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Research Article| Volume 22, ISSUE 3, SUPPLEMENT , S81-S91, April 2022
Contextual Factors Affecting Implementation of Pediatric Quality Improvement Programs
Elizabeth L. Cope, PhD, MPH
Elizabeth L. Cope
Address correspondence to Elizabeth Cope, PhD, MPH, AcademyHealth, 1666 K St NW, Suite 1100, Washington, DC 20006
AcademyHealth (EL Cope and M Khan), Washington, DC
Margaret Johnson, MBA
L&M Policy Research (M Johnson), Washington, DC
Marya Khan, MPH
Marya Khan
Heather C. Kaplan, MD, MSCE
Heather C. Kaplan
Perinatal Institute and James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine (HC Kaplan), Cincinnati, Ohio
Anne Sales, PhD, RN
Anne Sales
Department of Learning Health Sciences, University of Michigan Medical School (A Sales), Ann Arbor, Mich
Center for Clinical Management Research, VA Ann Arbor Healthcare System (A Sales), Ann Arbor, Mich
Kamila B. Mistry, PhD, MPH
Kamila B. Mistry
Child Health and Quality Improvement, Agency for Healthcare Research and Quality (KB Mistry), Rockville, Md
DOI:https://doi.org/10.1016/j.acap.2021.08.016
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Context is a critical determinant of the effectiveness of quality improvement programs. We assessed the role of contextual factors in influencing the efforts of 5 diverse quality improvement projects as part of the Pediatric Quality Measure Program (PQMP) directed by the Agency for Health Care Research and Quality.
We conducted a mixed methods study of 5 PQMP grantees involving semistructured interviews followed by structured worksheets to identify influential contextual factors. Semistructured interviews and worksheets were completed between August and October 2020. Participants were comprised of PQMP grantee teams (2–4 team members per team for a total of 15 participants). Coding and analysis was based on the Tailored Implementation for Chronic Diseases (TICD) framework.
Despite heterogeneity in the process and outcome targets of the PQMP initiatives, professional interactions, incentives and resources, and capacity for organizational change were the domains most commonly identified as influential across the grantees. While social, political, and legal factors was not commonly referenced as an important domain, payer or funder policies (a factor within this domain) was highlighted as one of the most influential factors. Overall, the incentives and resources domain was identified as the most influential.
We found that using a determinant framework, such as the TICD, is valuable in facilitating comparisons across heterogeneous projects, allowing us to identify key contextual factors influencing the implementation of pediatric quality measures across a diverse range of clinical topics and settings. Future quality improvement work should account for this and include resources to support infrastructure development in addition to program implementation.
contextual factors
pediatric quality measures
A determinants framework was used to identify barriers and facilitators for 5 pediatric quality improvement projects. Incentives and resources were determined to be most influential, suggesting a need for greater investment to improve the efficiency of future quality improvement efforts.
Context is a critical determinant of the effectiveness of any quality improvement (QI) program.
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By systematically assessing the role of contextual factors in a program's implementation, we can gain a better understanding of how the intervention worked, with lessons for others conducting similar efforts.
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Considering context in quality improvement interventions and implementation: concepts, frameworks, and application.
Acad Pediatr. 2013; 13: S45-S53https://doi.org/10.1016/j.acap.2013.04.013
Historically, implementation science frameworks have been used to provide a conceptual underpinning to analyze the influence of contextual factors for a range of interventions, including pediatric QI, primary care practice transformation, prevention and wellness projects, among others.
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Qual Life Res. 2020; ([e-pub ahead of print])https://doi.org/10.1007/s11136-020-02564-9
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Front Public Health. 2018; 6 (Published 2018 Jun 5): 150https://doi.org/10.3389/fpubh.2018.00150
As part of the first phase of the Pediatric Quality Measure Program (PQMP) directed by the Agency for Health Care Research and Quality (AHRQ), 7 Centers of Excellence developed new and enhanced pediatric quality measures covering a range of clinical conditions. These quality measures were developed to increase the portfolio of measures available to public and private purchasers of children's health care services under the Children's Health Insurance Program Reauthorization Act of 2009, Title IV, Section 401. In the second phase of the PQMP, 6 grantees assessed the feasibility and usability of the newly developed measures for QI. Each of the grantees launched and led one or more quality improvement collaboratives (QICs) to support QI activities targeting their respective measures.
QICs are a commonly used QI or implementation strategy that brings together multiple health care organizations to focus on the same goal and includes opportunities to share learnings and best practices in support of improving performance.
Zamboni K
Baker U
Tyagi M
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Given that the focus of each grantee's QIC was tied to one of the quality measures developed in the first PQMP phase, the QI work supported by the QICs reflected a variety of clinical conditions, measure types (process, outcome, experience), and data sources (claims, electronic health record [EHR], survey). Depending on the measure, the QICs engaged with individuals and organizations at different, and sometimes multiple, levels of the health care system—spanning patient, provider, health system, health plan, and state levels. Despite differences in the clinical focus and the level of the health care system at which each QIC was operating, all of the QICs aimed to improve systems, processes, and/or long-term outcomes of pediatric care among QIC participants.
The purpose of this analysis was to use an implementation science determinants framework to identify which, if any, contextual factors were common barriers or facilitators to improving pediatric care across a group of diverse QICs conducted as part of phase II of the AHRQ PQMP program.
Flottorp SA
Oxman AD
Krause J
A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice.
Implement Sci. 2013; 8 (Published 2013 Mar 23): 35https://doi.org/10.1186/1748-5908-8-35
We conducted a mixed methods study to identify the factors that facilitated or impeded the successful implementation of system and process changes within the PQMP QICs using the Tailored Implementation for Chronic Diseases (TICD) framework.
The TICD is a comprehensive, integrated checklist of determinants of implementation success organized into 7 domains that include factors that might impact implementation. The 7 domains include: guideline or quality measure factors, individual health professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social/political/legal factors. Consolidating other determinants frameworks, the TICD offers specificity and flexibility as it can be applied across different levels of organizations or systems, which was a key component of this analysis necessitated by how the QICs were organized.
We carried out data collection in 2 phases: first, we conducted semistructured interviews to obtain information about the QICs and respective system and process changes implemented by the QIC participants; second, we collected information to capture details about contextual factors influencing implementation of the system and process changes using structured worksheets based on the TICD domains. The first phase of data collection was used to inform the second phase. This paper focuses on the findings from the second phase of data collection.
Selection of QIC Projects
While some grantees executed more than one QIC to support QI targeted to multiple quality measures, for the purpose of this evaluation, we focused on activities related to one QIC and one measure from 5 of the grantees. We excluded one grantee because neither of their QICs advanced to a phase of active QI during our evaluation period. In consultation with the grantees and AHRQ, we identified specific system and process changes implemented by QIC participants as part of the QI activities within each QIC. Selection was driven by measures/system changes that progressed the most during the period of performance. Characteristics of the included measures and QICs are highlighted in Table 1. We focused our inquiry on key contextual barriers and facilitators of implementation of these specific system and process changes.
Table 1QICs Featured in the IS Analysis
PQMP Grantee
QIC Goals
QIC Participants
QIC Duration
Measure Targeted for Improvement
Intervention Selection Process
Main System and Process Changes
CEPQM Develop and implement a shared intervention across sites to garner shared learnings for reducing hospital readmissions Hospitals (n = 5) 36 months Pediatric 30-day all-condition hospital readmissions (NQF # 2393) All QIC participants agreed to implement the same intervention through a consensus-based decision-making process Parental confidence assessment: Hospitals developed and implemented a parental confidence assessment—focused on assessing parents' confidence in discharge instructions—that could be administered to parents before their child was discharged from the hospital
IMPLEMENT - Successfully establish and continue engagement in the collaborative
- Improve asthma outcomes, specifically the number of child emergency department visits for asthma Primary care practices (n = 11) 12 months, plus 9 months extension Rate of emergency department visit use for children managed for persistent asthma Grantee presented QIC participants with a menu of intermediate measures; QIC participants selected from these measures and then developed their own interventions Electronic health record (EHR) improvements for child asthma-related process measures: Participating practices focused mostly on improvements related to implementing decision support features and improving the sites' documentation capabilities to help capture and track the process measures. Strategies included: reconfigured visit report pull from EHR, smart forms, dot/smart phrases, asthma patient identification
NCINQ II Improve metabolic monitoring in children and adolescents prescribed an antipsychotic Health plans (n = 5) 18 months Metabolic monitoring for children and adolescents on antipsychotics (NQF # 2800) Grantee presented QIC participants with a menu of intervention options that could be tailored to participant specifications Health plan-level metabolic monitoring improvement strategies: All the plans focused on implementing safe and judicious practices for antipsychotic prescribing among youth—they selected the strategy that was best suited to their context. Strategies included: member outreach, standing lab order, data exchange, provider outreach, incentive program
