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Kung LH, Yan YH. Empirical Study on Hospitalist System: A Value Creation Perspective. Healthcare (Basel) 2024; 12:953. [PMID: 38786365 PMCID: PMC11121058 DOI: 10.3390/healthcare12100953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 05/25/2024] Open
Abstract
This study investigates the impact of hospitalist system awareness, motivation, and behavior on value creation within the healthcare context of Taiwan. As population aging and the prevalence of chronic diseases continue to rise, accompanied by increased medical resource consumption, the Taiwan Ministry of Health and Welfare introduced the hospitalist system. Despite its implementation, the number of participating hospitals remains low. Using a questionnaire survey conducted from October 2021 to March 2022, data were collected from medical teams involved in the hospitalist system. A total of 324 valid questionnaires were analyzed. The results reveal that hospitalist awareness positively influences participation motivation (β = 0.846, p < 0.001), which subsequently impacts participation behavior positively (β = 0.888, p < 0.001). Moreover, participation behavior significantly contributes to value creation (β = 0.869, p < 0.001), along with the direct effect of awareness (β = 0.782, p < 0.001) on value creation. In conclusion, the successful promotion and implementation of the hospitalist system rely heavily on the support and active participation of medical staff. Effective interactions and comprehensive information dissemination are essential for maximizing healthcare value creation.
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Affiliation(s)
- Liang-Hsi Kung
- Department of Nursing, College of Medicine, National Cheng Kung University, No. 1, University Road, Tainan City 701, Taiwan;
- Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), No. 670, Chongde Rd., East District, Tainan City 701, Taiwan
| | - Yu-Hua Yan
- Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), No. 670, Chongde Rd., East District, Tainan City 701, Taiwan
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de Bell S, Zhelev Z, Bethel A, Coon JT, Anderson R. Factors influencing effective data sharing between health care and social care regarding the care of older people: a qualitative evidence synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-87. [PMID: 38778710 DOI: 10.3310/ttwg4738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Background Sharing data about patients between health and social care organisations and professionals, such as details of their medication, is essential to provide co-ordinated and person-centred care. While professionals can share data in a number of ways - for example, through shared electronic record systems or multidisciplinary team meetings - there are many factors that make sharing data across the health and social care boundary difficult. These include professional hierarchies, inaccessible electronic systems and concerns around confidentiality. Data-sharing is particularly important for the care of older people, as they are more likely to have multiple or long-term conditions; understanding is needed on how to enable effective data-sharing. Objectives To identify factors perceived as influencing effective data-sharing, including the successful adoption of interventions to improve data-sharing, between healthcare and social care organisations and professionals regarding the care of older people. Methods MEDLINE and seven further databases were searched (in March 2023) for qualitative and mixed-methods studies. Relevant websites were searched and citation-chasing completed on included studies. Studies were included if they focused on older people, as defined by the study, and data-sharing, defined as the transfer of information between healthcare and social care organisations, or care professionals, regarding a patient, and were conducted in the United Kingdom. Purposive sampling was used to obtain a final set of studies which were analysed using framework synthesis. Quality appraisal was conducted using the Wallace checklist. Stakeholder and public and patient involvement groups were consulted throughout the project. Results Twenty-four studies were included; most scored highly on the quality appraisal checklist. Four main themes were identified. Within Goals, we found five purposes of data-sharing: joint (health and social care) assessment, integrated case management, transitions from hospital to home, for residents of care homes, and for palliative care. In Relationships, building interprofessional relationships, and therefore trust and respect, between professionals supported data-sharing, while the presence of professional prejudices and mistrust hindered it. Interorganisational Processes and procedures, such as a shared vision of care and operationalisation of formal agreements, for example data governance, supported data-sharing. Within Technology and infrastructure, the use of technology as a tool supported data-sharing, as did professionals' awareness of the wider care system. There were also specific factors influencing data-sharing related to its purpose; for example, there was a lack of legal frameworks in the area of palliative care. Limitations Data-sharing was usually discussed in the context of wider initiatives, for example integrated care, which meant the information provided was often limited. The COVID-19 pandemic has had significant impacts on ways of working; none of our included studies were conducted during or since the pandemic. Conclusions Our findings indicate the importance of building interprofessional relationships and ensuring that professionals are able to share data in multiple ways. Future work Exploration of the impact of new technologies and ways of working adopted as a result of the COVID-19 pandemic on data-sharing is needed. Additionally, research should explore patient experience and the prevention of digital exclusion among health and social care professionals. Study registration The protocol was registered on PROSPERO CRD42023416621. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135660), as part of a series of evidence syntheses under award NIHR130538, and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 12. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Siân de Bell
