Explanation & Elaboration

8. Setting

• Specifies how elements of the environment considered most likely to influence change/improvement in the involved site or sites were identified and characterized

Example

"Alice Peck Day Memorial Hospital (APD) is a 32 bed hospital located in Lebanon, New Hampshire, USA. The birthing center has six labour/delivery/recovery/postpartum rooms and a Level I nursery. This unit is usually staffed by a minimum of two nurses. During delivery, one-on-one nursing is provided. When this project started in 2001, two independent physician groups, employing four providers, admitted obstetric patients. Paediatric services were provided by 16 physicians distributed among four independent practices. Three anaesthesia practitioners provided continuous coverage. Caesarean deliveries are performed in the hospital's main operating room. The operative team consisted of the attending obstetrician, the first assistant, the paediatric provider, the anesthesiologist, two operating room staff and the birthing center nurse.

As the hospital has grown, physician groups have expanded, consolidated and changed practice patterns. Currently three obstetricians and three CNMs [clinical nurse midwives] are employed by the hospital. One additional CNM has a small independent practice. The majority of in-house paediatric services are now provided by one hospital-owned practice that employs four family practitioners and two paediatricians. Anaesthesia and operating room services are unchanged; although, we no longer consistently have a first assistant at all caesarean deliveries." [24]

Elaboration

This section describes the specific and relevant elements of the setting in which the improvement effort took place. It is an opportunity to expand upon the basic description that may be contained in 3. Background Knowledge and 4. Local Problem.  In the example, this hospital is located in a rural part of New Hampshire, and "rural" is also included in the title of this article. Rural sites often are hospitals with smaller patient capacity (i.e., number of hospital beds) and with smaller professional staff. The authors further describe the challenges of meeting emergency caesarean section time targets with the limited resources at this site, thus illustrating the financial and staffing limitations in this setting. Improvement in this example was not a matter of hiring a coordinator or purchasing new equipment; it was predicated on the current staff using the currently available resources, so describing the current situational factors - and how they changed throughout the study period - is stated. Implementing the changes described in this paper could be much different in a highly staffed, urban hospital with different staffing resources.

The paper later describes that the improvement efforts were undertaken in response to a sentinel event that involved a caesarean delivery response time, thus providing information regarding the underlying culture in which the change took place. In a small hospital, an adverse outcome affects almost everyone on staff. Describing how this event galvanized support for change was key in this article. This example could have been strengthened by more specific information about the degree of leadership support from middle and senior management as well as information about the history of prior change efforts, if any.

This framework of context and process description is necessary for readers to understand the generalizability (external validity) of the report. Identifying, understanding, and making changes to the processes and structures of care are essential to improvement work. This is in contrast to controlled trials where context is held constant through the design (e.g., randomization, blinding) and analysis (e.g., regression analysis). Clearly describing the context for the reader will assist in their efforts to extrapolate to their own setting.

References

24. Mooney SE, Ogrinc G, Steadman W. Improving emergency caesarean delivery response times at a rural community hospital. Quality & safety in health care. 2007;16(1):60-66.

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