P-HIP Improve participating hospitals' performance on counseling parents/caregivers regarding restricting access to potentially lethal means of suicide from their child/ adolescent treated for suicidality prior to discharge home and documentation in the medical record that the counseling was completed Hospitals (n = 8) 12 months Children/adolescents admitted to the hospital for dangerous self-harm or suicidality, should have documentation in the hospital record that their caregiver was counseled on how to restrict the child's/adolescent's access to potentially lethal means of suicide (eg, firearms, medications, car, etc.) prior to discharge Grantee presented QIC participants with a menu of intervention options that could be tailored to participant specifications Implementing a standardized documentation strategy for counseling through their EHR: Teams introduced a statement in the discharge template about counseling on the restriction of lethal means to serve as a reminder/prompt, and to ensure that documentation was completed
Q-METRIC - Improve care for children with sickle cell disease and specifically improve rates of appropriate antibiotic prophylaxis for children with sickle cell anemia
- Successfully identify target patient population
- Continued engagement in the collaborative State (n = 1)
Health plans (n = 3)
Clinics (n = 2) 12 months Appropriate antibiotic prophylaxis for children with sickle cell anemia (NQF # 3166) Grantee presented QIC participants with a menu of intervention options that could be tailored to participant specifications Developing patient registries/databases for children with sickle cell anemia: Sites developed approaches to identifying children with sickle cell anemia in their clinics or plans
QIC indicates quality improvement collaborative; IS, implementation science; and PQMP, Pediatric Quality Measure Program.
Semistructured Interviews
In August 2020, we conducted semistructured telephone interviews (supplemental file available upon request) with each of the grantees to elicit details about the nature of the QIC they convened. Grantees self-selected team members (from 2 to 4 members) to participate in the interviews. All teams included the principal investigator. Each interview was led by an experienced researcher (E.C. or M.J.). Interviews were recorded and transcribed. Interview notes and transcripts were independently reviewed by 2 research team members (M.J. and M.K.), with each extracting descriptive information about the QICs and system and process changes implemented. Results were compared and discrepancies resolved through consensus. Extracted information was used to prepopulate the first section of the worksheet for grantee review and confirmation and to provide background for the research team to better understand how each QIC functioned.
Between September and October 2020, each grantee was asked to complete a structured worksheet to identify relevant contextual factors that impacted QIC participants' implementation of system/process changes (supplemental file available upon request). Worksheet design was informed by the approach of Tomoaia-Cotisel et al,
in which authors used structured worksheets to collect information on contextual factors from 14 distinct research teams. Wording leveraged supplementary materials published by Flottorp et al,
the developers of the TICD checklist. Worksheets were tailored to each grantee by incorporating descriptive details of their QICs from the interviews. Grantees were asked to elaborate on how relevant factors in each TICD domain applied in their QIC context. Separately, grantees were asked to select the contextual factors they deemed "most influential" overall in the ability of QIC participants to successfully make system and process changes (allowing for several). Grantees completed the worksheets using free text. Typically, worksheets were completed by the same grantee team members as those who participated in the semistructured interviews.
All 5 worksheets were collected from grantees and independently coded by 2 research team members (M.J. and M.K.). The research team performed deductive content analysis of free text data from the worksheets using the TICD as a template. Specifically, contextual factors were coded using TICD domains, subdomains, and individual factors as a priori codes, noting whether factors were barriers and/or facilitators. Coding results were reviewed and compared. Any coding discrepancies were discussed and resolved through consensus (E.C., M.J., and M.K.). Factors that were indicated by grantees as "most influential," that is, those that had the most impact on implementation efforts, among their QIC participants were noted. Domains with the highest proportion of factors identified as relevant or "most influential" across grantee QIC participants were considered most salient and are referred to as such in the results. The team identified quotations from the worksheet responses to illustrate key themes or observations, particularly among the most salient domains.
This work was a component of a learning collaborative effort associated with the grantees' cooperative agreement awards, interviewees were only grantees and asked only about topics associated with the specific QICs established under their cooperative agreement awards. Interviewees were fully informed of how the information would be used and no sensitive information was collected.
We interviewed a total of 15 participants (2–4 per grantee team). All grantee teams included the principal investigator. Additional participants included one or more of the following depending on the grantee team: project manager, implementation lead, QI lead, and/or lead learning collaborative facilitator. In some cases, the same person served multiple roles. These interviewees were also responsible for completing the structured worksheets.
There were contextual factors within each of the TICD domains that were identified as important barriers and facilitators of successful implementation of system and process changes across the 5 QICs as shown in the data collected from the grantees' worksheets (Table 2).
Table 2Factors Identified by Grantees
Definitions were adapted using the supplementary Tailored Implementation for Chronic Diseases materials published by Flottorp et al8.
CEPQM
NCINQ II
P-HIP
Q-METRIC
1. Guideline factors
A. Quality measure
Quality of evidence supporting the measure How confident we are in the evidence base, reliability, and validity of the quality measure
Indicates factor was identified by grantee as being among the "most influential" factors for one or more of their quality improvement collaborative participants.
Indicates factor was identified by grantee as being relevant as a barrier or facilitator for one or more of their quality improvement collaborative participants.
Strength of the quality measure How confident we are that the desirable effects of improving the quality measure outweigh the undesirable effects
Clarity The clearness of the target population, the settings in which the quality measure is to be used, and the recommended change strategy
Cultural appropriateness The extent to which the quality measure is suitable in the social context where it is being implemented
Accessibility of the quality measure How accessible the specifications are
Source of the quality measure The organization(s) and people that developed the quality measure
Consistency with other practices The extent to which the quality measure and associated change strategy are consistent with other guidelines with which the targeted health care professionals might be familiar
B. Recommended intervention
Feasibility The extent to which implementing the quality measure and recommended change strategy is practical
Accessibility of the intervention The extent to which the quality measure and recommended change strategy is accessible
C. Recommended behavior
Compatibility The extent to which the recommended behaviors associated with the change strategy fits with current practices
Effort The amount of effort required to change or adhere
Trialability The ability to try out the recommended behaviors associated with the change strategy
Observability The degree to which benefits of the change strategy are visible
2. Individual health professional factors
A. Knowledge and skills
Domain knowledge The extent to which the targeted health care professionals have pre-existing knowledge or expertise about the targeted condition/practice
Awareness and familiarity with the quality measure The extent to which the targeted health care professionals are aware of and familiar with the change strategy
Knowledge about own practice The extent to which the targeted health care professionals are aware of their own practice in relationship to the change strategy
Skills needed to adhere The extent to which the targeted health professionals have skills that they need to adhere
B. Cognitions
Agreement with the quality measure The extent to which the targeted health care professionals agree with the quality measure and associated change strategies
Attitudes toward interventions in general The perceptions that the targeted health care professionals have regarding improvement change strategies in general
Expected outcome The extent to which the targeted health care professionals believe that adherence with the change strategy will lead to desired outcomes
Intention and motivation The extent to which the targeted health care professionals intend to adhere and are motivated to do so
Self-efficacy The targeted health care professionals' self-perceived competence or confidence in their abilities
Learning style The preferred ways in which the targeted health care professionals learn
Emotions The extent to which emotions affect adherence
C. Professional behavior
Nature of the behavior Characteristics of the behavior, including: frequency of performance for a patient, frequency of performance for a population of patients, the degree of habit or automaticity, whether it is within a sequence of other behaviors that have to be performed, and whether it is performed by one person or by different people
Capacity to plan change The extent to which the targeted health care professionals have the capacity to plan necessary changes in order to adhere
Self-monitoring or feedback The extent to which the targeted health care professionals have the capacity for self-monitoring or feedback to reinforce adherence with the change strategy
3. Patient and family factors
Patient and family needs Real or perceived needs and demands of the patient/family
Patient and family beliefs and knowledge Patients'/families' beliefs or knowledge or ability to learn, or the targeted health care professionals' ability or perceived ability to inform or teach patients/families necessary knowledge and skills
Patient and family preferences Patients'/families' values in relationship to professional values or those in the change strategy
Patient and family motivation The targeted health care professionals' ability or perceived ability to motivate patients/families to adhere
Patient and family behavior Patient/family behaviors that motivate or demotivate adherence with the change strategy
4. Professional interactions
Indicates domain was identified as most salient during the analysis. Domains with the highest proportion of factors identified as relevant or "most influential" across grantees were considered most salient.