- Exeter HS&DR Evidence Synthesis Centre, Department of Health and Community Sciences, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Zhivko Zhelev
- Exeter HS&DR Evidence Synthesis Centre, Department of Health and Community Sciences, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alison Bethel
- Exeter HS&DR Evidence Synthesis Centre, Department of Health and Community Sciences, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- Exeter HS&DR Evidence Synthesis Centre, Department of Health and Community Sciences, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Rob Anderson
- Exeter HS&DR Evidence Synthesis Centre, Department of Health and Community Sciences, University of Exeter Medical School, University of Exeter, Exeter, UK
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Ajer AKS, Øvrelid E. Integrating Digital Innovation Mechanisms in Digital Infrastructures: The Case of Digital Remote Care. Health Serv Insights 2023; 16:11786329231200704. [PMID: 37772276 PMCID: PMC10524064 DOI: 10.1177/11786329231200704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023] Open
Abstract
Digital innovation (DIN) is crucial for managing the growth of resource use in the hospital sector and for providing citizens with services aligned with the requirements of the modern world. DIN includes the co-creation of novel services, such as digital remote care (DRC) solutions. The healthcare sector, with a plethora of applications, is an example of a large digital infrastructure. Our study aims to explore how DRC initiatives can be integrated in large-scale digital infrastructures. Our in-depth case study, which explores 72 different DRC trajectories at 9 hospital health trusts in Norway, reveals the dynamic interplay among 3 key mechanisms - idealistic entrepreneurship, anchoring and remote infrastructure. Our contribution to the DIN literature is a model that shows the interplay among these key mechanisms, which increases the innovation pace, improves the innovations' scalability and provides a robust organisation that constantly implements innovations. As a contributions to DRC practice, lessons learned to speed up the innovation pace are offered: (1) Create a DRC organisational structure. (2) Ensure financial predictability. (3) secure anchoring upward in the governance structure. (4) Make the remote infrastructure appropriate for integration with the current digital infrastructure. (5) Advocate the success across the organisation to spur others to innovate.
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Affiliation(s)
- Anne KS Ajer
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Egil Øvrelid
- Department of Informatics, University of Oslo, Oslo, Norway
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Puckett C, Wong JC, Talbot S, Min HJ, Chokr N. Institutional role conflict in the digital age: The case of diabetes management at school. SSM. QUALITATIVE RESEARCH IN HEALTH 2023; 3:100215. [PMID: 37475882 PMCID: PMC10357960 DOI: 10.1016/j.ssmqr.2022.100215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
As the prevalence of pediatric diabetes grows and new technologies to manage diabetes emerge, there is increasing concern about consistency in health management across institutional settings, particularly in schools. While much is known about barriers at school, there are still gaps in understanding the institutional dynamics that shape health management in this setting. Using focus groups with 19 youth with type 1 diabetes (T1D) and applying institutional role theory, we find healthcare providers' recommendations conflict with school rules and norms, making it difficult to enact both the "sick role" and the "student role." These conflicts elicit negative responses from teachers and peers and stigmatize youth with T1D in school. Caregiver involvement often heightens rather than ameliorates conflict and teachers do not intervene in effective ways. Ultimately, youth must manage conflicts and stigma. By reframing challenges in health management as institutional role conflict, this paper contributes to sociological research by highlighting the importance of institutional roles, especially beyond healthcare. More broadly, the study suggests health research and policy should investigate how to better align institutional roles-rather than relying on youth and their families-to support health management of chronic illnesses across institutional settings.
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Affiliation(s)
- Cassidy Puckett
- Emory University, Department of Sociology, 1555 Tarbutton Hall, Room 225, Atlanta, GA, 30322, USA
| | - Jenise C. Wong
- University of California San Francisco, Division of Endocrinology, UCSF Benioff Children’s Hospital, USA
| | - Sloan Talbot
- Emory University, Department of Sociology, 1555 Tarbutton Hall, Room 225, Atlanta, GA, 30322, USA
| | - Hyojin Jennifer Min
- University of California San Francisco, Division of Endocrinology, UCSF Benioff Children’s Hospital, USA
| | - Nora Chokr
- University of California San Francisco, Division of Endocrinology, UCSF Benioff Children’s Hospital, USA
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Participant Perspectives on Community Health Workers' Critical Role in Their Experience of the Pathways Program to Address Complex Needs. J Ambul Care Manage 2023; 46:210-220. [PMID: 36939642 DOI: 10.1097/jac.0000000000000464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
This study aimed to describe participants' experiences of Pathways, a community hub care coordination model, including its impact on their lives and their relationship with the Pathways community health worker (CHW). The research team conducted semistructured, in-depth interviews with Pathways participants (n = 13) and analyzed interviews using thematic analysis. Interviews reveal how Pathways helps individuals navigate systems more confidently, increases access to needed resources, and improves well-being. CHWs defined participants' experience, providing a safe, reliable setting to make progress toward goals. Our findings support the evidence base for Pathways as an effective model of care coordination for people with complex needs.
