
Procedures: Patients with asthma using inhaled corticosteroids increased from median 25 to 50% (p < .0001), patients with an action plan 0 to 20% (p < .001), use of spirometry 0 to 40% (p <. 0001); cost of training each practice was $4194
Patients: NR
Taylor 2017 [87]; Tapp 2017 [108]
US
Asthma management
Community-based practices
# hospitals: 6
# providers: NR
# patients: 92
CT
Shared Decision Making (SDM) Toolkit (asthma management)
Implementation: Asthma half day clinic flow, initial and follow-up scripts
Provider: Spirometry technique, documentation template, follow-up patient information sheet, controller reliever posters, blank control dial, treatment goals and medication preferences form, prior authorization forms
Patient: Facts about asthma, allergy information, smoking cessation information, severity and control dials, medication options, medication planner, general types of asthma medications, how to use your inhaler handouts, asthma diary
Other intervention: A family medicine provider who was also part of the research team facilitated and tailored the implementation of the toolkit to the individual needs of each practice. The rollout typically consisted of hour-long weekly sessions with practice providers and staff. Adoption of the SDM intervention was reinforced with monthly meetings with representatives from participating practices and a refresher training at the end of year one.
Uptake: NR
Feasibility: NR
Providers: NR
Procedures: Patient surveys asking, “Who made the treatment decision today?” were collected from 319 of the SDM toolkit visits. 87% reported a shared decision was made between patient and provider with 6% indicating the patient mostly made the decision, 74% indicating it was shared equally and 7% indicating the provider mostly made the decision.
Patients: The toolkit intervention was associated with higher quality of life scores when compared to usual care (MD 0.9; CI 0.4–1.4). Models assessing the impact on individual quality of life domains (activities, emotions, symptoms) revealed similar results. Similarly, models examining differences in asthma control showed lower asthma control problems for children in the SDM toolkit intervention compared to usual care (MD − 0.9; CI − 1.6–0.2).
Nicolaidis 2016 [79]
US
Autism communication
Primary care
# hospitals: NR
# providers: 51
# patients: 259
Pre-post
Academic Autism Spectrum Partnership in Research and Education (AASPIRE) Healthcare toolkit
Implementation: Autism information/diagnosis/referrals, legal and ethical information, other educational resources
Provider: Autism Healthcare Accommodations Tool (AHAT), checklists and worksheets
Patient: Personalized accommodations report, patient information, checklists, worksheets
Other intervention: Patients recruited, sent AHAT to patient's PCP with a cover letter, information sheet about the study,
Uptake: NR
Feasibility: Most PCPs rated it as moderately or very useful and indicated that they would recommend it to their patients. Most answers from PCPs to open-ended questions were positive and provided examples of the tool's utility. However, several PCPs noted that they already were doing what was recommended in the report, and two PCPs felt that they did not have time to implement accommodations.
Providers: NR
Procedures: NR
Patients: Almost all autistic participants and supporters felt that the AHAT and the toolkit were easy to use, important, and useful. Over 90% said they would recommend the toolkit to a friend or their healthcare provider. The total number of barriers encountered by patients decreased significantly (p < .001). Participants’ self-efficacy in navigating the healthcare system also increased (p = .02). Participants described the toolkit as giving them a means to clarify and communicate their needs. Many participants felt that the toolkit validated their experience and empowered them to self-advocate more effectively. Participants also often gave examples of how the toolkit improved their self-efficacy, especially by helping them prepare for visits. Most participants were enthusiastic about how the AHAT report might affect their PCPs' behavior. Among the 43 patients who saw their PCP within the 1-month follow-up period, satisfaction with PCP communication improved significantly (p = .03). Participants described many concrete positive changes in providers or their staff. Several participants voiced frustration that their providers did not read the AHAT report or did not make any changes based on the report.
Chrisman 2011 [18]
US
Brain injury symptom management
Primary care
# hospitals: NR
# providers: 414
# patients: 0
RCT
Heads Up: Brain Injury in Your Practice
Implementation: Booklet describing diagnosis and management, CD with additional resources, online resources such as posters and custamizable handouts available
Provider: Palm card, Acute Concussion Evaluation (ACE) form
Patient: Patient information in English and Spanish
Other intervention: NR
Uptake: NR
Utility: NR
Providers: No difference in general concussion knowledge between intervention and control groups; intervention physicians less likely to recommend next day return to play after concussion (OR 0.31, CI 0.12, 0.76)
Procedures: NR
Patients: NR
Latsko 2015 [72]
US
Cancer care
Hospital
# hospitals: NR
# providers: 165
# patients: NR
Post-only
Treating Myelodysplastic Syndrome (MDS) Toolkit
Implementation: Summary of the patient survey, counseling guide
Provider: Diagnostic spectrum reference card, mobile app
Patient: Patient information sheets, free patient booklet order form
Other intervention: None
Uptake: 24% of responding oncology nurses reported having a toolkit.
Feasibility: NR
Providers: Comparison of the responses of nurses in possession of the toolkit: For MDS Education, oncology nurses reported on education at the following times: During the diagnostic workup (53 vs 41%); at each follow-up appointment (75 vs 51%); prior to a change in treatment (85 vs 74%); at completion of treatment (53 vs 33%) and at the time of disease progression (78 vs 68%). For side effect education, respondents reported: prior to administration of each treatment (93 vs 86%); at each treatment appointment (75 vs 70%); at the completion of each treatment (50 vs. 39%); and during follow-up calls after treatment (45 vs 40%).
Procedures: NR
Patients: NR
Gulati 2015 [67]
UK
Cancer screening
Primary care
# hospitals: 3374 practices that used toolkit between March 2012 and June 2013
# providers: 8163 users, 1002-1007 survey responders, 276 GPs making referrals
# patients: NR
Post-only
General Practitioner (GP) Skin Cancer Toolkit
Implementation: NR
Provider: Online resources including referral guidelines, real-life case histories, accredited quiz
Patient: NR
Other intervention: Promoted though regular email notifications to GPs and on the host home page
Uptake: Accessed by 8163 GPs 12586 times viewing 127036 page views and spending a median time of 4 min each (mean 5.37 min) over 255 days. 1/3 users used the site more than once; there were 6% more unique users and 23% more unique users than the next most popular education campaign on Doctors Net UK (DNUK) in 2012. Clinical case studies were used most commonly (3082 times by 2587 users), followed by the referral decision aid (2935 times) and the lesion recognition resource (2215 times).
Feasibility: Focus grousp principal themes included that GPs considered themselves to be gatekeepers for referring suspicious lesions, but were concerned about avoiding unnecessary referrals; existing resources were useful, but prior dermatology teaching had been poor; the toolkit was useful for diagnosing skin lesion and allaying patient anxiety, but did not influence referral rates. Criticisms of the toolkit included lack of information and images for borderline and atypical skin lesions. Suggested improvements to the toolkit included more clinical images, online forums for discussing uncertain cases and a zoom function for clinical images.
Providers: Reported confidence in recognizing different skin lesions suspicious of skin cancer was lower in 2013 compared to 2011 (p < 0.01) but there were no differences between toolkit users and non-users (p = 0.798). Confidence in knowledge of the appropriate referral pathways for malignant skin lesions was higher in respondents who used the toolkit (p < 0.01). There was no difference in perceived information and training about skin cancer recognition (p = 0.786). However, more respondents who had used and recalled using the toolkit said they had received adequate training and information compared to non-users (p < 0.05). The proportion of appropriate referrals increased from 21 to 32% (p < 0.0001).
Procedures: Although the absolute numbers of urgent skin cancer referrals and melanoma and non-melanoma diagnoses increased, there were no significant changes in the number of urgent GP referrals for suspected skin cancer (p < 0.001), diagnoses of melanoma (p < 0.001) or diagnoses of non-melanoma skin cancer (p < 0.001) between the toolkit user and non-user groups.
Patients: NR
Spruce 2012 [17]
US
Cancer screening
Primary care
# hospitals: NR
# providers: 30 out of 106 invited
# patients: NR
Post-only
Improving Colon Cancer Screening in Nevada with a Primary Care Toolkit
Implementation: Sample chart audits, tracking sheets, decision aids, office strategies to improve screening, resources
Provider: Phone scripts, care flow sheets, recommendations, algorithm
Patient: Reminder and results letters, postcards
Other intervention: NR
Uptake: NR
Utility: All participants were very satisfied or satisfied with the overall usefulness of the toolkit, 97% were very satisfied with the educational content, all were very satisfied that the info was presented clearly, 83% were very satisfied with office strategies to improve screening, all were very satisfied with algorithms and tools
Providers: 95% stated they would increase practice use of fecal immunochemical tests for those patients who are not eligible for or refuse a colonoscopy and would implement many of the toolkit recommendations
Procedures: NR
Patients: NR
Adsett 2014 [41]
Australia
Cardiac care
NR
# hospitals: NR
# providers: 340
# patients: NR
Post-only
HEART (Heart Education Assessment Rehabilitation Toolkit) Online
Implementation: Literature, references, links, videos, glossary
Provider: Assessment tools, clinical calculators (e.g. BMI), educational materials and tips for initiating patient education
Patient: Self-help resources
Other intervention: NR
Uptake: NR
Utility: Ratings of the toolkit on a five point scale (5 = strongly agree) were > 4 on 8 survey items related to content accuracy, ease of use, and relevance to practice
Providers: NR
Procedures: NR
Patients: NR
Callard 2012 [11]
UK
Care quality
Hospital
# hospitals: 2 trusts
# providers: NR
# patients: NR
Post-only
15 Steps Challenge toolkit
Implementation: Slide sets, briefing notes, action plan template
Provider: NR
Patient: Ward notice
Other intervention: NR
Uptake: 2000 electronic versions have been downloaded from May to December 2012
Utility: NR
Providers: NR
Procedures: NR
Patients: NR
Kemertzis 2018 [70]
Australia
Clinical decision making
Hospital
# hospitals: 1
# providers: 59
# patients: 11
Pre-post
Fertility Preservation Toolkit
Implementation: Instruction booklet
Provider: Referral forms, information and consent forms, research information and consent forms
Patient: Information sheets, booklet for patients and families, leaflets on fertility preservation options and brochure on treatments and fertility (male and female version)
Other intervention: Education session to introduce toolkit
Uptake: 59 of 104 (56.7%) agreed to participate in the evaluation
Feasibility: Clinicians were satisfied in 7/11 (64%) discussions, extremely satisfied or satisfied in 11/11 (100%). Reasons for dissatisfaction were missing documents within the toolkit, organization of the documents within the toolkit, and perception that there was too much written information which could overwhelm families and clinicians. The clinician perceived patient or family to have extremely or reasonably well understood the fertility preservation discussion in 10/11 (91%) cases and were perceived to be satisfied in all cases.
Providers: There was an overall improvement in participant confidence levels in providing up-to-date fertility preservation information (p = 0.005).
Procedures: There was an overall improvement in the provision of verbal (p = 0.003) and written (p = 0.02) information post toolkit use.