Communication and influence The extent to which the targeted health care professionals' adherence is influenced by professional opinions and communication
Team processes The extent to which professional teams or groups have the skills needed to adhere and interact in ways that facilitate or hinder adherence
Referral processes Processes for transferring patients and communication between different levels of care, between health and social services, and between the targeted health care professionals and targeted patients
5. Incentives and resources
Availability of necessary resources The extent to which the resources that are needed to adhere are available
Financial incentives and disincentives The extent to which patients/families, individual health professionals and organizations have financial incentives or disincentives to adhere
Nonfinancial incentives and disincentives The extent to which patients/families, individual health professionals and organizations have nonfinancial incentives or disincentives to adhere
Information system The extent to which the information system facilitates or hinders adherence
Quality assurance and patient safety systems The extent to which existing quality assurance or patient safety systems facilitate or hinder adherence
Continuing education system The extent to which the continuing education system facilitates or hinders adherence
Assistance for clinicians The extent to which clinicians have the assistance they need to adhere
6. Capacity for organizational change
Mandate, authority, accountability The mandate, authority, and mechanisms of accountability for making necessary changes
Capable leadership The extent to which clinical leaders or managers are capable of making necessary changes
Relative strength of supporters and opponents The extent of support and/or opposition to necessary changes
Regulations, rules, policies The extent to which organizational regulations, rules, or policies facilitate or hinder necessary changes
Priority of necessary change The relative priority given to making necessary changes
Monitoring and feedback The extent to which monitoring and feedback are needed at the organizational level and available to sustain necessary changes (including evaluations of improvement programs)
Assistance for organizational changes The extent to which external support is needed and available for necessary changes
7. Social, political, and legal factors
Economic constraints on the health care budget Limits on the total health care budget or its growth
Contracts The extent to which contracts may affect implementation of necessary changes
Legislation The extent to which legislation may affect implementation of necessary changes
Payer or funder policies The extent to which payer or funder policies may affect implementation of necessary changes
Malpractice liability The extent to which malpractice liability may affect implementation of necessary changes
Influential people The extent to which influential people may affect implementation of necessary changes
Corruption The extent to which corruption may affect implementation of necessary changes
Political stability The extent to which political stability may affect implementation of necessary changes
† Indicates factor was identified by grantee as being among the "most influential" factors for one or more of their quality improvement collaborative participants.
‡ Indicates domain was identified as most salient during the analysis. Domains with the highest proportion of factors identified as relevant or "most influential" across grantees were considered most salient.
§ Definitions were adapted using the supplementary Tailored Implementation for Chronic Diseases materials published by Flottorp et al
Most Salient Domains
The "incentives and resources," "professional interactions," and "capacity for organizational change" domains were identified as most salient across the QICs. Importantly, contextual factors within these domains were identified as important despite the heterogeneity in the level of the health care system where changes were made, the types of system and process changes implemented, and the complexity of the clinical areas of focus.
Incentives and Resources
Contextual factors within this domain were identified as important barriers and facilitators of successful implementation of system and process changes universally by grantees in their worksheet responses. Not only was this domain commonly discussed by grantees in free text responses, but several factors under this domain were also designated as "most influential." The 2 factors most commonly identified as having an impact on QIC implementation efforts were: the availability of necessary resources and information systems. Availability of necessary resources was reported as both a barrier and facilitator. For example, in the CEPQM QIC, as related to their strategy for developing and implementing a parental confidence discharge assessment, the grantee commented that "ultimately, resources—staff, QI expertise, and IRB expertise—ended up being critically important for getting this intervention off the ground. Even if there is leadership buy-in, without the additional resources, hospitals were unable to participate." Another grantee, Q-METRIC, reported that, within their QIC, without adequate resources—financial and staffing—it was challenging to make short-term progress and even more difficult to sustain long-term improvements in appropriate antibiotic prophylaxis for children with sickle cell anemia. This grantee noted that a lack of extrinsic incentives exacerbated the issue of resource availability, commenting "Without incentives or an extrinsic requirement to report, it is unlikely that adequate organizational resourcing and support will be made available to improve performance rates." The grantee supporting the NCINQ QIC had a similar observation, noting, "One of the most impactful factors in implementing the measures and strategies [for improving metabolic monitoring] was the existence of state mandate and existing infrastructure/mechanism for reporting … this created an incentive for providers and health plans to focus resources on this small, but highly vulnerable population…." Information systems were also noted as a key factor. In nearly all cases, information systems were facilitators to implementation efforts, particularly in cases where the information systems were able to be provided centrally by the QIC. For example, both the CEPQM and NCINQ QICs used their existing information systems to run performance reports to monitor their QIC participants' progress. Others, like the P-HIP and IMPLEMENT QICs leveraged and built out their information systems as part of the QIC activities to support the sustainability of improvement efforts.
Professional Interactions
Within this domain, the most commonly cited factor was team processes, which is the extent to which professional teams have the skills needed to facilitate or impede implementation. Although the clinical focus of each QIC varied (Table 1), all of the QICs were focused on making system and process changes that involved members of different departments and/or disciplines. Within the P-HIP QIC which focused on caring for children and adolescents admitted to the hospital for dangerous self-harm or suicidality, the grantee noted: "Setting expectations and clearly defining roles for conducting and documenting the counseling was essential given the many staff and departments involved…. Teams accomplished this in a variety of ways: having a dedicated role staffed 24/7 that was responsible for the counseling; …required training program for new residents who were responsible for educating parents/caregivers; and creating accountability for doing both the counseling and the documentation." Another grantee, highlighted an innovative approach that one health plan participating in the NCINQ QIC undertook to ensure a team-based approach for metabolic monitoring for children and adolescents on antipsychotics: "having a pharmacist on their QI team, which the other health plans had not done, but learned was a valuable approach through the QIC and explored incorporating it in their own QI work." The pharmacist had developed a corporate-wide strategy to encourage safer monitoring that involved, "standing lab orders … and pharmacy soft edits (to encourage discussion of alternate treatment options)."
Capacity for Organizational Change
Contextual factors within this domain were the most commonly identified barriers and facilitators of successful implementation of system and process changes, specifically capable leadership; priorities of necessary change; mandate, authority, accountability; and monitoring and feedback. Referencing the importance of capable leadership, grantees identified this factor as both a facilitator and a barrier. Grantees stated that having engaged and "bought-in" leaders improved resource allocation and focus on the QIC efforts. This was noted specifically by the grantee team supporting the NCINQ QIC. On the other hand, grantees reported that those participants with less involved leaders suffered from fewer resources, and at one of the participating sites, the project risked being de-prioritized (IMPLEMENT). Grantees also noted that priorities of necessary change, impacted their QICs' success. The IMPLEMENT QIC, which focused on EHR improvements for child asthma-related processes, reported that this factor was both a facilitator and a barrier. They shared that participants' "ability to modify or customize an EHR requires time and resources… Unless the particular measure is a priority for an organization, changes to the EHR may require a practice to 'wait their turn in line'." Similarly, other grantees reported that QIC participants struggled with competing priorities drawing resources and support away from their QI work as part of the QIC. On the other hand, within the P-HIP QIC, priorities of necessary change was identified as a facilitator. The grantee speculated that the pressure the QIC participants felt to reduce rates of suicide among children led to this QI work being prioritized by participating organizations.
Other Important Domains
While the other domains of the TICD were less consistently reported as relevant among grantees, there were individual contextual factors within these domains that appeared to be critical barriers and facilitators of successful implementation of system and process changes in both the qualitative and quantitative (Table 2) data provided by grantees, though findings were more heterogeneous. The importance of these factors appeared to be dependent on the specific context of the QIC, and there were few cross-QIC patterns based broadly on clinical topic (eg, behavioral health) or QIC participant composition (eg, health system level).
Social, political, and legal factors were the least referenced domain; however, 2 grantees reported that payer or funder policies was among their "most influential" factors impacting their QICs. The fact that the IMPLEMENT QIC was supported as part of the AHRQ PQMP program made the collaborative stand-out among other QI project options, facilitating recruitment of primary care practice participants: "…this group came together because of the unique opportunity to test the usability of a new pediatric quality measure." Conversely, the Q-METRIC QIC attributed some of their limited measure uptake to a lack of funder policies, "it is very difficult to convince systems or plans to invest resources when other required priorities exist."