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Hidefjäll P, Laurell H, Johansson J, Barlow J. Institutional logics and the adoption and implementation of remote patient monitoring. INNOVATION-ORGANIZATION & MANAGEMENT 2023. [DOI: 10.1080/14479338.2022.2162907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Patrik Hidefjäll
- Department of Learning, Informatics, Management and Ethics, Unit for Bioentrepreneurship, Karolinska Institutet, LIME, Stockholm, Sweden
- School of Business, Innovation and Sustainability, Halmstad University, Halmstad, Sweden
| | - Hélène Laurell
- School of Business, Innovation and Sustainability, Halmstad University, Halmstad, Sweden
| | - Jeaneth Johansson
- School of Business, Innovation and Sustainability, Halmstad University, Halmstad, Sweden
- Department of Social Sciences, Technology and Arts, Luleå University of Technology, Luleå, Sweden
| | - James Barlow
- School of Business, Innovation and Sustainability, Halmstad University, Halmstad, Sweden
- Imperial College Business School, Centre for Health Economics & Policy Innovation, London, UK
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Bernardi R, Wu PF. Online health communities and the patient-doctor relationship: An institutional logics perspective. Soc Sci Med 2022; 314:115494. [PMID: 36334494 DOI: 10.1016/j.socscimed.2022.115494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Taking an institutional logics perspective, this study investigates how "internet-informed" patients manage tensions between the logic of personal choice and the logic of medical professionalism as they navigate treatment decisions and the patient-doctor relationship. Based on 44 semi-structured interviews with members of an online health community for people with diabetes, this study finds that patients exercise a great deal of agency in evaluating healthcare options not only by activating the logic of personal choice but also by appropriating the logic of medical professionalism. Furthermore, patients are strategic in deciding what community advice to share with their doctor or nurse depending on the healthcare professionals' reaction to the logic of personal choice. In contrast to many previous studies that emphasise patient consumerism fuelled by information on the Internet, this study provides a more nuanced picture of patient-doctor relationship engendered by patients' participation in online health communities.
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Affiliation(s)
| | - Philip F Wu
- School of Business and Management Royal Holloway, University of London Egham
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Wankah P, Breton M, Steele Gray C, Shaw J. Enhancing inter-organisational partnerships in integrated care models for older adults: a multiple case study. J Health Organ Manag 2022; ahead-of-print. [PMID: 35619050 DOI: 10.1108/jhom-02-2022-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper was to develop deeper insights into the practices enacted by entrepreneurial healthcare managers to enhance the implementation of a partnership logic in integrated care models for older adults. DESIGN/METHODOLOGY/APPROACH A multiple case study design in two urban centres in two jurisdictions in Canada, Ontario and Quebec. Data collection included 65 semi-structured interviews with policymakers, managers and providers and analysis of key policy documents. The institutional entrepreneur theory provided the theoretical lens and informed a reflexive iterative data analysis. FINDINGS While each case faced unique challenges, there were similarities and differences in how managers enhanced a partnership's institutional logic. In both cases, entrepreneurial healthcare managers created new roles, negotiated mutually beneficial agreements and co-located staff to foster inter-organisational partnerships between public, private and community organisations in the continuum of care for older adults. In addition, managers in Ontario secured additional funding, while managers in Quebec organised biannual meetings and joint training to enhance inter-organisational partnerships. ORIGINALITY/VALUE This study has two main implications. First, efforts to enhance inter-organisational partnerships should strategically include institutional entrepreneurs. Second, successful institutional changes may be supported by investing in integrated implementation strategies that target roles of staff, co-location and inter-organisational agreements.
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Affiliation(s)
- Paul Wankah
- Faculté de Medecine et des Sciences de la Santé, Universite de Sherbrooke - Campus de Longueuil, Longueuil, Canada
| | - Mylaine Breton
- Département de sciences de la santé communautaire, University of Sherbrooke, Sherbrooke, Canada
| | - Carolyn Steele Gray
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
| | - James Shaw
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Canada
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Shaw J, Gutberg J, Wankah P, Kadu M, Gray CS, McKillop A, Baker GR, Breton M, Wodchis WP. Shifting paradigms: Developmental milestones for integrated care. Soc Sci Med 2022; 301:114975. [PMID: 35461081 DOI: 10.1016/j.socscimed.2022.114975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 10/18/2022]
Abstract
Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care.