Patients: NR
Pierce 2016 [81]
US
Critical care
Hospital
# hospitals: 6
# providers: NR
# patients: NR
CT
Critical Care Protocol Toolkit (CCPT)
Implementation: Written materials (list and description of steps involved in process), summary of key points
Provider: None
Patient: None
Other intervention: NR
Uptake: The toolkit group followed all 9 steps in the toolkit and used 14.3 ideas from the toolkit on average. The non-toolkit group missed or weakly addressed 5.3 steps on average.
Feasibility: The toolkit group experienced 13 barriers on average compared to 5.7 in the non-toolkit group (p = 0.512). Of the barriers encountered, the toolkit could have helped with barriers 62% of the time in the toolkit group compared to 77% in the non-toolkit group.
Providers: NR
Procedures: The control group missed or weakly addressed on average 3.3 of 9 key steps. The CCPT reduced implementation time from 56.4 days per step in the non-toolkit group to 46 days in the CCPT group (p = 0.327)NR
Patients: NR
Han 2013 [31]
US, UK, Australia, New Zealand, Canada, Ireland
Depression care
Primary care
# hospitals: NR
# providers: 666
# patients: NR
Post-only
MDPC (MacArthur Foundation Depression and Primary Care) Depression Toolkit
Implementation: Slide presentations, training manuals, literature references, cost calculator
Provider: Patient health questionnaire (PHQ-9), guides to diagnostic and treatment approaches, specialty care referral form
Patient: Educational materials
Other intervention: NR
Uptake: Since its launch, more than 20,000 users registered as members to read and download depression care resources
Utility: Respondents generally rated resources as useful but ranged from 68% (PHQ-9) to 10% (cost calculator). Eight-four percent rated information on screening and diagnosis as good or excellent (70% for treatment, 66% for patient education materials, and 67% for care management material). Sixty-three percent were very confident in the content; more than half indicated that expert answers to clinical questions on depression, expert discussions research findings, and content on common mental illnesses would improve the tool
Providers: 60% of respondents answered they had somewhat changed their practice after viewing the web site resources
Procedures: NR
Patients: NR
Gray 2017 [65]
Canada
Diabetes care
# hospitals: NR
# providers: 462 (baseline), 132 (follow-up)
# patients: NR
Pre-post
Building Competency in Diabetes Education: Physical Activity and Exercise
Implementation: see Fowles, 2014
Provider: see Fowles, 2014
Patient: see Fowles, 2014
Other intervention: Training workshops offered in which each component of the manual was presented, and participants were given time to practice instructions in motivational interviewing and how to perform and instruct patients in resistance exercises.
Uptake: NR
Feasibility: Participants found the resources helpful (M 5.1, SD 1.49). Frequency analyses of the 7 specific resources provided in the toolkit revealed that brochures concerning resistance training were referred to on a regular basis during sessions with patients (58%). Less than half reported referring regularly to the remaining 6 resources (informational brochures, counseling worksheets, decision tree, at-a-glance summary sheets, data collection sheets, resistance training brochures). A large majority reported that they most often used the resources when working with patients who were inactive but were ready for or preparing for physical activity (80%). Reported challenges included: time (37%), patients’ resistance (36%), patients’ physical limitations (27%), patients’ personal barriers (23%), participants’ lack of expertise (16%), lack of physical-activity resources (12%), and other (24%). Analysis of the 4-point impact ranking scale revealed that the impact of the challenges was moderate (M 2.4, SD 0.82).
Providers: Immediately following the workshop, particiapnts intended to implement the resources in their sessions with clients (M [median] 4.5/5, SD 0.64); 93% reported that they would very likely or definitely use the resources. Participants intended to increase the priority given to physical activity, employ the tools provided in the toolkit, incorporate resistance training into practice, and engage in novel ways to promote physical activity. The majority reported an increase in confidence across physical activity counseling. The most frequently reported areas were confidence in providing information and advice regarding the benefits of activity (86%); providing advice and instruction regarding resistance training (86%); and providing a physical activity program that accommodated patients’ individual needs or limitations (78%). Sixty-four percent reported an increase in confidence in their typical patients’ abilities to perform physical-activity behaviors appropriate for their fitness levels. The majority indicated that their confidence in making exercise referrals had not changed since the workshop training.
Procedures: Prior to having attended the workshop, 58% included physical-activity content in more than half of their sessions, while 29% addressed physical activity in < 25% of patient sessions. In the sessions in which physical activity was discussed, 73% spent < 25% of the session on physical activity content, and 30% discussed physical activity for < 10% of each session. At the 8–12-month follow up, 66% included physical-activity content in more than half of their sessions, while only 18% addressed physical activity in < 25% of sessions. However, in the sessions in which physical activity was discussed, 78% spent < 25% of the session on this topic. 8 themes emerged: more frequently and confidently discussing physical activity in sessions (27%); increasing focus on resistance training (26%); providing patients with physical-activity procedures and written information (14%); feeling better equipped to assess current physical-activity levels (7%); assisting patients in working around barriers to being involved in physical activity (5%); recommending specific ctivities (4%); encouraging other health professionals to integrate physical activity into practice (4%) and other (12%).
Patients: NR
Fowles 2014 [44]
Canada
Diabetes management
Community health center
# hospitals: 7
# providers: NR
# patients: 198
CT
Diabetes Building Competency in Diabetes Education: Physical Activity and Exercise
Implementation: Resource manual, literature review
Provider: Guidelines for risk stratification, assessments of readiness for exercise, referral process guide, clinical decision tree
Patient: Sample exercise programs, goal setting worksheets, decisional balance sheets, informational brochures, online material, resistance exercise video
Other intervention: 3-h training and 3-h regional workshop for diabetes educators
Uptake: NR
Utility: NR
Providers: Increased confidence in ability to provide physical activity and exercise counseling in intervention group (p < .001); greater knowledge about physical activity (p <. 03) but perceived physical activity counseling to be more difficult after receiving the trai
Procedures: NR
Patients: No significant difference in patient reported physical activity and exercise levels, efficacy perceptions, or mean glycated hemoglobin; no differences in relative use of medication or changes in medications or diet between toolkit and standard care groups
Alidina 2015 [55]
US
Elective delivery
Hospital
# hospitals: 1
# providers: NR
# patients: 1065
Pre-post
Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age
Implementation: Written materials, decision support flow chart, scheduling flow chart, sample scheduling form
Provider: Patient education talking points, patient education poster
Patient: Patient education brochure, flyer
Other intervention: NR
Uptake: Used toolkit to implement new scheduling processes.
Feasibility: NR
Providers: NR
Procedures: In the study group there were 4 patients versus 42 patients in the control group (p < 0.0001) delivered between 37/0 and 38/6 weeks without an indication.
Patients: There were 0 transfers to the NICU compared to 5 preintervention (p < .022) for non-medically indicated deliveries between 37/0 and 38/6 weeks.
Chesis 2015 [58]
US
Elective delivery
Hospital and staff obstetrician offices
# hospitals: 1
# providers: NR
# patients: NR
Pre-post
Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age
Implementation: see Alidina et al., 2015
Provider: see Alidina et al., 2015
Patient: see Alidina et al., 2015, flyer
Other intervention: Additional measuring tool developed by the Advocate System Obstetric Safety Committee to help drive appropriate patient scheduling and data collection
Uptake: NR
Feasibility: NR
Providers: NR
Procedures: Rate for non-medically indicated elective delivery was 25.0% pre-implementation in 2011; post-implementation by the end of 2011 it was 11%. In the 18 months prior to publication, it was 0.0%.
Patients: NR
Clancy 2012 [13]
US
Emergency preparedness
Hospital
# hospitals: 116
# providers: NR
# patients: NR
Post-only
NY State Department of Health Pediatric and Obstetric Emergency Preparedness Toolkit
Implementation: Training material stratified by hospital type, links to online courses, educational material and clinical guidelines, glossary
Provider: Safety checklists, triage algorithm, assessment tools, dosage guidelines
Patient: Fact sheet for parents/caregivers
Other intervention: NR
Uptake: 91% were aware of the toolkit, 86% had reviewed it
Utility: Reasons for not appointing pediatric physician/nurse coordinators: implementation not started, no person available, cost
Providers: NR
Procedures: 1 year after toolkit distribution, 60% of facilities had appointed a pediatric physician coordinator, 49% a pediatric nurse coordinator. Toolkit review was not associated with the presence of an emergency management plan
Patients: NR
Wyte-Lake 2016 [89]
US
Emergeycy preparedness
Home-based primary care
# hospitals: NR
# providers: 77
# patients: NR
Post-only
Home-Based Primary Care/Home Health Agency Disaster Preparedness Toolkit
Implementation: Written materials, source documents
Provider: Checklists, suggestions, examples of tools
Patient: NR
Other intervention: Introduced over a national call for VHA HBPC program directors, posted to VA pulse, written invitation to participate in web-based toolkit evaluation, reminder emails and letters
Uptake: NR
Feasibility: Of those respondents who found the toolkit very helpful (for clarity of design, comprehensiveness of information, and overall impression of the toolkit) approximately 60% had been part of the HBPC program for 5 years or less. The percentage of respondents who reported the toolkit to be helpful decreased as length of time in the HBPC program increased (22–25% for 6–10 years and 15–18% for ≥ 11 years). These results indicate that helpfulness of the toolkit was associated with fewer number of years with the HBPC program (p < 0.05). Length of time in the HBPC program manager role was not found to be associated with perceived helpfulness of the toolkit. On a 4-point Likert scale, respondents were asked if they agreed or disagreed that the topics covered in the toolkit were relevant to their preparedness protocol. Of those who implemented their disaster preparedness protocol more frequently (3–5 times/year or 1–2 times/year), two-thirds (66–67%) strongly agreed that the topics covered in the toolkit were relevant. Conversely, of those who implemented their protocol very infrequently or never, only 23% strongly agreed that the topics covered in the toolkit were relevant to their work (p < 0.05). When asked, How often do you see yourself using this toolkit?, 8% indicated that they will never use the toolkit. The rest indicated that they would use the toolkit moderately or extensively (data not shown). HBPC program representatives were asked to describe the types of support they would need to implement the toolkit. They suggested speaking with others who have implemented the toolkit, sharing it with leadership and hospital-wide committees, collaborating with local law enforcement and receiving online training, especially discipline-specific training. They also would appreciate reminders about the toolkit.