Within the domain of Guideline Factors, the most commonly cited factors were quality of evidence supporting the measure and source of the quality measure. While the domain overall was not identified as one of the most influential among grantees, the specific factor of quality of evidence supporting the measure was identified among the "most influential" factors impacting implementing success. This is not surprising given that a core criterion of a PQMP measure is having a robust evidence base.
Among the most commonly cited factors related to Individual Health Professional Factors were domain knowledge, awareness and familiarity with the quality measure, and intention and motivation. Nearly all grantees noted that dedicated and motivated health professionals who were already familiar with the quality measure were well-positioned to facilitate implementation within their QIC participating sites. Nature of the behavior and capacity to plan change were also highlighted as key factors, with one grantee in particular noting that their QIC's strategy to "hardwire changes" into their team processes served as a facilitator for easier adoption.
Finally, the most commonly cited factor within the domain of patient factors was patient and family beliefs and knowledge. This factor was reported to be important particularly among QICs where system and process changes required engagement directly with patients and families, and principally when timing was an important part of the process. For example, participants in the CEPQM QIC administered their parental discharge readiness assessment near the time of discharge, when parents may have been reluctant to acknowledge their lack of confidence in the discharge instructions to expedite taking their child home. In another case, the grantee found that the counseling strategy implemented by participants in the P-HIP QIC worked best within the first 3 days of admission, allowing parents time to adjust to the circumstances.
Our study sought to identify common influential contextual factors across a set of 5, highly heterogeneous pediatric QI initiatives. These QI initiatives differed in terms of type of participants, clinical topics, measures of focus, and specific system and process changes being implemented. While each initiative supported participants' QI efforts using a QIC model, the differing approaches used by these QIC's to support improvement varied and added to the heterogeneity. Within QICs, participants were generally given the freedom to identify system and process changes that would be best suited for their own setting—meaning specific system and process changes varied within as well as across QICs. In addition, the timeframe allowed for QIC activity varied across these initiatives with some QIC's occurring over 12 months and others over 36 months. While this amount of heterogeneity generates substantial complexity in the evaluation, it allowed us to identify a number of key contextual factors that are common barriers and facilitators of pediatric quality initiatives across the board, regardless of QI approach or clinical focus.
The key contextual factors across domains that seemed to transcend the heterogeneity across QICs and were consistently highlighted as important barriers and facilitators included team processes, availability of necessary resources, information systems, capable leadership and priorities of necessary change. The need for organizational systems and infrastructure to support improvement was consistently identified in the QI initiatives, a finding that is aligned with the broader literature demonstrating the critical role of organizational, systemic, and cultural factors affecting implementation.
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Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: a literature review and qualitative analysis.
Healthc (Amst). 2016; 4: 22-29https://doi.org/10.1016/j.hjdsi.2015.12.005
Not surprisingly, because QI, at its core, is data-driven, having a data infrastructure to monitor changes in processes and outcomes of care related to the target quality metric was identified as important in all QICs. By creating a centralized and automated structure, information systems provide a powerful tool for organizations to support staff in carrying out their QI initiatives. As noted by Karltun et al, a consistent information and knowledge management infrastructure is crucial for clinical QI as it creates reinforcing enabling conditions, even across diverse health care settings.
Karltun A
Sanne JM
Aase K
Knowledge management infrastructure to support quality improvement: a qualitative study of maternity services in four European hospitals [published correction appears in Health Policy. 2020 May;124:575].
Health Policy. 2020; 124: 205-215https://doi.org/10.1016/j.healthpol.2019.11.005
Given its relevance across all QICs, information systems clearly represent a key factor for similar QI initiatives to consider—and leverage—as a way to systematically support implementation.
Observations from our evaluation also provide insights not only into the important role that extrinsic incentives, such as state mandates or required reporting of quality measures, play in procuring resources, but also into how external sponsors (like QICs or state agencies) can provide infrastructure for data collection and reporting of pediatric quality measures. In addition, reflections on the role of payer or funder policies by some grantees underscore the role that entities within the sociopolitical environment play in either facilitating or hindering successful improvement. Particularly important for pediatric QI is the observation that measures in the CMS Child Core Set or those that are aligned with QI focused incentive programs received greater attention by QIC participant leadership.
Ensuring the local context is set up to support QI efforts targeting pediatric quality measures is critical and, ideally, should be addressed before beginning the QI initiative. Based on our analysis, it is clear that resources—human, infrastructure, financial—are needed to support effective pediatric focused QI activities. However, securing, and having dedicated resources can be challenging. There is an opportunity for Federal and state level governments to play a more substantial role in providing resources, whether through the creation of grants to support more pediatric QI work (eg, PQMP-like opportunities), by advancing value-based payment opportunities through Medicaid and CHIP that incentivize engagement in pediatric QI work, or through supporting registries that link varied data sources and can be used to track key quality measures. Lastly, the decision to adequately resource a QI effort is directly linked to whether that initiative was prioritized by the organization, and, in many organizations, pediatric quality is not identified as a top priority. Prioritization of pediatric quality by payers and health systems is an important first step in securing the resources needed for effective pediatric QI work.
There were some notable limitations to this analysis. First, we collected data from the individuals who managed and led the QICs, so our findings may not represent the full range of experiences from the QIC participants. The retrospective nature of the project may also have led to underreporting of some factors. Also, due to the variation both in how the QICs defined success and in the maturity of the projects, we were not able to adequately assess success as measured by improvement in the pediatric quality measure across the projects, so we focused on those factors that influenced the implementation of system and process changes. Finally, the small sample size and high heterogeneity precludes inferential analysis, such as assessing associations between influential contextual factors and QIC characteristics.
Despite the difficulties inherent in the retrospective data collection and analysis used in this study, it is important to make sense out of complex implementation projects to facilitate future implementation efforts across disparate sites. This is particularly important in pediatrics. Compared to the adult care setting, pediatrics is characterized by less funding and fewer resources, for a number of reasons including its comparatively smaller and less burdened population, as well as the reality that a higher proportion of children come from low-income families and communities, compared with adults.
Koball H
Moore A
Hernandez J
Basic Facts About Low-Income Children: Children Under 9 Years, 2019.
National Center for Children in Poverty, Bank Street College of Education, New York2021
As we found, these resource limitations can have real impact on the ability to carry out effective QI. While QI in pediatrics has been an active area for some time,
Schwartz S
Rehder K
Quality improvement in pediatrics: past, present, and future.
Pediatr Res. 2017; 81: 156-161https://doi.org/10.1038/pr.2016.192
this study is the first of its kind to explore commonly salient contextual factors that affect QI functioning across heterogeneous health system actors, clinical foci, measures, and change strategies. Based on our findings, as well as those in other studies, ensuring adequacy of resources at both an individual and collective (QIC) level will be essential to supporting effective activities in the future.
Coles E
Anderson J
Maxwell M
The influence of contextual factors on healthcare quality improvement initiatives: a realist review.
Syst Rev. 2020; 9 (Published 2020 Apr 26): 94https://doi.org/10.1186/s13643-020-01344-3
We found that using a determinant framework is valuable in facilitating comparisons and learning across heterogeneous QI projects. Through the use of semistructured interviews and worksheets based on the TICD framework, we were able to identify key contextual factors influencing the implementation of pediatric quality measures across a diverse range of clinical topics and settings. We found that factors related to the professional interactions, incentives and resources, and capacity for organizational change domains appeared to transcend measure topics and clinical settings as important drivers of implementation efforts.
The authors extend their gratitude to the individuals from the Pediatric Quality Measures Program grantee teams featured in this article; the authors' team is very grateful for their contributions, including technical guidance, support with data collection, and review of this manuscript. The authors also thank Robyn Sagatov, PhD, MHS, RDN from the Agency for Healthcare Quality and Research for her insightful reviews.
Financial statement: This project was conducted under contract to Agency for Healthcare Research and Quality (contract number HHSA290201400003I/75Q80119F32002).
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
This article is published as part of a supplement sponsored by the US Department of Health and Human Services, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality.
Accepted: August 21, 2021
Received: February 2, 2021
The authors have no conflicts of interest to disclose.
Copyright © 2021 by Academic Pediatric Association