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Affiliation(s)
- James Shaw
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, 160-500 University Avenue, Toronto, Ontario, M5G 1V7, Canada.
| | - Jennifer Gutberg
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Paul Wankah
- Department of Community Health, University of Sherbrooke, Canada
| | - Mudathira Kadu
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Carolyn Steele Gray
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Canada
| | - Ann McKillop
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Mylaine Breton
- Department of Community Health, University of Sherbrooke, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Research Chair Implementation and Evaluation Science, Institute for Better Health, Trillium Health Partners, Canada
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Gifford R, van der Vaart T, Molleman E, van der Linden MC. Working together in emergency care? How professional boundaries influence integration efforts and operational performance. INTERNATIONAL JOURNAL OF OPERATIONS & PRODUCTION MANAGEMENT 2022. [DOI: 10.1108/ijopm-10-2021-0644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeEmergency care delivery is a process requiring input from various healthcare professionals within the hospital. To deliver efficient and effective emergency care, professionals must integrate rapidly at multiple interfaces, working across functional, spatial and professional boundaries. Yet, the interdisciplinary nature of emergency care presents a challenge to the optimization of patient flow, as specialization and functional differentiation restrict integration efforts. This study aims to question what boundaries exist at the level of professionals and explores how these boundaries may come to influence integration and operational performance.Design/methodology/approachTo provide a more holistic understanding of the inherent challenges to integration at the level of professionals and in contexts where professionals play a key role in determining operational performance, the authors carried out an in-depth case study at a busy, Level 1 trauma center in The Netherlands. In total, 28 interviews were conducted over an 18-month period.FindingsThe authors reveal the existence of structural, relational and cultural barriers between (medical) professionals from different disciplines. The study findings demonstrate how relational and cultural boundaries between professionals interrupt flows and delay service processes.Originality/valueThis study highlights the importance of interpersonal and cultural dynamics for internal integration and operational performance in emergency care processes. The authors unveil how the presence of professional boundaries creates opportunity for conflict and delays at important interfaces within the emergency care process, and can ultimately accumulate, disrupting patient flow and increasing lead times.
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Manis DR, Bielska IA, Cimek K, Costa AP. Community-informed, integrated, and coordinated care through a community-level model: A narrative synthesis on community hubs. Healthc Manage Forum 2022; 35:105-111. [PMID: 34610778 PMCID: PMC8873305 DOI: 10.1177/08404704211046604] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
We identify the core services included in a community hub model of care to improve the understanding of this model for health leaders, decision-makers in community-based organizations, and primary healthcare clinicians. We searched Medline, PubMed, CINAHL, Scopus, Web of Science, and Google from 2000 to 2020 to synthesize original research on community hubs. Eighteen sources were assessed for quality and narratively synthesized (n = 18). Our analysis found 4 streams related to the service delivery in a community hub model of care: (1) Chronic disease management; (2) mental health and addictions; (3) family and reproductive health; and (4) seniors. The specific services within these streams were dependent upon the needs of the community, as a community hub model of care responds and adapts to evolving needs. Our findings inform the work of health leaders tasked with implementing system-level transformations towards community-informed models of care.
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Affiliation(s)
- Derek R. Manis
- McMaster University, Hamilton, Ontario, Canada
- McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Iwona A. Bielska
- McMaster University Medical Centre, Hamilton, Ontario, Canada
- Hamilton Niagara Haldimand Brant Local Health Integration Network, Hamilton, Ontario, Canada
| | - Kelly Cimek
- Hamilton Niagara Haldimand Brant Local Health Integration Network, Hamilton, Ontario, Canada
| | - Andrew P. Costa
- McMaster University, Hamilton, Ontario, Canada
- McMaster University Medical Centre, Hamilton, Ontario, Canada
- McMaster University, McMaster Children’s Hospital, Hamilton, Ontario, Canada
- St. Joseph’s Health System, Hamilton, Ontario, Canada
- Schlegel Research Institute for Aging, Waterloo, Ontario, Canada
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Sarkies MN, Moullin J, Ludwick T, Robinson S. Guest editorial. J Health Organ Manag 2021. [DOI: 10.1108/jhom-10-2021-513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Mæhle PM, Smeland S. Implementing cancer patient pathways in Scandinavia how structuring might affect the acceptance of a politically imposed reform. Health Policy 2021; 125:1340-1350. [PMID: 34493379 DOI: 10.1016/j.healthpol.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 07/14/2021] [Accepted: 08/27/2021] [Indexed: 11/19/2022]
Abstract
Through political decisions all three Scandinavian countries implemented national reforms in cancer care introducing cancer patient pathways. Though resistance from the professional community is common to top-down initiatives, we recognized positive receptions of this reform in all three countries and professionals immediately contributed in implementing the core measures. The implementation of a similar reform in three countries with a similar health care system created a unique opportunity to look for shared characteristics. Combining analytical framework of institutional theory and research on policy implementation, we identified common patterns of structuring of the initial implementation: The hierarchical processes were combined with supplementary structures located both within and outside the formal management hierarchy. Some had a permanent character while others were more project-like or even resembled social movements. These hybrid structures made it possible for actors from high up in the hierarchy to communicate directly to actors at the operational hospital level. Across the cases, we also identified structural components acting together with the traditional command-control; negotiation, consensus and counseling. However, variations in the presence of these did not seem to have significant impact on processes causing decisions and acceptance. These variations may, however, influence the long-term practice and outcome of cancer-care pathway-reform. Knowledge from our study should be considered when orchestrating future health care reforms and especially top-down politically initiated reforms.
