Improving the Quality of Healthcare

Background
Total joint arthroplasty is a common surgical procedure that reduces chronic joint pain and improves function as well as quality of life for older adults with osteoarthritis [1]. With the promotion of fast-track surgeries, the length of a hospital stay for joint arthroplasty patients is decreasing [2–4]. Assisting patients in completing the transition of the perioperative period, restoring function, and returning to normal life have become important di- rections for medical staff to explore.

The KTA framework was developed in Canada by Graham and colleagues in the 2000s, in response to the confusing multiplicity of terms used to describe the process of transforming knowledge to action [5]. This framework proposes a dynamic and iterative process consisting of two interacting phases: (1) the knowledge- creation cycle and (2) the action cycle. The knowledge- creation cycle consists of three phases and involves dis- tilling knowledge from its most basic form to create a collection of synthesized, appraised, and user-friendly products catered to the needs of researchers and clini- cians alike. The action cycle is the process of translating

    knowledge into practice comprising seven components:

• Correspondence: yaping0535@163.com
  1Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China 2Bone Necrosis and Joint Preservation Reconstruction Center, China-Japan Friendship Hospital, Beijing, China
  Full list of author information is available at the end of the article

(1) identifying the problem, (2) adapting knowledge, (3)
assessing barriers, (4) implementing, (5) monitoring, (6) evaluating, and (7) sustaining [6]. The application of this

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framework has significantly and positively influenced clinical practice and patient outcomes [6–10]. To our knowledge [11], there are few reports on the application of the KTA framework in China; use of the framework for joint arthroplasty patients has not been explored.
The aim of this study was to investigate the effect of the KTA framework to improve the quality of care tran- sition for joint arthroplasty patients. It is worth mention- ing that we used a questionnaire with good reliability and validity for evaluation, which ensured the authenti- city of the implementation effect of our medical care. Furthermore, our work serves as a reference point for the consistent improvement of care transition and con- tributes to the evidence base guiding the formulation of health strategies by medical institutions.

Methods
Design and setting
The study followed a quasi-experimental design. A total of 160 patients who underwent joint replacement at a tertiary hospital from September to November 2018 and

January to March 2019 were selected as the study partic- ipants using convenience sampling. A total of 141 pa- tients responded to the survey (response rate, 88.1%). The demographic characteristics of the participants are shown in Table 1. Demographic data of both groups in- cluded gender, age, highest education level, marital sta- tus, and direct family members; the differences were not statistically significant (P > 0.05). Patients from the first cohort were included in the control group, and patients from the second cohort were included in the observation group. The control group received routine medical care, while the observation group received medical care based on the KTA framework (Fig. 1). Transitional care quality was assessed by the Care Transition Measure (CTM) and followed up on 1 week after discharge.
The CTM was designed to assess the effectiveness
of interventions aimed at improving care transitions [12], and it is a valid and reliable tool used for meas- uring the quality of care transition [13, 14]. A Chin- ese version (CTM-C), with reliability and validity established, is used to assess the quality of

Table 1 Characteristics of the respondents (N = 141)
Characteristic Category CG (N = 90) OG (N = 51) χ2 P
Gender 0.086a 0.769*
Male 34 18

Age (years) Female 56 33
0.488b
0.936*
< 50 11 6
50–59 22 15
60–69 33 17

Highest education attained 70–79 24 13
6.124b
0.050*
Junior high school or below 46 37
Technical secondary school/high school 32 11
College or above 12 3
Marital status
Married
86
46
1.965b
0.417*
Unmarried 1 1
Widowed 3 4
Direct family members
Spouse
63
29
3.467b
0.505*
Living alone 1 1
Nanny 2 2
Children 20 17
Others 4 2
P values calculated using the χ2 method
CG control group, OG observation group, TKA total knee arthroplasty, UKA unicompartmental knee arthroplasty, THA total hip arthroplasty
aPearson’s chi-square
bFisher’s exact test
*No significant difference among groups (P > 0.05)

transitional care in mainland China [15]. The content validity index for the CTM-C’s total scale is 0.99. It is composed of 17 items, each using a 4-point Likert scale ranging from “strongly disagree” to “strongly agree.” Factor analysis revealed four dimensions—gen- eral self-care preparation, written plan, doctor–patient communication, and health monitoring—with a cumu- lative variance of 58.96%. The Cronbach’s α for the total scale was 0.85, while that for each factor varied from 0.61 to 0.89 [15]. Finally, the average score of the items in the percentage system was used as the scale score, and the following conversion formula was used: scale score = (average score of items − 1) 100/3. The score ranged from 0 to 100, with a higher score indicating an improvement in the quality of care tran- sition in the hospital [16].
Two trained volunteers conducted telephone follow-up to evaluate the quality of care transition provided by the medical staff during hospitalization, and it was conducted in two parts. The first part involved the collection of demo- graphic data, while the second involved the administration of the CTM-C to assess the quality of care transition.
The study was approved by the institutional review board of the China-Japan Friendship Hospital and ad- hered to the Helsinki Declaration. Participants’ written informed consent was not required because the ques- tionnaire was anonymized and posed less than minimal risk.

Data analysis
Descriptive statistical analysis was conducted to summarize the participants’ demographic characteristics. Categorical data were reported as frequencies. Compari- sons were conducted using the Pearson chi-squared test. Fisher’s exact test was used for 2 × 2 tables where more than 25% of the expected counts were less than five for the chi-squared test. The Mann–Whitney U test was im- plemented as the nonparametric test of the two inde- pendent samples. The differences in the four dimensions and overall quality of care transition were also analyzed using the Mann–Whitney U test. A two-tailed P value of
< 0.05 was considered statistically significant. All data analyses were performed using IBM SPSS Statistics for Windows version 19.0 (IBM Corp., Armonk, NY, USA).