In my March Bullet Journal set up article I shared a peek into a simple hack I came up with at the top corner of the pages to make it easier to find information that's in your pages. Today I'm going to walk you through how it works!
I grabbed one of the sheets from the back of my other Leuchtturm1917 notebooks and trimmed it down to form two smaller pieces.
Next, I added a bit of washi tape so they would create little fold-outs. I added one to each cover so I could flip them out no matter which page I'm on.
Here you can see how the signifiers at the top corner of the pages are lined up to the Signifier Magnifiers.
This was the first event I added to my Bullet Journal so I added it first. I think it comes in handy to quickly browse through my Bullet Journal to see when these things occurred.
I love my Gratitude Log and seeing everything awesome that happened throughout the course of the month all in one place. It's been a long time since I tried out logging what I'm grateful for in my Dailies. The reason I wanted to try it out this time around was a desire to go fully back to basics and pare down updating all of the various logs and collections. Sometimes I have more than 2 or 3 things I want to write down that I'm grateful for and I think it's fun to have it as part of the dailies as true reflection of my day to day by writing things down as they happen. Because the monthly Gratitude Log helped me ingrain it as a habit, the past issue of forgetting to log it has now been resolved. Also, it feels good to be able to write things down as I think of them :) If you'd like to try daily gratitude logging but think you might forget, try out Ryder's awesome daily gratitude brackets :).
I love writing and receiving letters. A few months ago I got a private mailbox and made it public so people can send me letters if they'd like to and I like keeping track of the letters I receive that I need to respond to. I had come up with a pen pal tracker back in January, but it didn't really work out for me, one of the columns needed to be more (<- / ->) to indicate whether I received or responded to a letter. Then I saw all sorts of pen pal trackers and Charlotte's was my favorite, but ultimately I decided that simple is best and what's more simple than an adorable signifier? :) The envelope means I need to respond to a letter and I fill the top part to indicate that I wrote back.
Just a cute way to keep track of when I last purchased groceries. It's handy to know how long ago I bought the celery that's sitting in the veggie drawer.
I like watching movies and logging them, what more is there to say?
As much as I love my Waiting On and Shipment Tracker, I found I didn't have that many things to wait on or for haha, so I decided to go back to one of my favorite signifiers of all time that Josh Medeski came up with. The little hourglass is perfect to fill the bottom of when you hear word back from whoever you're waiting on or a package arrived that you were waiting for.
Am I the only one who doesn't like doing laundry? I think it'll be fun if nothing else to draw these little washer and bubble signifiers to keep up with laundry duties.
I fill it in when the event has occurred. This is an experiment right now, I'm trying out a simple future planning signifier. The way it works is that when I add a task that occurs tomorrow or in a few days I'll place an arrow signifier to the left of the bullet and add the date to the left of that. When I place this arrow at the top corner of the page I won't add the date next to it, it'll only be a way to see that I have a future event occurring which makes it easy to scan the page. Right now my life is pretty simple, so the future events usually occur the next day or a few days from now. I tend to flip through the previous days' daily logs each day to work on previous days' tasks. I guess if you're busier a different future planning system would work better for you.
I typically use this signifier if I have a task or event that I've migrated forward a couple of times and really need to get done. It's easy to see when I'm scanning the top corners of the pages to help me focus.
This is simple and obvious. If I want to buy something, I'll add the signifier to the corner of the page to indicate that there's something on that page that I want to purchase. When I finally buy it, I'll add a little check mark next to it because it wouldn't make sense if I tried to fill it in.
I have a bit of allergic eczema apparently, partly due from cat dander, the weather, soaps, and certain synthetic fibers such as acrylic and polyester. Sometimes I'll have a little rash breakout so I have to apply this intense prescription cream on, which works really well, but I don't want to apply it regularly because it's a really strong cream. I recently bought CeraVe from Costco and oh my goodness it is wonderful! It's making my skin so soft and healing up the dry patches so, so well. I had used Aquaphor before and though I liked it, CeraVe is working so much better for me, I highly recommend it if you have dry skin as well! Anywho, the signifier is to indicate when I used the stronger cream to make sure I don't use it too often, which I usually don't but it's good to stay aware of these things.
Here you can see the Signifier Magnifier in action. The signifiers at the corners of the page match up to the ones on the flip-out card.
The idea is to rapid-log bullets and signifiers as needed and then re-add the relevant signifiers to the corner of the page to make it easy to scan for pertinent information. Signifiers give further context to bullets so use and come up with ones that are meaningful to you.
Here's the other side of the notebook with the Signifier Magnifier flip-out peeking out. Sometimes I won't write a note that I did something and will just add it to the corner of the page. This is most common with the laundry and grocery shopping because it acts as a little indication that I did it but didn't need to write it down as a note first, or at all.
I also don't place all the signifiers I use into the Signifier Magnifier because they don't really need to be magnified, such as what I ate. Here you can see it as a mug, but I don't really need it magnified.
I'm pretty flexible about it. I left a little room underneath in case I want to add some more signifiers later on.