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Affiliation(s)
- Per Magnus Mæhle
- Department of Health Management an Economy, Faculty of Medicine, University of Oslo and Oslo University Hospital Comprehensive Cancer Centre, Norway.
| | - Sigbjørn Smeland
- Department of Clinical Medicine, Faculty of Medicine, University of Oslo and Division of Cancer Medicine, Oslo University Hospital Comprehensive Cancer Centre, Norway
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Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168818. [PMID: 34444567 PMCID: PMC8394059 DOI: 10.3390/ijerph18168818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022]
Abstract
Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.
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Sarkies M, Robinson S, Ludwick T, Braithwaite J, Nilsen P, Aarons G, Weiner BJ, Moullin J. Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks. J Health Organ Manag 2021. [DOI: 10.1108/jhom-02-2021-0056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PurposeAs a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.Design/methodology/approachThe authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.FindingsWithin the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.Originality/valueThis paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.
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Maehle PM, Hajdarevic S, Håland E, Aarhus R, Smeland S, Mørk BE. Exploring the triggering process of a cancer care reform in three Scandinavian countries. Int J Health Plann Manage 2021; 36:2231-2247. [PMID: 34291498 DOI: 10.1002/hpm.3278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/13/2021] [Accepted: 07/01/2021] [Indexed: 11/06/2022] Open
Abstract
Cancer incidence is increasing, and cancer is a leading cause of death in the Scandinavian countries, and at the same time more efficient but very expensive new treatment options are available. Based on the increasing demand, high expectations and limited resources, crises in public legitimacy of cancer care evolved in the three Scandinavian countries. Similar cancer care reforms were introduced in the period 2007-2015 to address the crisis. In this article we explore processes triggering these reforms in countries with similar and well-developed health care systems. The common objective was the need to reduce time from referral to start treatment, and the tool introduced to accomplish this was integrated care pathways for cancer diagnosis, that is Cancer Patient Pathways. This study investigates the process by drawing on interviews with key actors and public documents. We identified three main logics in play; the economic-administrative, the medical and the patient-related logic and explored how institutional entrepreneurs skillfully aligned these logics. The article contributes by describing the triggering processes on politically initiated similar reforms in the three countries studied and also contributes to a better understanding on the orchestrating of politically initiated health care reforms with the intention to change medical practice in hospitals.
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Affiliation(s)
- Per Magnus Maehle
- Department of Health and Society, Faculty of Medicine, University of Oslo, Norway.,Division of Cancer Medicine, Comprehensive Cancer Centre, Oslo University Hospital, Norway
| | - Senada Hajdarevic
- Department of Nursing and Department of Public Health and Clinical Medicine, Family Medicine, University of Umeå, Sweden.,Department of Public Health and Clinical Medicine, Family Medicine, University of Umeå, Sweden
| | - Erna Håland
- Department of Education and Lifelong Learning, NTNU, Trondheim, Norway
| | - Rikke Aarhus
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Denmark
| | - Sigbjørn Smeland
- Division of Cancer Medicine, Comprehensive Cancer Centre, Oslo University Hospital, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Erik Mørk
- Department of Strategy and Entrepreneurship, Norwegian Business School, Oslo, Norway.,Warwick Business School, University of Warwick, Coventry, UK
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Anderson M, Pitchforth E, Asaria M, Brayne C, Casadei B, Charlesworth A, Coulter A, Franklin BD, Donaldson C, Drummond M, Dunnell K, Foster M, Hussey R, Johnson P, Johnston-Webber C, Knapp M, Lavery G, Longley M, Clark JM, Majeed A, McKee M, Newton JN, O'Neill C, Raine R, Richards M, Sheikh A, Smith P, Street A, Taylor D, Watt RG, Whyte M, Woods M, McGuire A, Mossialos E. LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet 2021; 397:1915-1978. [PMID: 33965070 DOI: 10.1016/s0140-6736(21)00232-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 12/10/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Michael Anderson
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Emma Pitchforth
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Miqdad Asaria
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Carol Brayne
- Cambridge Public Health, University of Cambridge, Cambridge, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, BHF Centre of Research Excellence, NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anita Charlesworth
- The Health Foundation, London, UK; College of Social Sciences, Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Angela Coulter
- Green Templeton College, University of Oxford, Oxford, UK; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Bryony Dean Franklin
- UCL School of Pharmacy, University College London, London, UK; NIHR Imperial Patient Safety Translational Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Margaret Foster
- National Health Service Wales Shared Services Partnership, Cardiff, UK
| | | | | | | | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Gavin Lavery
- Belfast Health and Social Care Trust, Belfast, UK
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Pontypridd, UK
| | | | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ciaran O'Neill
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
| | - Mike Richards
- Department of Health Policy, London School of Economics and Political Science, London, UK; The Health Foundation, London, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Smith
- Centre for Health Economics, University of York, York, UK; Centre for Health Economics and Policy Innovation, Imperial College London, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - David Taylor
- UCL School of Pharmacy, University College London, London, UK
| | - Richard G Watt
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Moira Whyte
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Michael Woods
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, UK; Institute of Global Health Innovation, Imperial College London, London, UK.