Providers: NR
Procedures: NR
Patients: NR
Henry 2012 [14]
Mongolia
Emergency/surgery capacity
Hospital
# hospitals: 338 (hospitals in 12 provinces)
# providers: NR
# patients: NR
Pre-post
Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit
Implementation: WHO recommendations for minimum standards to improve quality and safety, equipment lists and needs assessment, manual, trainer's guide, detailed training material, model training workshops, research tool
Provider: Best practice protocols, care guides, diagnostic tools, safety checklists, link to videos on surgical procedures
Patient: NR
Other intervention: 5-day training program and site visits given by participants in WHO Training of Trainers workshop
Uptake: 67% of provinces and 53% of hospitals implemented the program
Utility: NR
Providers: NR
Procedures: Increase in number of surgical procedures performed, decrease in number of surgical procedures referred to other facilities
Patients: NR
Cox 2017 [60]
UK
End-of-life care
Care homes
# hospitals: 6
# providers: 78 (pre), 103 (post)
# patients: NR
Pre-post
End of Life Care Toolkit (part of Care Homes and hOspitals Innovating Collaboratively to increase End of life care options [CHOICE] Project)
Implementation: Written materials
Provider: Written materials
Patient: NR
Other intervention: Three training sessions (1 h each) in each care home
Uptake: NR
Feasibility: NR
Providers: After the intervention, there was a trend for staff to report feeling more supported in terms of emotional and clinical support in the care home and feeling able to source external support GP/district nurse; Q11 hospice/palliative care nurse), even out of hours. The results suggested confidence in ability to discuss death and dying with residents was lower post-intervention, although this change in confidence did not reach statistical significance (p ≥ .05). Mean scores suggest interventions did not affect staff confidence in terms of discussing death and dying with relatives, identifying end of life, or the creation of EoLC plans. Staff confidence in managing each of the 24 end of life symptoms including pain, anxiety, nausea and vomiting, and mouth care increased post-intervention, however, this trend did not reach statistical significance.
Procedures: NR
Patients: A comparison of a 5-month period before and after the intervention indicated a 59% reduction in the number of residents who died in the local NHS hospital in comparison to a 21% reduction from the comparison care homes.
Carroll 2012 [16]
US
Fall prevention
Hospital
# hospitals: 8
# providers: NR
# patients: 364
RCT
Fall TIPS (Tailoring Interventions for Patient Safety)
Implementation: NR
Provider: Fall risk assessment scale, individualized bed poster, plan of care
Patient: Peronalized patient/family education handout
Other intervention: NR
Uptake: NR
Utility: NR
Providers: NR
Procedures: Patients on the intervention units were more likely to have fall risk documented (89 vs 64%; p < .0001); there were significantly more comprehensive plans of care for the patients on the interventions documented but no difference were found regarding documentation of completed interventions
Patients: NR
Coe 2017 [59]
US
Fall prevention
Clinical and community-based organizations
# hospitals: 23 clinical and 27 community-based organizations
# providers: NR
# patients: 20317
Post-only
Stopping Elderly Accidents, Deaths, and Injuries (STEADI)
Implementation: Stories about falls prevention programs and successes
Provider: Tests, fact sheets, case studies, additional resources
Patient: Educational materials and brochures
Other intervention: Statewide falls prevention learning collaborative (includes full day statewide learning sessions twice per year, expert-led falls prevention webinars are offered several times per year, ongoing trainings on each intervention in multiple modalities), referral of qualified patients to community-based interventions (Tai Chi, Matter of Balance [MoB], and Assisted Home Safety Assessment and Modification [AHSA]).
Uptake: Over a period of 21 months of implementation clinical sites assessed patients using the STEADI protocol and referred 4726 individuals to PWTF community sites for falls prevention interventions. Of those, 44% enrolled in the PWTF-sponsored community interventions and of those enrolled 45% completed the interventions. Organizations also recruit individuals directly. There were 2256 “walk-ins” and 989 “completers.” Overall, > 4359 individuals enrolled, and ~ 1945 completed interventions.
Feasibility: Stopping Elderly Accidents, Deaths and Injuries implementation was challenging for the primary care sites as falls risk assessment was a new area and requires systems change. PWTF sites experienced challenges such as securing support from senior leadership and clinical staff; the lack of reimbursement for specific clinical components; no data fields in EMR to capture or assess falls assessments; and lack of workflows and processes for implementing STEADI. Clinical and community staff faced challenges in referring and enrolling individuals into community interventions due to reluctance due to the time commitment, lack of understanding of risk, and unfamiliarity with programs or organizations running the programs. Partnerships tested multiple strategies to overcome these issues.
Providers: NR
Procedures: During a 9-month period 48% of patients were screened for falls risk and 30% of those who screened positive received an evaluation of their gait, strength and balance. Of those who screened positive, 37% received a plan of care and a multifactorial clinical risk assessment. Of the patients screened, 6% received referrals to a community falls prevention intervention. Of those referred, 44% enrolled in the community interventions.
Patients: NR
Dykes 2009 [61]; Zuyev 2011 [109]
US
Fall prevention
Hospital
# hospitals: 4
# providers: NR
# patients: 685
Pre-post
Fall TIPS (Tailoring Interventions for Patient Safety) Toolkit
Implementation: see Carroll et al. (2012)
Provider: see Carroll et al. (2012)
Patient: see Carroll et al. (2012)
Other intervention: NR
Uptake: Adherence with toolkit adoption measures ranges from 72% (bed poster) to 97% (fall risk assessment completed), varying by site and component
Utility: Feedback from end users is positive
Providers: NR
Procedures: Mean number of fall risk assessments completed per day increased from 1.7 to 2.0 one month after implementation (p < .003)
Patients: The mean fall rate decreased from 3.28 to 2.80 falls per 1000 patient-days post intervention and the mean fall with injury rate decreased from 1.00 to 0.54 per 1000 patient-days.
Fisher 2013 [10]
UK
Fall prevention
Hospice
# hospitals: 1
# providers: NR
# patients: NR
Pre-post
Falls prevention and management toolkit
Implementation: Policy document (framework for multi-factorial assessment and definition of fall)
Provider: Assessment and care plan tool, incident report form
Patient: NR
Other intervention: NR
Uptake: There are hospices that continue to use the toolkit, some have made small or substantial adaptations to meet local requirements
Utility: NR
Providers: NR
Procedures: NR
Patients: The author's hospice reduced falls to 4.3 per occupied bed per year in 2011–2012 from 5.1 in 2007
Stalhandske 2008 [52]
US
Fall prevention
Hospital
# hospitals: 65 out of 70 initial volunteers
# providers: 42
# patients: NR
Pre-post
National Falls Toolkit
Implementation: CD, informational brochures, posters, flyers, sample buttons for identifying advocates or resources, online resources
Provider: Morse Fall Scale pocket card, video on performing a balance assessments
Patient: Videos on hip protectors for patients/caregivers
Other intervention: Falls data monitoring
Uptake: NR
Utility: NR
Providers: NR
Procedures: Changed or implemented a fall risk assessment (14%), changed the system of tracking falls data (12%), honed in on an area of vulnerability (10%), changed or implemented a falls policy (7%), changed or implemented a falls team (7%), increased use of documentation or falls prevention interventions (5%), became more proactive in falls prevention (5%), other ways such as implementing specific interventions (21%)
Patients: Over the course of the 2 years, there was a reduction in major injuries (e.g., 64% in behavioral health setting); fall rate remained relatively stable
Ryan 2013 [30]
Canada
Geriatric care
Primary care
# hospitals: 181 out of 220 invited
# providers: NR
# patients: NR
Post-only
Geriatrics, Interprofessional Practice, and Interorganizational Collaboration (GiiC) Toolkit
Implementation: Topic overviews, FAQs, materials for broader reading, interprofessional and interorganizational collaboration elements (eg, team assessment, recognizing states of team development, team problem solving, understanding organizational outcome expectations, v
Provider: Pocket guides, algorithms and clinical tools, self-directed learning materials downloadable to personal computers or flash drives
Patient: Bilingual patient handouts
Other intervention: 16-h “train-the-facilitator” workshops, small-group discussions to support implementation, 2–4 months coaching from consultants, 6 months refresher day and practice review, annual meeting
Uptake: 79% of identified family health teams and 85% of community health centers participated in the initiative; the toolkit has been downloaded 41,556 times; 48% of participants reported moderate or a lot of change in their team's care of frail seniors
Utility: NR
Providers: Participant ratings of knowledge gain and confidence in geriatric competencies was 3.46 (1 not at all, 5 a great deal). Participant ratings of perceived learning and facilitator confidence were 3.67, and 4.15 in interprofessional and 4.02
Procedures: NR
Patients: NR
Dore 2013 [34]
US
Health literacy
Rheumatology practice
# hospitals: NR
# providers: 18
# patients: NR
Pre-post
Health Literacy Universal Precautions Toolkit for Rheumatology (HLUPTK-R)
Implementation: Material on forming teams, raising awareness, organizational assessment, Plan-Do-Study-Act worksheets, educational material, videos
Provider: Quick start guide for providers, medication dosing form, checklists, tips for addressing language differences and patient education
Patient: Links to online resources for patients
Other intervention: 20-min introductory presentation
Uptake: 72% participants stated HLUPTK-R Qick Start techniques were incorporated into their practice
Utility: 54% of users thought that incorporating health literacy techniques added time to the patient's visit, but all thought the time was worthwhile; all believed the techniques were helpful in their practice
Providers: 77% of users agreed that their knowledge of health literacy was improved and that incorporating the quick start techniques had a positive impact on patient care
Procedures: All toolkit users used the encouraging questions technique, 62% used the teach-back method, 23% used the medication review technique
Patients: NR
Mabachi 2016 [75]
US
Health literacy
Primary care
# hospitals: 12 practices
# providers: 3 individuals/site
# patients: NR
Post-only
Health Literacy Universal Precautions (HLUP) Toolkit
Implementation: NR
Provider: NR
Patient: NR
Other intervention: Practices identified and ranked the top four of 11 priority tools they wanted to implement; practices were assigned to implement two tools. Technical assistance providers from the research teams conducted chec-in calls at 2 ,4, 8, and 16 weeks.
Uptake: Practices used the Toolkit “flexibly.” They did not always implement all portions of their assigned tools. Practices found that some tools were best implemented in tandem and recognized the efficiencies in implementing them in this manner.
Feasibility: Specific implementation barriers were noted by the participating practices, including (1) competing demands/staff capacity, (2) bureaucratic challenges, (3) technological challenges, (4) limited quality improvement experience, and (5) limited support from leadership. Linking health literacy implementation activities to other practice-wide QI initiatives (e.g., patient-centered medical home accreditation) raised staff awareness and increased engagement.
Providers: While practices worked independently on toolkit implementation, they benefited from having external support and accountability. Three-fourth of the practices reported that they plan to continue to use the Toolkit as a resource to guide their health literacy-related QI work. 8/12 practices indicated they would continue with their 2 assigned tools and the improvement implemented during the study period.
Procedures: NR
Patients: NR
Koelling 2006 [28]
US
Heart failure
Hospital
# hospitals: 14
# providers: NR
# patients: 1806
CT
Guidelines Applied in Practice - Heart Failure (GAP-HF) Tool Kit
Implementation: Quality performance charts
Provider: Heart failure standard admission orders, heart failure specific clinical pathway, heart failure patient discharge contract
Patient: Self-management diary
Other intervention: 6 monthly learning sessions
Uptake: NR
Utility: NR
Providers: NR
Procedures: NR
Patients: Baseline-adjusted 30-day readmission rate was statistically reduced (p = .003) but not 30-day mortality (p =. 101) comparing intervention and control group
Perumalswami 2016 [80]
US
Hepatitis C care
Primary care
# hospitals: NR
# providers: NR
# patients: NR
Post-only
HepCure (Hepatitis C education and patient engagement)
Implementation: NR
Provider: Open access toolkit (a dashboard) that enhances providers’ ability to deliver guideline-based HCV care; and a tele-education platform for medical providers
Patient: Linked patient app that provides education, medication reminders, and a platform for tracking adherence and symptoms
Other intervention: None
Uptake: Weekly tele-education sessions have been conducted 57 times since February 2015, with 322 unique attendees and an average of 22 (plus or minus 9) attendees a week. Five hundred forty-six downloads of patient app from November 2014 to May 2016.