text:
Articles by Andy Jowett
New game round-up
What connects a sadistic turtle-crushing businessman with a gurgling purple sea monster? Like, we have any idea. But they both feature in out latest round-up of the best new online games.
There's nothing like good old games, except perhaps great new ones. There's a lot of them out there, but here at Casual Girl Gamer, we leave no web-based stone unturned to find the very best titles for you to get your beat-em-up, tower defence and/or RPG groove on.
The latest tip-top batch takes us from the grimy, soul-shredding depths of corporate hell to ethereal temples of light and cold cyberworlds from the not-too-distant future. How about that then? And the best part is they're all free. So let's crack on, shall we?
Published by Andy Jowett on 15th November 2010
Top ten hardest games
So you fancy yourself as a bit of a mean gamer. You always opt for the hardest settings when playing games. Well, we have a challenge for you - ten of the most difficult online games we could find.
They're tricky, they're testing, they're downright infuriating. They'll make you laugh, they'll possibly make you cry and they'll almost certainly have you coming back for more, just to show them. Just to show them good! They are the hardest games you can find online.
Now, burying the needle on the Casual Girl Gamer hard-o-meter takes more than flooding the screen with overwhelming waves of bad guys - the candidates here are less bashing and blasting, more baffling, befuddling and bewitching. Indeed, there's hardly an enemy to be seen in our collection of brain teasers, tests of skill and just plain maddening fun.
Top ten launching games
There is something about the idea of wantonly launching objects - in particular small animals - into the air that tickles human beings. We would never do it in real life, of course, but give us a game that let's us do it, and we simply can't stop playing.
Ten games that make you think about life
Games might not yet be recognized as art but they are increasingly being used to explore the kind of deep themes that were previously the preserve of artists and philosophers.
Top 10 most relaxing online casual games
Some games aim to soothe and calm your nerves rather than get your heart pounding like crazy with non-stop action.
Ten Chain Reaction Games
We have collected together the best free online chain reaction games we could find for your playing pleasure.
Best point-and-click games of 2010
A bit early maybe, but we think our point-and-click-obsessed readers are going to love this: the best point-and-click games of the year.