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18
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Gertner AK, Franklin J, Roth I, Cruden GH, Haley AD, Finley EP, Hamilton AB, Palinkas LA, Powell BJ. A scoping review of the use of ethnographic approaches in implementation research and recommendations for reporting. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2. [PMID: 34056611 PMCID: PMC8153409 DOI: 10.1177/2633489521992743] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Researchers have argued for the value of ethnographic approaches to implementation science (IS). The contested meanings of ethnography pose challenges and possibilities to its use in IS. The goal of this study was to identify sources of commonality and variation, and to distill a set of recommendations for reporting ethnographic approaches in IS. Methods: We included in our scoping review English-language academic journal articles meeting two criteria: (1) IS articles in the healthcare field and (2) articles that described their approach as ethnographic. In March 2019, we implemented our search criteria in four academic databases and one academic journal. Abstracts were screened for inclusion by at least two authors. We iteratively develop a codebook for full-text analysis and double-coded included articles. We summarized the findings and developed reporting recommendations through discussion. Results: Of the 210 articles whose abstracts were screened, 73 were included in full-text analysis. The number of articles increased in recent years. Ethnographic approaches were used within a wide variety of theoretical approaches and research designs. Articles primarily described using interviews and observational methods as part of their ethnographic approaches, though numerous other methods were also employed. The most cited rationales for using ethnographic approaches were to capture context-specific phenomena, understand insiders’ perspective, and study complex interactions. In reporting on ethnographic approaches, we recommend that researchers provide information on researcher training and position, reflect on researchers’ positionality, describe observational methods in detail, and report results from all the methods used. Conclusion: The number of IS studies using ethnography has increased in recent years. Ethnography holds great potential for contributing further to IS, particularly to studying implementation strategy mechanisms and understanding complex adaptive systems. Researchers have proposed that ethnographic methods may be valuable to implementation research and practice. Ethnographic approaches have their roots in the field of anthropology, but they are now used in many fields. These approaches often involve a researcher spending time in “real-world” settings, conducting interviews and observation to understand a group of people. That said, researchers disagree on the meaning of ethnography, which presents a challenge to its use in implementation science (IS). We searched for articles in the field of IS that described their methods as ethnographic. We then reviewed the articles, looking for similarities and differences in how and why ethnographic approaches were used. Many of these articles said they used ethnographic methods because they were interested in issues like context, research participants’ views, and complex interactions. We found a large amount of variation in how ethnographic methods were used. We developed recommendations for describing ethnographic methods in a way that readers can clearly understand. We also made several observations of the value ethnographic approaches can bring to IS. Ethnographic methods may be especially useful to studying unplanned and unexpected changes that take place during implementation. These recommendations and observations could be helpful to implementation researchers wishing to use ethnographic methods.