Feasibility: NR
Providers: NR
Procedures: NR
Patients: NR
Adams 2014 [45]
US
Hospital readmission
Hospital
# hospitals: 1
# providers: NR
# patients: 336
Pre-post
Project Re-Engineered Discharge (Project RED) Toolkit
Implementation: Detailed implementation guide, workbooks
Provider: After Hospital Care Plan forms, post-discharge follow-up phone call script
Patient: Booklet, checklist for appointments
Other intervention: Patient discharge questionnaire, contact sheets (in English and Spanish)
Uptake: NR
Utility: NR
Providers: NR
Procedures: 94–95% of patients reported having received written information regarding medications, their condition, and when to seek medical attention
Patients: Re-admissions were reduced by 32%; 99–100% of patients reported knowing their medication regiment and when to call the doctor or seek emergency care post-intervention
Mitchell 20015 [78]
US
Hospital readmission
Hospital
# hospitals: 10
# providers: NR
# patients: NR
Pre-post
Project Re-Engineered Discharge (Project RED) Toolkit
Implementation: Detailed implementation guide, workbooks
Provider: After Hospital Care Plan forms, post-discharge follow-up phone call script
Patient: Booklet, checklist for appointments
Other intervention: 8-hour training, monthly telephone-based technical assistance calls for 1 year
Uptake: 7/10 successfully implemented the RED program as planned. Eight hospitals chose to initiate RED implementation in 1 or 2 units or wards and/or for patients with a particular diagnosis (i.e.,CHF patients only).
Feasibility: The 7 implementing hospitals had the following common features: highly visible commitment from senior leadership, empowered interprofessional implementation team, established methods for sharing results and assessing accountability, buy-in from staff and stakeholders, and flexible in-house IT support. Nine of the participating hospitals implemented a site-specific adaptation of the RED protocol during the study period. All 10 hospitals revised the 2-day postdischarge telephone call script included in the RED Toolkit.
Providers: Members of the implementation teams believed that the RED processes enhanced patient care, provided tools to help patients better manage their medical conditions, and had an important impact on job satisfaction, staff morale, and engagement.
Procedures: Four hospitals did not hire personnel to perform RED responsibilities and instead used unit nurses for discharge education; two teams used nonclinical personnel or third-party vendors to conduct the 2-day post-discharge phone call.
Patients: All 7 hospitals reported modest reductions in 30-day readmissions for at least one of the 3 diagnostic areas targeted by CMS for payment penalties (congestive heart failure [CHF], acute myocardial infarction [AMI], and pneumonia [PNA]). All but 2 hospitals reported a 0.5% or greater reduction in 30-day all-cause readmissions after the implementation. 5 hospitals achieved a greater net decrease in readmission rates than the national average for CHF patients, 4 surpassed the national average decrease for AMI readmissions, and 5 exceeded the national average decrease for PNA readmissions.
Enfield 2014 [40]
US
Hospital-acquired infections
Hospital
# hospitals: 1
# providers: NR
# patients: NR
Pre-post
Center for Disease Control and Prevention's Carbapenem-resistant Enterobacteriaceae (CRE) Toolkit
Implementation: Research overview, material to raise awareness, implementation strategies (e.g., regional approach to CRE), organizational risk assessment tool, references
Provider: Laboratory standards chart, care algorithm
Patient: NR
Other intervention: Limited access to rooms and common areas, terminally clean room policy enhanced, monitoring of environmental cleaning and feedback
Uptake: All components implemented, but some were already in place before the intervention
Utility: NR
Providers: NR
Procedures: Compliance with hand hygiene increased from 71% before to 86% after (p < 0.001); surface testing revealed 39% of tested items exceeding threshold levels before and 12% after (with 6% and 14% in subsequent periods, showing a sustained effect)
Patients: Before, incidence rate of CRE was 7.77 cases/1000 patient-days, after 1.22 cases/1000 patient-days (p = .001); rate of extensively drug-resistant Acinetobacter baumannii (XDR-BA) was 6.79 cases/1000 patient-days before, after no cases were identified
Randle 2006 [26]
UK
Hospital-acquired infections
Hospital
# hospitals: 6
# providers: 127
# patients: 43
Pre-post
Clean-Your-Hands Campaign Toolkit
Implementation: Educational material, posters for staff and patients, marketing materials (aprons, badges, etc.), evaluation tool
Provider: Alcohol hand rubs
Patient: Leaflet, posters
Other intervention: Campaign project manager trained pilot teams in evaluation tool use
Uptake: NR
Utility: Respondents indicated the framework for implementation was helpful and the major success element were the alcohol hand rubs
Providers: 70% of nurses and 60% of doctors agreed that the presence of wipes encouraged them to clean their hands, 76–84% indicated posters made staff think about their hand hygiene, 74% indicated they cleaned their hands more frequently
Procedures: Compliance with hand cleaning increased from 32% (before toolkit) to 41% at 3 months and 63% at 6 months
Patients: 16/43 patients had asked staff to clean their hands, 35/43 found posters etc. useful
Septimus 2016 [84]; Huang 2013 [91]
US
Hospital-acquired infections
Hospital
# hospitals: 136 ICUs in 95 hospitals
# providers: NR
# patients: 305583 admissions (pre-period)/ 102220 (post)
Pre-post
Universal ICU Decolonization Toolkit: An Enhanced Protocol
Implementation: Protocol overview, scientific rationale, flow chart, readiness assessment and FAQ, training and educational materials, chlorohexane bathing skills assessment
Provider: Nursing protocol, safety information
Patient: NR
Other intervention: Five coaching calls
Uptake: NR
Feasibility: Challenges identified included concerns about mupirocin resistance and questions about peer review of the original trial results, Most facilities were able to easily implement daily CHG bathing, as this practice, fit within normal nursing work flow and did not require a physician order.
Providers: NR
Procedures: NR
Patients: The raw CLABSI rate (CLABSI events divided by number of central line–day) dropped from 1.1/1000 to 0.87/1000 central line–days postintervention. There were 672 CLABSIs per 587 891 central line–days in the 24-month preintervention period, and 181 CLABSIs per 208 175 central line–days in the 8-month post-intervention period. After implementation, the rate of CLABSI decreased by 23.5% (CI 9.8–35.1%; p = .001).
Kuhlman 2014 [47]
US
Infant safe sleep
Pediatric and obstetric clinics
# hospitals: 2
# providers: NR
# patients: 309
Post-only
Safe Sleep Toolkit
Implementation: NR
Provider: Brief healthcare provider script
Patient: Parental checklist, nationally available resources (links to videos, posters, brochures, door hangers)
Other intervention: NR
Uptake: NR
Utility: NR
Providers: NR
Procedures: Providers engaged in discussion regarding safe sleep with most parents who reported intentions/behavior in opposition to the recommendations for safe sleep
Patients: NR
Haley 2015 [68]
US
Kidney disease care
Primary care and nephrology practices
# hospitals: 9 primary care and 5 nephrology practices
# providers: 25 pre, 24 post interviews
# patients: 292 chart audits
Pre-post
Advanced Chronic Kidney Disease (CKD) Patient Management Toolkit
Implementation: Guide to tool selection, patient identification tools, patient management tools, physician education materials. slide presentation, clinical practice guidelines, awareness letter,
Provider: Identification and action plan card, identification and action plan poster, glomerular filtration rate (GFR) calculator, CKD chart flags/stickers, referring physician faxback form, CKD post-consult letters, advanced CKD management flow sheet and algorithm
Patient: CKD patient diary, CKD patient education resources, venipuncture reminder card, vascular access passport
Other intervention: Education sessions at each site, made modifications to some tools and one additional tool created (CKD Screening Protocol/When to Refer)
Uptake: Site champions and physician leaders were contacted 3 years after completion of the study and asked whether the improvements in awareness of CKD, communication, the referral process, and comanagement of patients with CKD had been sustained and whether tools were still in use. Of those who had remained active in their respective practices over that time frame, 5 responded with 14 of 15 answers being affirmative.
Feasibility: Increased communication between practices was associated with enhanced satisfaction scores. On a Likert scale, satisfaction with comanagement reported by nephrologists improved from 2.6 to 4.3. Corresponding satisfaction levels of PCPs were 4.3 and 4.7. Of the 16 respondents with preimplementation levels less than “satisfied,” 15 noted improvement, with 6 improving from “somewhat unsatisfied” to “satisfied” or “very satisfied.”
Providers: Preimplementation, few practices reported familiarity with CKD clinical practice guidelines, and CKD screening was limited mostly to diabetic patients. Postimplementation, all practices reported increased awareness of risk factors for kidney disease. Pre-implementation, few used specific triggers for nephrology referrals, although several cited creatinine level. Then, 2.0 mg/dL or when dialysis questions arose. Postimplementation transcripts revealed increased consistency of referral timing, with practices providing more vigilant monitoring of high-risk patients: managing CKD up to stage 3 and all reporting referral by stage 4. Several nephrologists and their site champions noted the need for timely nephrology appointments. Postintervention nephrology interviews revealed heightened attention to communication and comanagement. Practices reported the project altered the content of nephrology postconsult letters, advanced comanagement goals, and improved teamwork among office staff.
Procedures: At the outset, care processes and mechanisms varied among practices. Postimplementation improvement was observed for CKD identification, referral, and communication and execution of comanagement plans. 166/171 tasks and 124/144 subtasks were in place postimplementation, compared with 78 and 51 pre-implementation. Nephrology practices likewise improved postimplementation, particularly in their referral processes and communication. Postintervention questionnaires confirmed that patients with CKD were being referred earlier—none later than stage 4. Analysis of audits revealed improvement in GFR documentation (p=.01); most performed well with respect to ordering creatinine levels within 1 year for these high-risk patients preimplementation and all postimplementation (p = .2). The referral rate of patients with CKD was 24% pre-implementation and 39% postimplementation (p = .4). 4/7 showed an average 45% increase and a 5th showed a 100% increase in referral of patients with CKD stage 4. The rate of patients with GFRs ≤ 30 mL/min who were referred to nephrology was higher than the overall rate of referral of patients with CKD and did not increase (p = .7); the percentage of those with GFRs ≤ 30 mL/min was similar pre- and postimplementation (p = .3). Although there were too few practices for a formal comparison, those consistently using all tools performed better in terms of achieving project goals or improvements than those that did not.
Patients: NR
Fernald 2015 [63]
US
Medical errors
Primary care
# hospitals: 24 recruited, 22 actively participated
# providers: NR
# patients: NR
Pre-post
Quality Improvement for Laboratory Testing Processes in Primary Care: Implementation Guide and Toolkit
Implementation: Written materials, priorities worksheet, process mapping guide and example
Provider: NR
Patient: NR
Other intervention: Initial site visit to introduce toolkit and study requirements and conduct initial process mapping and observation activity
Uptake: 20/22 actively participating practices were able to initiate a laboratory testing improvement process using the toolkit as a guide; 4 practices completed their activities withing the 6-week time period allotted, but many continued their effort after the study period.