redpajama_set_name: RedPajamaCommonCrawl


We've planted a few more things in the garden: bright lights chard, icile radishes and yukon gold potatoes. So, along with the onions we planted last week, our garden is off to a good start I think.
This entry was posted in Garden & Yard and tagged bright lights chard, chard, gardeing, garden, icile radishes, potatoes, radishes, vegetables, yukon gold potatoes. Bookmark the permalink.
Looking forward to seeing them sprouting!


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Into the Storm » Specials
TV Movie: Into the Storm: Churchill at War
First Aired: May. 31, 2009 on HBO
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[show all]Into the Storm stars Brendan Gleeson as the intrepid British leader whose fiery rhetoric inspired Allied forces to fight back against Hitler's Germany to with everything they've got. As the flames of war spread throughout Europe, Winston Churchill rose to the call and became a national hero, disregarding the detrimental effects his actions had on both his political career and his marriage to lifelong supporter Clemmie in a single-minded effort to defeat one of history's greatest tyrants.
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CPE (Certificate of Proficiency in English) — Экзамен по английскому языку, разработанный и проводящийся подразделением Кембриджского Университета ESOL (English for Speakers of Other Languages). Старейший из кембриджских языковых экзаменов. Впервые был представлен в 1913 году. Сертификат соответствует уровню C2 Шкалы Совета Европы и является экзаменом, подтверждающим наивысший уровень владения английским языком. Срок действия сертификата неограничен.

Формат и содержание экзамена
Экзамен состоит из 5 частей — Reading, Writing, Use of English, Listening, Speaking. К столетию экзамена в 2013 году Cambridge ESOL планирует пересмотреть формат экзамена.

Reading
Содержит 4 задания. Общее количество вопросов — 40. На выполнение этой части отводится полтора часа

Задание 1
Представляет собой три текста с 6 пропусками в каждом, которые необходимо заполнить, выбрав правильный вариант ответа. Каждый правильный ответ оценивается 1 баллом. Задание родственно 1 заданию части Use Of English экзамена CAE.

Задание 2
Представляет собой 4 текста, к каждому из которых поставлено по два вопроса с выбором ответа из 4 вариантов. Каждый правильный ответ оценивается 2 баллами

Задание 3
Представляет собой текст, разбитый на параграфы. 7 параграфов пропущено. Экзаменуемому предлагаются эти параграфы в неправильном порядке. Задача — заполнить пропуски в правильном порядке. Один параграф является лишним. За каждый правильный ответ (всего их 6) выставляется 2 балла

Задание 4
Представляет собой текст и 7 поставленных к нему вопросов с выбором ответа из 4 вариантов. Каждый правильный ответ оценивается 2 баллами

Writing
Содержит два задания, на выполнение которых отводится 2 часа.

Задание 1
Экзаменуемому предлагается небольшой фрагмент текста (письма, вырезки из газеты, рекламы и.т.п), содержащий до 100 слов. Используя данную информацию требуется написать статью, письмо, отчет или проект-предложение. Письменный ответ должен содержать 300—350 слов.

Задание 2
Необходимо выполнить одно задание из 4 на выбор. Задания могут требовать написание статьи, конкурсного проекта (competitional letter), обзора, отчета, проекта-предложения, эссе, информационного листка.
Одно из заданий (номер 5) базируется на основе одной из трёх книг, предложенной к прочтению экзаменуемым. Задание имеет варианты a, b,c — необходимо выбрать один из них (каждый из вариантов базируется на одной из трёх книг). Список книг публикуется на официальном сайте экзамена в начале года и остается неизменным в течение всего года. Задание может представлять собой статью, обзор или эссе.

Use Of English
Часть, в которой проверяется владение английской грамматикой. Содержит 5 заданий. На выполнение отводится полтора часа

Задание 1
Представляет собой текст с 15 пропусками. Необходимо заполнить каждый пропуск одним словом. Варианты ответа не предлагаются. Каждый правильный ответ оценивается 1 баллом.

Задание 2
Представляет собой текст с 10 пропусками. К каждому пропуску предложено слово, которое необходимо как-то изменить (формой, временем, наклонением, сделать другое слово на основе данного и пр), чтобы заполнить пропуск. Каждый правильный ответ оценивается 1 баллом.

Задание 3
Представляет собой 6 вопросов. В каждом имеются 3 предложения с 1 пропущенным словом. Во всех трёх пропущенное слово — омоним (одинаковое по написанию, но разное по значению). Каждый правильный ответ оценивается 2 баллами.

Задание 4
Представляет собой 8 вопросов. В вопросе предлагаются два предложения, одинаковых по смыслу. Во втором предложении пропущена часть слов. Предлагается также одно слово. Необходимо используя от 3 до 8 слов, включая данное и не изменяя его, заполнить пропуск так, чтобы второе предложение стало бы одинаковым по смыслу с первым. Правильный ответ может быть оценен 1 или 2 баллами в зависимости от полноты и степени правильности.

Задание 5
«Изложение» (summary). Представляет собой два текста с двумя вопросами со свободным ответом к каждому, а также вопрос, на который необходимо ответить, написав краткое изложение текстов (объёмом не 50-70 слов).

Listening
Содержит 4 задания. Занимает около 40 минут. Все задания проигрываются дважды.

Задание 1
4 коротких записи, к каждой из которых предлагается по два вопроса с выбором правильного ответа из 3 вариантов. Правильный ответ оценивается одним баллом.