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Affiliation(s)
- Alex K Gertner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joshua Franklin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Isabel Roth
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | | | - Amber D Haley
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Erin P Finley
- VA Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alison B Hamilton
- VA Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lawrence A Palinkas
- Department of Children, Youth and Families, University of Southern California, Los Angeles, CA, USA
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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Oksavik JD, Aarseth T, Solbjør M, Kirchhoff R. 'What matters to you?' Normative integration of an intervention to promote participation of older patients with multi-morbidity - a qualitative case study. BMC Health Serv Res 2021; 21:117. [PMID: 33541351 PMCID: PMC7863321 DOI: 10.1186/s12913-021-06106-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/20/2021] [Indexed: 02/05/2023] Open
Abstract
Background Interventions in which individual older patients with multi-morbidity participate in formulating goals for their own care are being implemented in several countries. Successful service delivery requires normative integration by which values and goals for the intervention are shared between actors at macro-, meso- and micro-levels of health services. However, health services are influenced by multiple and different institutional logics, which are belief systems guiding actors’ cognitions and practices. This paper examines how distinct institutional logics materialize in justifications for patient participation within an intervention for patients with multi-morbidity, focusing on how variations in the institutional logics that prevail at different levels of health services affect vertical normative integration. Methods This qualitative case study of normative integration spans three levels of Norwegian health services. The macro-level includes a white paper and a guideline which initiated the intervention. The meso-level includes strategy plans and intervention tools developed locally in four municipalities. Finally, the micro-level includes four focus group discussions among 24 health professionals and direct observations of ten care-planning meetings between health professionals and patients. The content analysis draws on seven institutional logics: professional, market, family, community, religious, state and corporate. Results The particular institutional logics that justified patient participation varied between healthcare levels. Within the macro-level documents, seven logics justified patients’ freedom of choice and individualization of service delivery. At meso-level, the operationalization of the intervention into tools for clinical practice was dominated by a state logic valuing equal services for all patients and a medical professional logic in which patient participation meant deciding how to maintain patients’ physical abilities. At micro-level, these two logics were mixed with a corporate logic prioritizing cost-efficient service delivery. Conclusion Normative integration is challenging to achieve. The number of institutional logics in play was reduced downwards through the three levels, and the goals behind the intervention shifted from individualization to standardization. The study broadens our understanding of the dynamic between institutional logics and of how multiple sets of norms co-exist and guide action. Knowledge of mechanisms by which normative justifications are put into practice is important to achieve normative integration of patient participation interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06106-y.
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Affiliation(s)
- Jannike Dyb Oksavik
- Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway.
| | - Turid Aarseth
- Faculty of Business Administration and Social Sciences, Molde University College, Specialized University in Logistics, Molde, Norway
| | - Marit Solbjør
- Department of Public Health and Nursing, Trondheim, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ralf Kirchhoff
- Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway
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Mansfield E, Sandercock J, Dowedoff P, Martel S, Marcinow M, Shulman R, Parks S, Peters ML, Versloot J, Kerr J, Zenlea I. Implementing integrated care pilot projects in hospital settings – an exploration of disruptive practices. JOURNAL OF INTEGRATED CARE 2020. [DOI: 10.1108/jica-12-2019-0051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeIn Canada, integrated care pilot projects are often implemented as a local reform strategy to improve the quality of patient care and system efficiencies. In the qualitative study reported here, the authors explored the experiences of healthcare professionals when first implementing integrated care pilot projects, bringing together physical and mental health services, in a community hospital setting.Design/methodology/approachEngaging a qualitative descriptive study design, semi-structured interviews were conducted with 24 healthcare professionals who discussed their experiences with implementing three integrated care pilot projects one year following project launch. The thematic analysis captured early implementation issues and was informed by an institutional logics framework.FindingsThree themes highlight disruptions to established logics reported by healthcare professionals during the early implementation phase: (1) integrated care practices increased workload and impacted clinical workflows; (2) integrating mental and physical health services altered patient and healthcare provider relationships; and (3) the introduction of integrated care practices disrupted healthcare team relations.Originality/valueStudy findings highlight the importance of considering existing logics in healthcare settings when planning integrated care initiatives. While integrated care pilot projects can contribute to organizational, team and individual practice changes, the priorities of healthcare stakeholders, relational work required and limited project resources can create significant implementation barriers.
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21
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HUGHES GEMMA, SHAW SARAE, GREENHALGH TRISHA. Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts. Milbank Q 2020; 98:446-492. [PMID: 32436330 PMCID: PMC7296432 DOI: 10.1111/1468-0009.12459] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced. CONTEXT Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts. METHODS We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care. FINDINGS We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other. CONCLUSIONS Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.
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Affiliation(s)
- GEMMA HUGHES
- Nuffield Department of Primary Care Health SciencesUniversity of Oxford
| | - SARA E. SHAW
- Nuffield Department of Primary Care Health SciencesUniversity of Oxford
| | - TRISHA GREENHALGH
- Nuffield Department of Primary Care Health SciencesUniversity of Oxford
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Bernardi R, Exworthy M. Clinical managers' identity at the crossroad of multiple institutional logics in it innovation: The case study of a health care organization in England. INFORMATION SYSTEMS JOURNAL 2019. [DOI: 10.1111/isj.12267] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Roberta Bernardi
- School of Economics, Finance and ManagementUniversity of Bristol Bristol UK
| | - Mark Exworthy
- Health Services Management Centre (HSMC)University of Birmingham Birmingham UK
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Abstract
Purpose
Models of integrated care are prime examples of complex interventions, incorporating multiple interacting components that work through varying mechanisms to impact numerous outcomes. The purpose of this paper is to explore summative, process and developmental approaches to evaluating complex interventions to determine how to best test this mess.