Feasibility: Comments on the toolkit were consistently positive, noting that the toolkit was straightforward, organized helpfully, and provided good talking points to align staff and providers. The process mapping exercise was very helpful.
Providers: Practices rapidly acknowledged that ongoing problems exist in laboratory testing processes, that they needed help addressing these problems, and that they faced challenges in finding patient-centered solutions compatible with practice priorities and available resources.
Procedures: NR
Patients: NR
Leape 2006 [27]
US
Medical errors
Hospital
# hospitals: 58
# providers: 76
# patients: NR
Post-only
Reconciling Medications (RM) Toolkit and Communicating Critical Test Results (CCTR) Toolkit
Implementation: Safe practice recommendations, implementation strategies, sample forms, sample flow charts, sample policies, example 'failure modes effects and criticality analysis' (FMEC), data collection tool, spreadsheet to track progress, example audit tool, workshe
Provider: Test tracking log sheet, communication tools for reporting critical test results, reconciling medication form, patient medication card
Patient: NR
Other intervention: Collaborative groups met 4× over 18 months
Uptake: 88% of hospitals participated in one or both collaboratives; of 58 participating hospitals, 50 enrolled teams for RM and 40 enrolled teams for CCTR; 10–15% of teams were unable to get beyond
Utility: 91% of RM teams and 75% of CCTR teams found implementing the recommended practices difficult; human and institutional factors were cited as more significant barriers than costs
Providers: NR
Procedures: NR
Patients: NR
Mueller 2013 [49]
US
Medication management
Hospital
# hospitals: 2
# providers: NR
# patients: NR
Post-only
Medication Reconciliation Implementation toolkit
Implementation: Educational and instructional materials including teach-back technique; didactic slide deck, videos, and case study for role-playing to practice best possible medication history taking; return on investment spreadsheet; process map
Provider: Pocket cards, discharge instructions, medication reconciliation forms, vendor lists, social marketing materials, AHRQ pharmacy health literacy assessment tool
Patient: NR
Other intervention: Formal training program or automated screening tool
Uptake: NR
Utility: Limited resources were cited as a challenge to implementation; positive feedback on videos, other implementation tools less positively rated
Providers: Perception of the study’s impact on patient outcomes to date varied by site, site 1 was more positive about the perceived impact on the quality and efficiency of medication reconciliation
Procedures: NR
Patients: NR
McHugo 2007 [38]
US
Mental health
Community mental health center
# hospitals: 53 centers approached, 49 completed
# providers: NR
# patients: NR
Pre-post
Evidence-Based Practices Implementation Resource Kits
Implementation: User's guide, implementation tips, introductory videos, slide presentations, brochures, fidelity scales with protocols
Provider: Practice demonstration video and workbook
Patient: NR
Other intervention: Consultant-trainers provided training and clinical supervision to program leaders and implementers
Uptake: 92% sites completed the project
Utility: NR
Providers: NR
Procedures: 55% scored at least 4/5 on evidence-based practice fidelity scale at 2 years
Patients: NR
MacDonald-Wilson 2017 [110]
US
Mental health decision support
Community mental health centers
# hospitals: 52
# providers: NR
# patients: NR
Time series
Toolkit: Decision Support
Implementation: Viewer’s guide, video tutorials, guide to reliable information resources, leadership team pledge
Provider: Decisional balance worksheet, affirmation posters, adoption milestones and worksheets
Patient: Information on self-care strategies
Other intervention: 12-month learning collaborative with monthly webinars and 3 in-person learning sessions, electronic workbooks to collect process data, implementation milestones, and quality improvement activities through the Plan, Do, Study, Act process.
Uptake: Participation was high and remained high over time, 88% of CMHCs attended monthly support calls, 80% completed a PDSA cycle each month, and 80% delivered a completed workbook on time each month. A total of 469 PDSAs were completed over the collaborative ranging from 2 to 38 PDSAs per agency with the expectation of 11 PDSAs per agency. The majority of the PDSA content focused on improvements around access and training of staff on the Recovery Library and using the Decisional Balance Worksheet. Fewer PDSAs focused on improvements to the quality improvement process within agencies or general provision of decision support in care. 52% completed the tenth and final implementation milestone,.a large percent reached milestone eight (17%) and milestone nine (17%). Progress in meeting the goal for the process aim improved significantly over time (p < .0001). The average percent of staff meeting either the Research or Support process aim in the first quarter of the collaborative as reported by CMHCs was 38% which progressed steadily over the next three quarters, 65, 69, 75%, respectively.
Feasibility: Across CMHCs, the importance of the agency in supporting implementation in order to ensure success was evident. Despite the majority of activity and responsibility of the learning collaborative placed on the QIT, staff members emphasized the importance of a top down approach in which success of implementation of new practices is more likely if agency leadership is involved.
Providers: 31% of providers rated themselves a 4.5 (indication that practices were moving toward sustainability) and 29% rated themselves 5.0 (all project goals completed; organizational changes permanent). For the outcome aims of the learning collaborative, progress in meeting the goal for high ratings of confidence, Involvement, and competence by individuals in service improved (p < .0001). The percent service users meeting goal at baseline was 47% which increased over the next 4 quarters (49, 56, 59, and 64%). Competence in supporting shared treatment decisions was higher than confidence (p < .001) and involvement (p = .01). Confidence in accessing reliable health information over the internet was lower than ratings of involvement (p = .02).
Procedures: NR
Patients: NR
Miller 2014 [43]
US
Multiple sclerosis symptom management
Multiple Sclerosis clinic
# hospitals: 10
# providers: 37
# patients: 405
Pre-post
Toolkit: Constructing an Adaptive Care Model for the Management of Disease-Related Symptoms Throughout the Course of Multiple Sclerosis
Implementation: Implementation instructions and tips; sample data collection form; slide deck
Provider: Clinical management algorithm, clinical practice guidelines, best practices for symptom management, online continuing medical education activities
Patient: NR
Other intervention: Training for intervention heads, planning meetings, live workshop
Uptake: NR
Utility: Providers reported time and personnel constraints as a barrier to implementation, providers reported the intervention allowed for comprehensive management of the disease, and improved patient care overall
Providers: Providers reported increased awareness of MS symptoms
Procedures: 6% (p = .003) improvement in documented symptom assessment for mobility impairment/falls and 10% (p < .001) for spasticity assessment documentation; documented care plan performance measures improved for fatigue (13%, p = .007) and mobility impairment/falls (13%, .040). Use of the timed 25-foot walk test increased from 25 to 46% (p < .001), use of clinic questionnaire for spasticity improved from 3 to 9% (p < .001). Use of behavioral modifications, pharmacotherapy, and physical therapy remained unchanged
Patients: NR
Guillory 2017 [66]
US
Newborn screening
Hospitals
# hospitals: 13
# providers: 117 physicians, hospital administrators, and other health care professionals, 215 nurses
# patients: 11322
Pre-post
Critical Congenital Heart Deiseas (CCHD) Toolkit
Implementation: PP presentation for physicians, PP presentation for nurses, sample nursery policy, Taryn's Story (4 minute video script), Lifesaving Newborn Screen (30 s PSA script)
Provider: Algorithm card, sample physician order, sample screening log, wall poster for newborn nursery
Patient: Brochure (English/Spanish) for positive screen, brochure (English/Spanish) for families
Other intervention: A hospital nurse champion (HNC) was identified for each facility to serve as a leader, with responsibilities of training personnel, facilitating implementation, and identifying and addressing barriers. Nurse educators and HNCs conducted an accredited, 1-hour training session at each hospital to ensure standardization of education for the newborn nursing staff.
Uptake: NR
Feasibility: NR
Providers: The pretest average was 71% and improved to 92.5% (p < .0001). In hospitals with CCHD NBS implemented prior to TxPOP, nurses’ pretest scores showed a relative lack of knowledge on the subject. In all trainings, questions requiring application of the clinical algorithm were missed most frequently, particularly on the pretest.
Procedures: There were 1236 admissions to neonatal intensive care unit (NICU) and 11,710 admissions to newborn nursery or mother/baby unit, with 39 screened prior to 24h, 239 transferred from the newborn nursery before 24h, 32 with echocardiograms (ECHO) for other reasons, 3 parental refusals, and 75 with unknown screening status. 97% were screened after 24 h of age as recommended. There were no missed cases of CCHD. Missed screenings opportunities represented 0.66% of eligible patient encounters. Most occurred in the early phase of implementation of the project. The causes for missed screens, such as lack of awareness, lost probes, process problems, and timing of screening were collected, addressing these issues resulted in improvement in overall screening rates, from 97 to 99% (p < .0001).
Patients: Eleven newborns had a positive screen. One patient was confirmed with CCHD (tricuspid atresia with hypoplastic right heart). Other important nontargeted diagnoses included seizure, abdominal distension, and other noncritical cardiac conditions. Two newborns were found to be healthy. Three were transferred from the birthing hospital to an urban facility for high level of care.
Dobbins 2005 [29]
Canada
Nursing best practices
NR
# hospitals: 11
# providers: 41
# patients: NR
Post-only
Toolkit: Implementation of Best Practice Guidelines
Implementation: Self-assessment guide, action plan template, expense worksheet, stakeholder scenario worksheet, barriers and facilitators resources, guide to social marketing, sustainability action plan
Provider: NR
Patient: NR
Other intervention: 1-day launch workshop
Uptake: 85% respondents reported reading the toolkit, 43% of users completed the worksheets, > 1000 toolkit copies requested, > 1600 nurses have signed up for workshop
Utility: 85% of those who read the toolkit found it to be helpful during implementation
Providers: NR
Procedures: NR
Patients: NR
Main 2017 [77]
US
Obstetric care
Hospital
# hospitals: 147
# providers: NR
# patients: 337630
CT
Comprehensive quality improvement tool kit for hemorrhage
Implementation: Obstetric Hemorrhage Safety Bundle, Rounding/Huddles Templates, Placenta Accreta Protocol Sample, slide decks/presentations/webinars, sample forms, resource guide, Code C materials
Provider: Debrief forms, evaluation form
Patient: Patient, family, and staff support bundle
Other intervention: Physician and nurse pairs mentored groups of 5–8 hospitals (groups were often geographic or system based). The mentors were not from the facilities they supported and served as facilitators leading the monthly telephone calls, providing small group leadership and personal accountability. A CMQCC staff member also supported the mentor groups and attended all telephone calls to coordinate and share lessons and ideas from all the groups. In-person full-day meetings for learning and sharing involving all hospital teams were held toward the beginning and the end of the project. Additionally, hospitals were encouraged to share resources and discussion on a collaborative electronic mailist list/resource sharing service. A key feature of the collaborative was the use of the CMQCC Maternal Data Center for data collection of structure, process, and outcome measures.