Задание 2
Кандидату предлагается текст с 9 пропусками. Предлагается заполнить пропуски, прослушав 3-4 минутный монолог. Правильный ответ оценивается одним баллом.

Задание 3
Диалог, длящийся 3-4 минуты, после которого предлагается 5 вопросов с выбором правильного ответа из 4 вариантов. Каждый правильный ответ оценивается 1 баллом.

Задание 4
Диалог, длящийся 2-3 минуты, в котором говорящие спорят, меняют точки зрения и пр. Предлагается 6 утверждений, к каждому из которых необходимо отметить — кто из участников (или оба) высказал данное мнение. Каждый правильный ответ оценивается 1 баллом.

Speaking
Содержит 3 задания. Задания выполняются парой кандидатов. Если остается нечетное число кандидатов, то могут быть сформированы тройки. Время, которое занимает часть — 19 минут. Если задания выполняются тройкой кандидатов, то время пропорционально увеличивается. Эта часть оценивается двумя экзаменаторами, один из которых ведёт беседу, другой — выставляет оценки по критериям.

Задание 1
Кандидаты отвечают на вопросы экзаменатора, рассказывают о себе, отвечают на общие вопросы. На это задание отводится 3 минуты.

Задание 2
Кандидату предъявляется одна или более картинок. Вначале кандидат должен ответить на заданный вопрос, затем оба кандидата должны ответить на вопрос, придя к какому-то мнению по поводу материала. (занимает 4 минуты)

Задание 3
Экзаменатор предъявляет карточку с фотографией и несколькими предлагаемыми идеями, о которых кандидату предстоит говорить в течение 2 минут. После окончания 2 минут экзаменатор просит второго кандидата сделать комментарий о сказанном. Затем экзаменатор дает задание обоим участникам на основе материала (4 минуты). После чего участники меняются местами. В сумме часть занимает 12 минут.

Оценивание работ
Каждая из частей имеет своё количество баллов за задания, но в итоге все баллы приводятся к 40 по формуле:
(Баллы, набранные кандидатом × 40) ÷ максимально возможное число баллов.

Соотношение баллов и итоговой оценки
Каждая из частей оценивается отдельно, но все части дают по 20 % в общую оценку. Даже если одна часть сдана плохо, кандидат имеет шансы сдать весь экзамен в целом и получить сертификат.
Кандидат, набравший от 60 до 74 %, получает оценку C (pass).
Кандидат, набравший от 75 до 79 %, получает оценку B.
Кандидат, набравший от 80 % и более, получает оценку А.

Кандидат, набравший меньше 60%, но в пределах шкалы предыдущего уровня, получает сертификат С1. Кандидат, не набравший достаточно баллов для уровня С1, не получает сертификата вовсе.

Признание сертификата
Сертификат признается многими работодателями и рядом университетов в Великобритании. Кроме того, сертификат признается Британской пограничной службой (UKBA), как удостоверяющий достаточное знание английского языка при подаче документов на иммиграционую визу TIer 1 (до закрытия программы).

Центры тестирования
До 2007 года в России за приём экзаменов отвечал Британский совет, однако после закрытия учебного центра Британского Совета в России были аккредитованы ряд известных языковых школ.

Примечания

Ссылки
 Общее краткое описание экзамена
 Кембриджские экзамены на странице экзаменационного центра BKC
 Описание экзамена на странице ESOL
 Экзамены ESOL
 Краткое описание типов заданий и принципов оценивания
 FAQ по кембриджским экзаменам
 Рассказ человека, который сдал CPE
 CPE-FAQ

Тесты на знание английского языка

redpajama_set_name: RedPajamaWikipedia


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MARS HILL AUDIO Reprints are readings of individual articles and essays from magazines, journals, and pamphlets on subjects of cultural significance. Some articles have been selected to complement the content on recent issues of the MARS HILL AUDIO Journal, offering listeners an opportunity to explore a subject in greater depth or from a slightly different angle. Other articles are chosen to provide a primer on important cultural and theological issues.


Father Louis Wolken died at St. Teresa's Residence, Maryknoll New York on July 12, 2015. He was 96 years old and a Maryknoll priest for 69 years.
Louis John Wolken was born in St. Louis, Missouri on July 2, 1919, son of Louis and Rose Mary Steffen Wolken. He had one sister, Marie, who died in 1956. Louis attended Cathedral Latin School (Junior Seminary for the diocese of St. Louis) and St. Louis Preparatory Seminary before entering Maryknoll in September 1938. He was ordained at Maryknoll, New York on June 9, 1946.
Following ordination, Father Wolken was assigned to higher studies, returning to his native St. Louis to earn his B.S. degree in Physics. He served on the Venard faculty from 1947 to 1953, assuming the responsibilities of Second Consultor and Prefect of Studies in 1950.
Father Wolken was assigned to the Maryknoll Mission Region in Japan in April 1953, and after language studies, he was named assistant pastor at Fushimi Parish in Kyoto. In 1955 he was appointed Consultor to the North Asia Society Superior, serving also as Acting Superior while the appointed Superior attended the General Chapter. In 1956 he was appointed Second Consultor and, in 1958 First Consultor. During that time he also served as Pastor of Sonobe Parish.
Father Wolken returned to the United States in April 1959. He was appointed Vice-Rector and later Rector at the Venard. He also studied at the University of Scranton, receiving his M.A. in Secondary Education Administration in May 1964, at which time he was appointed Rector of the Chesterfield Seminary. In 1966 he was also appointed as Director of the Brothers Training Program at Chesterfield. He was transferred to Glen Ellyn in that capacity in 1968.
In July 1971 Father Wolken was reassigned to Japan, serving as pastor of various parishes in the Kyoto Diocese, including Kinugasa, Uji, Otsu and Momoyama. In 1973 he was appointed Assistant to the Regional Superior. He continued in pastoral work until 2002, when he returned to the United States and took up residence at Mission St. Teresa's. Father Wolken was assigned to the Senior Missioner Community in March 2004. For many years, he served as manager of the Business Office at St. Teresa's, offering assistance to any residents who wished to have help in managing their personal accounts, check cashing, etc..
A Rosary and wake service was held at 4:00 p.m. on July 16, 2015 at St. Teresa's. The body was received at the Maryknoll Society Center at 9:30 a.m. on July 17, 2015 with prayers in the Lady Chapel until 10:45 a.m. The biography was read by Rev. Richard Aylward. Mass of Christian Burial followed at 11:00 a.m. and was concelebrated in Queen of Apostles Chapel. Father Emile Dumas was Principal Celebrant and Father Robert Reiley was homilist. Burial followed in Maryknoll Society Cemetery with Father Thomas O'Brien conducting the graveside service.


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