Design/methodology/approach
This viewpoint draws on the evaluation and complex intervention literatures to describe the advantages and disadvantages of different methods. The evaluation of the electronic patient reported outcomes (ePRO) mobile application and portal system is presented as an example of how to evaluate complex interventions with critical lessons learned from this ongoing study.
Findings
Although favored in the literature, summative and process evaluations rest on two problematic assumptions: it is possible to clearly identify stable mechanisms of action; and intervention fidelity can be maximized in order to control for contextual influences. Complex interventions continually adapt to local contexts, making stability and fidelity unlikely. Developmental evaluation, which is more conceptually aligned with service-design thinking, moves beyond these assumptions, emphasizing supportive adaptation to ensure meaningful adoption.
Research limitations/implications
Blended approaches that incorporate service-design thinking and rely more heavily on developmental strategies are essential for complex interventions. To maximize the benefit of this approach, three guiding principles are suggested: stress pragmatism over stringency; adopt an implementation lens; and use multi-disciplinary teams to run studies.
Originality/value
This viewpoint offers novel thinking on the debate around appropriate evaluation methodologies to be applied to complex interventions like models of integrated care.
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Abstract
Introduction: Creating coordination and concerted action between sectors of modern healthcare is an inherent challenge, and decision makers in search for solutions tend replicate new models across countries and settings. An example of this is the translation of the North West London integrated care pilot into a large-scale trial that took place in the Danish Municipality of Odense from 2013–2016. This article highlights the findings from our evaluation of the ill-fated project and discusses lessons learned. Methods: We examined implementation and short-term outcome in a multi-method evaluation based on qualitative interviews, direct observation, electronic surveys and quantitative analysis of change in service use and costs, using patient level data and a matched control group. Results and discussion: Despite an ambitious setup, ample financing, a shared governance structure and a well-functioning project organisation, implementation failed at the clinical level. Also, service use and costs for included patients increased significantly, without yielding the intended results. Primary explanations relate to an overly optimistic timeframe and a failure to take professionals’ wishes, daily practices and values into account. The results underline the importance of basing future attempts at integrated care on thorough studies of the perception of actual needs and timing, including rigorous pilot testing on a smaller scale, before attempting large-scale implementation.
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"It just happens". Care home residents' experiences and expectations of accessing GP care. Arch Gerontol Geriatr 2018; 79:97-103. [PMID: 30237122 DOI: 10.1016/j.archger.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Care homes provide personal care and support for older people who can no longer be supported in the community. As part of a larger study of integrated working between the NHS and care homes we asked older people how they accessed health care services. Our aim was to understand how older people resident in care homes access health services using the Andersen model of health care access. METHODS Case studies were conducted in six care homes with different socio-economic characteristics, size and ownership in three study sites. Residents in all care homes with capacity to participate were eligible for the study. Interviews explored how residents accessed NHS professionals. The Andersen model of health seeking behaviour was our analytic framework. FINDINGS Thirty-five participants were interviewed with an average of 4 different conditions. Expectations of their health and the effectiveness of services to mitigate their problems were low. Enabling factors were the use of intermediaries (usually staff, but also relatives) to seek access. Residents expected that care home staff would monitor changes in their health and seek appropriate help unprompted. CONCLUSIONS Care home residents may normalise their health care needs and frame services as unable to remediate these which may combine to disincline older care home residents to seek care. Care access was enabled using intermediaries -either staff or relatives-and the expectation that staff would proactively seek care when they observed new/changed needs. Residents may over-estimate the health-related knowledge of care home staff and their ability to initiate referrals to NHS professionals.
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Abstract
Purpose
The purpose of this paper is to examine the role of organizational space in attempts at practice redesign and innovation that involve a break with the traditional professional boundaries in a recently established Danish hospital department.
Design/methodology/approach
Organizational ethnography combined with Bourdieusian theorization. The data used for this paper are derived from 13 months of ethnographic fieldwork. The author performed participant and meeting observations combined with interviews and the reading of internal and external documents.
Findings
Despite the department’s attempts at pursuing practice redesign and innovation by breaking with the institutionalized professional boundaries as well as role hierarchies, and emphasizing collaboration between nurses and doctors, the paper demonstrates how the attempts at change meet invisible impediments in practice and how organizational space plays an important yet, overlooked part in reproducing field tradition.
Originality/value
By virtue of Bourdieusian theorization in combination with organizational ethnography, the paper contributes with unique insights into a seldom studied part of hospital organization, which is how organizational space, rather than being a backdrop for organizational life, is constructed and used by professionals whose habitus renders this space an active component in delimiting professional work as well as the scope of change.
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