Uptake: Overall, 54% of hospitals completed 14 of 17 bundle elements, 76% reported regular unit-based drills, and 65% reported regular posthemorrhage debriefs.
Feasibility: NR
Providers: NR
Procedures: NR
Patients: Women in hospitals engaged in the hemorrhage CMQCC CPMS experienced a 21% reduction in severe maternal morbidity among hemorrhage patients over baseline. Not participating hospitals showed a nonsignificant 1.2% reduction over the same time period. Women with prior hemorrhage experience averaged a 29% reduction (without prior experience 15% reduction (both significant changes).
Fine 2014 [42]
US
Pain management
Long-term care facility
# hospitals: 7
# providers: 51
# patients: 350
Pre-post
Toolkit: Enhancing the Management of Neuropathic Pain in the Long-term Care Setting
Implementation: Algorithm and instructions for implementation, sample data collection form, performance measure instructions, slides, list of resources
Provider: Assessment videos, clinical guidelines, assessment scales, pocket guide
Patient: NR
Other intervention: In-service meeting led by an expert faculty member
Uptake: NR
Utility: NR
Providers: NR
Procedures: Patients with documented pain care plan increased from 86 to 93%; documented pain assessments on admission, a physical exam to assess pain, documented causes of pain symptoms, and assessment of effectiveness of pain management by a doctor did not change significantly
Patients: NR
Pulver 2012 [12]
Australia/New Zealand
Pain management
Hospital
# hospitals: 73
# providers: NR
# patients: 716
Pre-post
Acute Postoperative Pain Management (APOP) Toolkit
Implementation: Slide deck, informational resources such as evidence-based information on key messages to structure interactions with hospital staff, further reading list, electronic drug use evaluation audit tools, posters
Provider: Pain scales, pain assessment and pain management plan discharge checklist (can be laminated for use at ward stations and medication folders)
Patient: Patient guide
Other intervention: NR
Uptake: NR
Utility: NR
Providers: NR
Procedures: Patients who had a pain score used to assess pain at rest and movement 48–52 vs previously 24% (p < .0001), patients with documented pain management plan 58–65 vs 40% (p < .0001)
Patients: NR
Parkman 2013 [32]
US
Patient safety
Hospital
# hospitals: 4
# providers: 25 out of 87 initially interested
# patients: NR
CT
Professional Conduct Toolkit
Implementation: Online educational modules focusing on teamwork, communication, management support, and reporting of errors (slides, videos), TeamSTEPPS action planning guide
Provider: Tip sheets for connecting, conflict competence checklist
Patient: NR
Other intervention: NR
Uptake: NR
Utility: 50% of respondents found the information “some” or “very much” helpful, 95% stated that their expectations for the course were met or exceeded
Providers: No difference in safety perception between groups, no increased culture of safety awareness (knowledge), sensitivity (attitude), and competence behaviors (skills and actions); communication openness mean scores were unchanged at time 1 and 2
Procedures: NR
Patients: NR
Schauberger 2006 [25]
US
Patient safety
Ambulatory care clinics
# hospitals: 7
# providers: NR
# patients: NR
Pre-post
Ambulatory Patient Safety Toolkit
Implementation: Description of 11 evidence-based practices, descriptions of methods to accomplish goals, forms, worksheets, tools, criteria for accomplishment, suggestions for reassessment
Provider: NR
Patient: NR
Other intervention: Half-day videoconference, collaborative meeting before improvement phase
Uptake: All teams implemented best practices in all 11 categories
Utility: Patient partnering, allergy list accuracy, and medication list accuracy were perceived as the most difficult and longest to implement
Providers: NR
Procedures: Medication list accuracy improved from 61 to 75% (p < .001), sustained at 1 year (76%); allergy list accuracy was 89% at baseline and did not change significantly (87%, 90%)
Patients: NR
Thomason 2016 [88]
US
Patient Safety
Veterans Health Administration Spinal Cord Injury/Disorder (SCI/D) Centers
# hospitals: 23
# providers: 51
# patients: NR
Pre-post
Spinal Cord Industry Pressure Ulcer Monitoring Tool (SCI-PUMT) Toolkit
Implementation: Flyer, video-recorded presentations, knowledge and competency verification tests, two manikins, facility implementation plan, guidelines for overcoming barriers
Provider: SCI-PUMT, quick reference guidelines, healing continuum and graph, pocket guide
Patient: NR
Other intervention: Introduced at a conference, implementation supported by learning collaborative’s clinical champions and networking calls.
Uptake: 3254 downloads of SCI-PUMT toolkit items. The average number of potential SCI-PUMT users per SCI/D center was 11 (most report 1-3 certified wound care specialists available. 65% reported that SCI-PUMT training resulted in > 50% of potential users at their sites. 30% of sites were classified as high adopters (76-100% of staff using the SCI-PUMT); 52% reported < 50% of PrUs were assessed using the SCI-PUMT. Three sites used all 15 toolkit elements.
Feasibility: 24 facilitators and 38 barriers were identified. Most barriers to implementation reflected “contextual” factors (time constraints, availability of the certified wound care nurses and documentation, training, leadership issues). Documentation was viewed as both a facilitator and barrier. One-third of clinical champions identified their ability to document the SCI-PUMT as a facilitator to implementation, whereas many sites identified the inability to document SCI-PUMT elements in the VA electronic healthcare record as a major barrier to implementation. Other facility-reported barriers included challenges in educating staff, the time required for SCI-PUMT completion, and staff buy-in.
Providers: Response rate for the knowledge verification of conference participants was high: pretest 94 and posttest 84%. Only 3 of the 10 knowledge-based questions were answered correctly by > 85% of participants on the pre-test; all 10 questions were answered correctly by at least 95% of participants on the post-test.
Procedures: NR
Patients: NR
Lannon 2008 [24]
US
Pediatric preventive care
Primary care
# hospitals: 15
# providers: NR
# patients: NR
Pre-post
Bright Futures Training Intervention Project toolkit
Implementation: Planning guides, progress reports, inventory tools, planning worksheets, slide presentations, Plan-Do-Study-Act cycle tool, user guides to tools
Provider: Screening tools, care algorithms, visit documentation forms
Patient: Handouts
Other intervention: 2 workshops, training in quality-improvement methods, monthly conference calls and data feedback, and listserv moderated by faculty
Uptake: Tested or implemented: recall/reminder systems (87%), community linkages (80%), and identification of children with special health care needs (80%); no practice implemented all 6 components; 9 practices tested or implemented 1 or 2 components
Utility: Practice teams reported that facilitators of office system implementation included the perception that a component could be implemented quickly and/or easily, especially when a tool or template was immediately available. Barriers included time, cost, lack of agreement with recommendations, and lack of belief that changes would lead to improved health outcomes
Providers: NR
Procedures: Increases in the use of a preventive services prompting systems and the proportion of families asked about special health care needs (p < .0001); proportion of children who received a structured developmental assessment and use of strength-based approaches were not statistically significant
Patients: NR
Byrne 2011 [36]
US
Perinatal care
Hospital
# hospitals: 1
# providers: NR
# patients: 27,737 births, 60,015 triage evaluations
Pre-post
California Perinatal Quality Care Collaborative Antenatal Corticosteroid Therapy (ANS) Toolkit
Implementation: Evidence-based guidelines, user’s guide, rationale, examples of hospital based quality improvement tools, problem identification worksheets
Provider: NR
Patient: NR
Other intervention: Part of quality improvement initiative
Uptake: NR
Utility: NR
Providers: NR
Procedures: Performance on quality measure for antenatal steroid administration increased from 77% to 100% (p < .01), significantly higher than the mean state-wide performance (p < .01)
Patients: NR
Kohler 2015 [71]
US
Perinatal care
Hospital
# hospitals: NR
# providers: NR
# patients: NR
Pre-post
Improving Health Care Response to Preeclampsia
Implementation: Patient care and treatment recommendations, simulations/drills, sample nursing management policy and procedure, classification of evidence grading, slideset for professional education, etc.
Provider: Suspected preeclampsia and eclampsia algorithms, preeclampsia early recognition tool, sample medication boxes, ICD-9 coding, etc.
Patient: Patient information (information, sheet, sample discharge instructions)
Other intervention: Participation in the California Maternal Quality Care Collaborative Preeclampsia Collaborative
Uptake: NR
Feasibility: NR
Providers: NR
Procedures: At baseline 14% of women with blood pressures meeting the criteria were treated, post-intervention 84% were treated within 30 minutes and 90% within 60 min.
Patients: NR
Lyndon 2016 [74]
US
Perinatal care
Hospital
# hospitals: 31
# providers: 22
# patients: NR
Post-only
Improving Health Care Response to Obstetric Hemorrhage Version 2.0 A California Quality Improvement Toolkit ("Obstetric Hemorrhage Toolkit")
Implementation: Emergency management plans (checklist, table chart, flow chart, pocket card), carts/kits/trays checklist, educational tools, educational information, professional education slideset
Provider: Poster, debriefing tool, massive transfusion event protocols, blood loss calculator and quantification tools, etc.
Patient: Patient education resources
Other intervention: Part of year long quality care collaborative with phone calls
Uptake: NR
Feasibility: Common issues.that served to either help or hinder implementation related to organizational context, including local culture within the organization; local structure and experience of the implementation team; degree of administrative support there was for the team and the project in terms of resources for equipment, personnel, and data collection; existing resources already in place in a given institution; clinician engagement that was affected by relationships between different departments; quality of communication; and degree of hierarchy in existing relationships. Most respondents rated the 10 components as “very useful—critical to retain.” Two recommended practices were rated lower in both degree of implementation and usefulness: routine active management of the third stage of labor, and hemorrhage debriefings. Each of these two recommended practices was rated as critical to retain by 60% of participants.
Providers: NR
Procedures: 77% indicated they had implemented or implemented and sustained each of the 10 recommended practices.
Patients: NR
Ezzat 2017 [62]
Canada
Physical therapy
Practices
# hospitals: NR
# providers: 238
# patients: NR
Post-only
Achilles tendinopathy Toolkit (ATT
Implementation: Summary of the evidence of physical therapy interventions with clinical implications, details (e.g., methods and findings) of the individual articles that informed the evidence summaries
Provider: Treatment algorithm, relevant outcome measures and supporting resources specific to: exercise prescription, LASER dosage calculation, major medical and surgical interventions
Patient: NR
Other intervention: To support its adoption by PABC members, a webinar demonstrating how to use the ATT involving a series of case studies was conducted in June 2012 with over 100 participating PTs and subsequently over 800 views of the recorded session. It has also been presented at national and international conferences.
Uptake: Regarding toolkit awareness, 81% said they were aware of the ATT, the majority learned about the ATT through PABC email/website (95%). Of those who indicated they were aware of the ATT, 53% indicated that they had explored its contents.
Feasibility: 86% agreed that the toolkit was helpful in clinical decision-making. The toolkit assisted in informing treatment and exercise progressions, provided confirmation and confidence of treatment approach and acted as a guide with evidence to inform clinical decision-making. 88% would recommend the toolkit to others. Time was the most frequently indicated barrier (45%) followed by: “the quality of some of the evidence in the toolkit is questionable” (23%); “the toolkit provides ‘recipes’ that do not allow for enough decision making by the therapist” (15%) and “I don’t know where to find or access the toolkit” (15%). 31% indicated no barriers. When asked if anything was missing from the ATT, participants suggested some additional treatment strategies, as well as requesting patient handouts or pictures and a more concise summary of the research.