Results
Comparison of the quality of care transition between the two groups
As shown in Table 2, the observation group receiving medical care based on the KTA framework fared signifi- cantly better than the control group in the dimensions of general self-care preparation and written plan; the dif- ference was statistically significant (P < 0.05). The quality of care transition in the observation group was better than that of the control group, and this difference was statistically significant (P < 0.05). There was no signifi- cant difference in the dimensions of doctor–patient

Table 2 Comparison of the quality of care transition between the two groups with joint arthroplasty via the CTM-C
Groups Number Dimension 1 (mean rank) Dimension 2 (mean rank) Dimension 3 (mean rank) Dimension 4 (mean rank) Total factor (mean rank)
CG 90 64.55 58.81 66.58 67.45 63.56
OG 51 82.38 92.51 78.80 77.26 84.14
Z – 2.537 – 4.872 – 1.839 – 1.394 – 2.882
P 0.011* 0.000* 0.066 0.163 0.004*
Dimension 1, general self-care preparation; dimension 2, written plan; dimension 3, doctor–patient communication; dimension 4, health monitoring
P values calculated using the Mann–Whitney U test
CTM-C The Chinese version of Care Transition Measure, CG control group, OG observation group
*Significant difference among groups (P < 0.05)

communication and health monitoring between the two groups (P > 0.05).

Discussion
Effect of using the KTA framework to improve the quality of care transition of joint arthroplasty patients
Our findings indicate that using the KTA framework with joint arthroplasty patients improved the quality of their care transition. Patients gave a good evaluation for the overall quality of care transition (84.14). Although there was no significant influence on the doctor–patient communication and health monitoring dimensions, our findings suggest that the medical care based on the KTA framework could help to improve the quality of care transition due to the contribution of the general self- care preparation and written planning dimensions. In terms of scores alone, each dimension showed an im- provement in the observation group compared to the control group. The application of the KTA framework has significantly and positively influenced clinical prac- tice. There is still room for the improvement in quality of care transition, which needs further exploration in re- search and by the medical staff.

Focus on the quality of care transition of patients with joint arthroplasty
Our findings further suggest medical staff need to focus
on the quality of care transition of patients with joint arthroplasty. As shown in Table 2, the participants in the control group gave a poor evaluation to general self- care preparation, written plan, doctor–patient communi- cation, and health supervision dimensions, with each di- mension scoring below 70. The overall evaluation of the quality of care transition was also low (63.56). Compared to developed countries, research into care transition started later and developed slowly in China. Most stud- ies pay attention to patients’ needs for care transition, as well as exploring modes of care transition [17], while paying less attention to the evaluation of the quality of care transition. Although the current study was con- ducted in a tertiary hospital, our findings may also hold value for other types of medical institutions.

Clinical applications of the KTA framework
In this study, we first identified the problem based on the results of the control group, after which we carried out knowledge retrieval, integration, and output and lo- calized the knowledge. As shown in Fig. 1, the steps in- cluded assessing the barriers to knowledge use, developing practical interventions for the control group, and monitoring knowledge use. The outcomes were assessed using CTM-C. In addition, knowledge was maintained and utilized. The KTA framework provides a logical, valuable tool for clinical practice. Through this, we were able to make meaningful conclusions that could be used as a basis for future studies. This is, to our knowledge, the first study using the KTA framework, along with a questionnaire with good reliability and val- idity, to improve the quality of care transition for joint arthroplasty patients; however, our study does have some limitations. First, participants were purposively se- lected from patients with joint replacement in the ortho- pedic department of a level-three, class-A hospital. Non- random grouping affects the reliability of research re- sults to some extent. Considering this, we analyzed the demographic data of the two groups of participants; the differences were not statistically significant (P > 0.05). Second, the sample size was not large enough, which may limit the generalizability of our results.

Conclusion
With the advent of the era of fast-track surgery, the quality of care transition for patients undergoing joint replacement is worthy of attention. The KTA framework provides a logical, valuable tool for clinical practice. Using the KTA framework with joint arthroplasty pa- tients helps to improve the quality of care transition, which is worth promoting.

Abbreviations
CTM: Care Transition Measure; CTM-C: Care Transition Measure – Chinese Version; KTA: Knowledge-to-action

Acknowledgements
The researchers thank the study participants for sharing their personal views.

Authors’ contributions
YX and JZ contributed to the study concept and design. YX, SL, and PZ coordinated the sampling and data collection. YX and SL contributed to the data analysis. YX contributed to writing the manuscript. YX and JZ contributed to the critical review of the manuscript. All authors approved the final manuscript.

Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Availability of data and materials
Data collected from the survey were anonymized. The raw data from which the paper’s results were derived can be made available on request.

Ethics approval and consent to participate
The study was approved by the hospital’s institutional review board. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was not required as questionnaire responses were anonymized, and the study carried less than minimal risk.

Competing interests
The authors declare that they have no competing interests.

Author details
1Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China. 2Bone Necrosis and Joint Preservation Reconstruction Center, China-Japan Friendship Hospital, Beijing, China. 3Department of Bone and Joint Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Hepingli, Chaoyang District, Beijing 100029, China. 4Department of Nursing, China-Japan Friendship Hospital, Beijing, China.

Received: 30 October 2019 Accepted: 15 January 2020

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