Providers: 49% indicated that they had changed their clinical practice based on the knowledge gained from the ATT, 87% agreed that they feel more justified in applying physiotherapy treatments that they were already using. 9% indicated they were very aware of the evidence before exploring the ATT, this increased to 45.5% of respondents after exploring the ATT. 46% agreed that they were better equipped to collaborate with physicians or other health care professionals after exploring the ATT.
Procedures: 18% met the full combined criteria for following the toolkit recommendations for treating AT; use of outcome measures 51%; those who explored the ATT had greater odds of following the best practice recommendations for each of the individual questions and all criteria combined (OR 2.8; CI 1.3–6.0).
Patients: NR
Brown 2015 [57]
US
Psychotherapy decision support
Psychotherapy clinic
# hospitals: NR
# providers: 704
# patients: 9,785 (in first 18 months), 30,410 (after >18 months)
Pre-post
A Collaborative Outcomes Resource Network (ACORN) Clinical Decision Support Toolkit
Implementation: NR
Provider: Database of psychotherapy treatment outcomes, clinical information system, secure web interface
Patient: NR
Other intervention: None
Uptake: NR
Feasibility: NR
Providers: NR
Procedures: NR
Patients: The overall upward trend in psychotherapy outcomes is evident for all users (d 0.80 vs 0.87; 9% gain), but particularly among high frequency Toolkit users. Multiple regression with number of months and toolkit use as predictors of severity adjusted effect size revealed that both are separate contributors to the observed gains in effect size (p < .00, less than 0.1% variance overlap).
Sopcak 2016 [86]
Canada
Screening
Primary care
# hospitals: 3
# providers: 25
# patients: 91
Post-only
Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER)
Implementation: Clinical resources, clinical guidelines, etc.
Provider: Spaghetti diagram, BETTER algorithms, BETTER health survey, bubble diagram, prescription, goal sheet, decision support tools, questionnaires, etc.
Patient: Life expectancy calculator, risk assessments, action plans, guidelines, patient education information, smoking cessation plan, physical activity videos/toolkit/guide, etc.
Other intervention: Before implementation, PPs participated in training provided by the BETTER team, which involved an introduction to the BETTER approach and tools, the prevention visit process and Brief Action Planning.
Uptake: NR
Feasibility: Based on respondents’ answers, complexity and cost affected the implementation. In addition to completing forms for the visit, PPs (prevention practitioners) described that they had to complete data collection forms to enable the measurement of study outcomes. Primary care providers (physicians and PPs) identified the complexity of the intervention, particularly the amount of paperwork and the time needed to collect information, as the main barriers of the intervention. A 30–60-min prevention appointment would be too costly. The perceived fit of the intervention within primary care settings varied, some physicians were skeptical. Physicians in Newfoundland and Labrador did not have a billing code for prevention and lifestyle counseling at the time of the study, which was a barrier for implementing a CDPS program. In the context of competing health care demands and scarce resources, respondents expressed that acute care trumps prevention, limited resources, specifically the lack of staff, made it difficult to allocate more time or resources to CDPS. BETTER 2 was also perceived as not being a good fit with primary care providers who believed that they did a good job of CDPS already. The importance of having a local champion to facilitate program implementation was exemplified when one of the local champions left, recruitment and uptake stalled. Two activities emerged as essential for the implementation of BETTER 2: planning and engaging, and interprofessional collaboration.
Providers: Data suggested that to be successful in their role, PPs need skills in time management, planning for the PP visit, and prioritizing the medical and clinical information. The PPs also needed to be good communicators and effective listeners, who are comfortable with conducting personalized one-on-one visits with patients.
Procedures: NR
Patients: Patients commented positively on their prevention visits. Patients appreciated that the visits were personalized as well as the time taken to go over CDPS in a comprehensive way. Patients saw visits as beneficial for a variety of reasons. None expressed that the prevention visit with a PP was a duplication of services or that the information given at the visit was irrelevant. Patients felt that having CDPS visits with the PP helped alleviate the stress on physicians.
Shellhaas 2016 [85]
US
Screening, quality improvement
Obstetric practices
# hospitals: 15 recruited, 12 completed
# providers: 17
# patients: 700 (data), 83 (survey)
Pre-post
Gestational Diabetes Mellitus (GDM) Toolkit
Implementation: None
Provider: Three-pocket folder with worksheets and tools for office flow and postpartum care, resources for GDM management, and general prenatal resources
Patient: Two separate single-ring bound 5 × 7 in booklets: one for pregnant women at high risk of GDM, one for pregnant women diagnosed with GDM
Other intervention: Monthly learning sessions (1-h webinars), four optional individual coaching calls
Uptake: 12/15 practices remained actively engaged during project period. > 70 provider toolkits, 2345 patient toolkits (845 high-risk and 150 diagnosed) disseminated
Feasibility: The 3 sites that disengaged reported doing so for inability to commit time (3–5 h/month) and resources. 92% responded that provider toolkit resources were helpful or very helpful. All but one site reported that patient toolkit resources were helpful.
Providers: NR
Procedures: At project end, 59% of charts indicated a follow-up appointment scheduled within 4 weeks of GDM diagnosis. Of women with a delivery recorded, 69% completed a postpartum visit and 40% had a documented type 2 diabetes screen. Prenatal nutrition, weight gain, breastfeeding, and exercise education were over 90% at baseline. Baseline to 11 month follow up education rates were 67% to 100% for type 2 diabetes risk, 63% to 96% for family planning use, and 40% to 90% for smoking cessation. GDM screening prior to 28 weeks gestation was 87% at baseline and 95% at completion.
Patients: 91% reported that resources provided were helpful or very helpful. 99% indicated they would attend their postpartum visit and 87% would probably or definitely be screened for type 2 diabetes.
Sarna 2017 [83]
US
Smoking cessation
Hospital
# hospitals: 8
# providers: 283
# patients: NR
Pre-post
Registered Nurses Referral to Quitlines - Helping Smokers Quit Louisiana Toolkit
Implementation: 45-min prerecorded webcast and additional downloadable print resources on tobacco dependence treatment, website with national and state-specific tobacco control resources
Provider: Clinician pocket guide, brochure, quitline card
Patient: None
Other intervention: None
Uptake: There are some significant differences in the tobacco dependence intervention outcomes of nurses who viewed the webcast, compared with those who did not (N unclear).
Feasibility: NR
Providers: NR
Procedures: Changes in the proportion of nurses who consistently delivered the 5As significantly increased for all aspects of the intervention 3 months after the intervention, except Asking patients about their smoking status (high level at baseline), at 6 months, most changes were sustained. Nurses were more likely to Advise smokers to quit (OR 1.99, CI 1.23, 3.23, p < 0.005), and more likely to Assess willingness to quit, Assist with a quit plan, and to recommend the quitline (OR 4.38, CI 2.73, 7.03, p < 0.0001). Assisting with a quit plan and Arranging for follow-up were not sustained at 6 months. Consistent recommendation of a smoke-free home reached statistical significance at 6 months.
Patients: NR
Shershneva 2010 [22]
US
Smoking cessation
NR
# hospitals: NR
# providers: 37
# patients: NR
Post-only
CS2day Toolkit
Implementation: Slide decks, patient cases, links to online resources
Provider: Care algorithms, medication charts, drug interaction table, role-modeling videos, quit-smoking plans, posters for practice rooms
Patient: Handouts in English and Spanish
Other intervention: NR
Uptake: NR
Utility: Survey results indicated that expectations were met and the tools were well-received
Providers: Clinicians reported using tools as education materials for themselves, reminders in practice, patient handouts, resources for teaching others, and references to support system changes
Procedures: NR
Patients: NR
Pratt 2012 [15]
US
Staff trauma support
NR
# hospitals: NR
# providers: 36
# patients: NR
Post-only
Clinician Support Tool Kit for Healthcare
Implementation: 10 informational modules with tools, references, and examples; organizational assessment tool
Provider: NR
Patient: NR
Other intervention: NR
Uptake: 725 of requested a download (of 6261 people who visited the website within 12 months)
Utility: 75% of survey respondents found the toolkit extremely or very helpful, 88.9% found it easy to navigate, and 96.2% liked the format
Providers: 62.5% of respondents reportedly used the toolkit to make positive changes in their institution
Procedures: NR
Patients: NR
Brooks 2013 [50]
US
Substance abuse
Outpatient substance abuse treatment center
# hospitals: 3
# providers: 19
# patients: NR
Pre-post
RoadMAP Relapse Prevention Group Counseling Toolkit
Implementation: NR
Provider: Handbook, clinician's guide to sessions, video vignettes, posters for practice room, worksheets, teaching aids
Patient: Worksheets, recovery cards to document progress
Other intervention: 3-h training
Uptake: 80% reported they voluntarily used toolkit materials during the time between the post-training and 6-month follow-up
Utility: NR
Providers: Moderate or large baseline to post-training effect sizes for counselor adherence to toolkit content for 13 of 21 targeted behaviors. Post-training adherence gains were largely maintained at the 6-month follow-up (non sign).
Procedures: NR
Patients: NR
Levy 2017 [73]
US
Substance use screening
Primary care
# hospitals: NR
# providers: 599
# patients: NR
Pre-post
Adolescent Screening, Brief Intervention, and Referral for Treatment for Alcohol and Other Drug Use Toolkit for Providers
Implementation: Educational materials, confidentiality laws, practice vignette, practice cases for role play
Provider: Screening tools, referral resources, naloxone information, treatment program information, decision tree, quick guide
Patient: None
Other intervention: Distributed toolkit to all physicians in Massachusetts; also made available primary prevention print resources, as well as websites and phone consultation for advice and/or treatment referral information
Uptake: NR
Feasibility: Regarding barriers to screening, 2014 respondents were less likely than 2008 respondents to endorse responses related to “lack of knowledge” (36 vs 52%, adjusted odds ratio [AOR] 0.5, p = 0.001). Lack of time or staff resources as barriers to screening remained unchanged.
Providers: Logistic regression analyses controlling for the demographic characteristics (physicians’ practice setting and gender) found significantly higher rates of physicians in 2014 compared with 2008 reporting annual substance use screening (96 vs 88%, AOR 2.8, p = 0.04) and any use of a validated tool (56 vs 43%, AOR 1.8, p = 0.006).
Procedures: NR
Patients: NR
Nace 2011 [20]
US
Vaccination
Long-term care facility
# hospitals: 6
# providers: NR
# patients: NR
Pre-post
American Medical Directors Association Immunization Toolkit
Implementation: Booklet with educational material and resources for increasing the uptake of vaccinations and managing influenza outbreaks, 2 DVDs
Provider: NR
Patient: NR
Other intervention: Email distribution list, half-day of collaborative training offered to 3/6 facilities
Uptake: NR
Utility: NR
Providers: NR
Procedures: Facilities that received the toolkit alone experienced decreases in worker influenza (29.3% to 25.8%), resident influenza (78.9% to 58.2%), and resident pneumococcal (20.2% to 6.3%) immunization rates. Facilities who received the tooklkit and collaborative training increased rates by 10.9, 4, and 29.9 percentage points.
Patients: NR
Nowalk 2014 [51]; Nowalk 2013 [51]; Nowalk 2012 [96]
US
Vaccination
Primary care
# hospitals: 4
# providers: 24
# patients: 5592
Pre-post
4 Pillars Toolkit
Implementation: Educational materials, case studies, lists of barriers, supplementary ideas, bibliography, organized in 4 pillars (convenient access, notification, office system changes such as immunizations given as part of vital signs, motivation elements such as feedb
Provider: Standing order program, prompts in electronic medical record
Patient: Leaflet, posters
Other intervention: Introduction to toolkit in lunch meeting, weekly progress reports to immunization champion, online refresher course ($20 incentive)
Uptake: All sites reported using at least 5/14 strategies
Utility: Most staff at 3/4 sites believed the toolkit improved efficiency for adult vaccinations
Providers: NR
Procedures: Pneumococcal vaccination rates increased for high-risk adults (25 vs 40%, p = .02) but not for older adults (44% vs 52%, p = .26) and in 2/4 practices among both high-risk and older adults (p<.05); influenza vaccination rates increased significantly in 3/4 sites and overall (22 vs 33%, p < .001)
Patients: NR
Zimmerman 2014 [46]; Lin 2016 [111]; Nowalk 2014 [54]; Nowalk 2016 [53]
US
Vaccination
Primary care
# hospitals: 20
# providers: NR
# patients: 536-8183 patients/facility
RCT
4 Pillars Toolkit for Increasing Childhood Influenza Immunization
Implementation: see Nowalk et al. (2013)
Provider: see Nowalk et al. (2013)
Patient: see Nowalk et al. (2013)
Other intervention: EMR programmed to include best practice alert, visited to introduce the toolkit at a meeting, provided feedback on immunization rates, created online videos and a PSA for local TV, community outreach efforts, early delivery of vaccine, donated vaccines
Uptake: All intervention sites used 1 or more elements of the toolkit
Utility: NR
Providers: NR
Procedures: Intervention practices increased vaccination rates more than controls (p = 0.034)
Patients: NR
Abraham 2007 [39]
US
Weight management
Primary care
# hospitals: 5
# providers: 183
# patients: NR
RCT
America-on-the-Move Toolkit
Implementation: Tip sheets, posters
Provider: BMI charts
Patient: Patient readiness assessment, educational patient materials
Other intervention: NR
Uptake: NR
Utility: 64% of providers felt behavioral counseling training would improve toolkit effectiveness
Providers: NR
Procedures: Control providers provided nutrition counseling to overweight patients in 40–49% of visits, compared to 30-39% among intervention providers
Patients: NR
Gibson 2016 [64]
US
Weight management
Primary care
# hospitals: 2
# providers: NR
# patients: 134
Pre-post
5210 Let's Go! Childhood Obesity Resource Toolkit for Healthcare Professionals
Implementation: Educational materials and references, toolkit user guide, etc.
Provider: Healthy Habits Questionnaire, BMI-for-Age Growth Charts, decision support chart, motivational interviewing materials, etc.
Patient: “5210” posters and drink comparison displays, educational brochures, etc.
Other intervention: Trackers for chosen; staff education: (a) accuracy with anthropometric measures to facilitate correct diagnosis of overweight and obesity, (b) assessment and evaluation of the child’s lifestyle behaviors through use of a questionnaire, (c) consistent health messaging related to nutrition and physical activity, and (d) use of motivational interviewing to guide a mutually established action plan.
Uptake: Each clinic implemented the “5210” program with all child office encounters and not just for wellness visits.
Feasibility: An unexpected finding was the importance of establishing incentives and a reward system for “5210” participants.
Providers: NR
Procedures: Profound changes occurred with large shifts in documentation of BMI percentile (from 27 to 98%; p < 0.05), education and counseling (from 9 to 87%; p < 0.05), and accurate diagnosis of overweight or obesity (from 0 to 32%; p < 0.05). There was a statistically significant decrease in documentation of blood pressure readings (from 72 to 60%; p < 0.05). Use of the screening questionnaire increased from 0 (was not utilized before the project) to 88%.
Patients: The education foci that were prioritized and selected by 89% included eat more fruits and vegetables (35%), spend less time watching television and playing video/computer games (25%), and drink more water (21%) and less sugar-based beverages (8%). Parents, especially of younger children, commented that the questionnaire heightened the awareness of the lifestyle habits of the family and motivated the parent to make changes in their diet and physical activity.
Kinsinger 2009 [37]
US
Weight management
Primary care
# hospitals: 17
# providers: NR
# patients: 30–70 patients/facility
Post-only
MOVE (Managing Overweight/Obesity for Veterans Everywhere) Weight Management Program
Implementation: Administrative manuals, posters, banners, pens
Provider: Promotional brochures, clinical references, BMI chart, online training modules
Patient: Handouts
Other intervention: Biannual screening for overweight/obesity, online baseline assessment and summary report, diet/activity logs, pedometers (optional), telephone check-ins, group support sessions (optional)
Uptake: 98.7% of VA facilities have MOVE! programs in place. 3000–4000 patients per month have a first move visit. 100,000 patients have had at least 1 Move!-related visit. Of patients who might benefit, 7.5% have participated
Utility: NR
Providers: NR
Procedures: 66% of primary care patients have been screened for obesity
Patients: NR
Rueda-Clausen 2014 [82]
Canada
Weight management
Primary care
# hospitals: 4
# providers: NR
# patients: 102
Pre-post
5As of Obesity Management for Adults
Implementation: Evidence for use, core principles
Provider: 5As (adult, pediatric, pregnancy) practitioner checklist, desktop tool to facilitate discussion, practitioner guide
Patient: Patient tear-off pad
Other intervention: 90-min standardized training program
Uptake: NR
Feasibility: NR
Providers: NR
Procedures: At baseline, 19% of patients with obesity reported that their provider initiated a conversation about their weight. Implementing the 5As tool and training did not affect the frequency of standard practices such as measuring blood pressure, body weight or waist circumference, but it did cause an increase (19–39%, p = 0.03) in the number of participants reporting a dialogue about weight management. The tool also improved the follow-up/and coordination activities and increased the use of all the obesity management 5As components (significant for both Assess and the Assist components).
Patients: NR
Sample 2013 [35]
US
Weight management
Primary care (pediatric)
# hospitals: 4
# providers: 24 out of 56 invited
# patients: NR
Post-only
Pediatric Obesity Toolkit
Implementation: Educational materials and tools, child obesity rates by county map of North Carolina
Provider: Clinician reference guide, BMI and blood pressure charts, decision support charts, reference lists, motivational interviewing guide, community resources, algorithms, prescription pads
Patient: Handouts
Other intervention: 1-hour training session
Uptake: Universal assessment and screening tools and patient handouts were used on a daily basis by most respondents; 1/4 reported using the staged treatment, motivational interviewing guide, and quick reference guides weekly; 33% indicated that the ICD-9 codes,
Utility: 29% of respondents cited ICD-9 codes and reference articles as the most useful tools; 64% rated ICD-9 codes as very useful and 57% found the reference articles very useful
Providers: NR
Procedures: 39% stated that they counseled every child and family on weight and healthy lifestyles, 62% counseled only during well-child checks, no providers counseled about weight and healthy lifestyles during sick child visits
Patients: NR
Smith 2011 [21]
US
Weight management
Primary care
# hospitals: NR
# providers: 226–278 responded out of 1429–1580 invited
# patients: NR
Pre-post
Americans In Motion (AIM) to Change Toolkit
Implementation: Practice manual to develop a culture of fitness, implementing small changes in the practice
Provider: BMI calculator, presciption pads
Patient: Posters, food and activity journal, fitness assessment
Other intervention: NR
Uptake: 46% used the BMI calculator, 10% the fitness prescription pads for at least some patients, 46–48% did not use any toolkit components
Utility: 21–24% reported systematic screening was not feasible due to time constraints
Providers: Attitudes about the importance and usefulness of BMI increased during the study
Procedures: Rates of height measurement (57% to 74%) and BMI calculation (50% to 70%) increased; 19% of providers used the food and activity journal, 11% the personal fitness assessment
Patients: NR
Stiff 2014 [21]
US
Weight management
Primary care
# hospitals: 1
# providers: 22
# patients: 88
Pre-post
Promoting Healthier Weight in Adult Primary Care
Implementation: Assessment for readiness to change, literature overview and references, implementation tips
Provider: Clinical algorithm, motivational interviewing techniques, online resources, charts and definitions (“what is a serving”)
Patient: Weight and health profile form, patient informational resources
Other intervention: Clinic staff training and support, education packet specific for patient’s stage of change
Uptake: NR
Utility: Estimated time spent using the toolkit: < 3 min (23%), 3–7 min (54%), 8–11 min (23%), > 12 min (23%); 85% of providers stated that the extra time was beneficial for the patient, 8% indicated the toolkit took too much time; Over half of providers reported they liked using the tool and thought it should continue to be used in the clinic
Providers: 70% thought nursing staff should use the toolkit and refer for follow-up as appropriate
Procedures: NR
Patients: The average acceptability rate of the toolkit among patients was over 90%
Mulloy 2008 [33]
US
Wrong site surgery
Hospital
# hospitals: 325
# providers: 519
# patients: NR
Pre-post
AORN Correct Site Surgery Tool Kit
Implementation: Guidelines for implementing universal protocol for Wrong Site Surgery, letters to nurses, physicians, facility chief executive officers, and healthcare risk managers; FAQs
Provider: Pocket reference card, educational program on CD, policy template
Patient: Information for patients
Other intervention: NR
Uptake: NR
Utility: 92% of registered nurses and 73% of the hospital respondents found the Correct Site Surgery Tool Kit helpful; 68% of registered nurses stated they had changed their practice after receiving the toolkit
Providers: NR
Procedures: NR
Patients: The reported rate of wrong site surgery per 100,000 surgeries peaked initially (4.27), with declining rates in one (3.67) and 2 years later (3.14)
  1. CI 95% confidence interval, BMI body mass index, EMR electronic medical record, ICD international classification of diseases, MD mean difference, N number of, NR not reported, OR odds ratio
  2. Toolkit categories: implementation aiming to introduce the intervention, initial awareness campaign; provider: elements supporting healthcare providers during routine care; Patient: material for patients such as handouts;
  3. Result categories: uptake: uptake of toolkit or toolkit components and adherence to toolkit/components; utility: information on the feasibility of using the toolkit, acceptability of the toolkit and its components, reported barriers and facilitators, and staff satisfaction with the toolkit; provider: effects on learning, self-reported confidence, or attitudes, self-reported behavior changes, and intentions; procedures: changes in procedures, organizational results (e.g., tests ordered, costs); patients: patient health outcomes, patient satisfaction, and other patient-reported outcomes
  4. aThe evidence table is organized by toolkit topic