An effectiveness analysis of healthcare systems using a systems theoretic approach

Health Management: Evaluating the Relationship between Organizational Factors, Psychosocial Risks at Work, Performance Management, and Hospital Outcomes

Introduction-Health system (HS) health organizations are complex and are in constant dynamic interaction with multiple elements, including political, environmental, societal, legal, and organizational factors, along with human components, such as human resources, patients, and other stakeholders. Objective-This research aimed to study three HS organizations, identifying and characterizing the elements of health organizations and the factors related to professionals, determining their influence on economic and financial performance results, as well as results related to the professionals and to the patients comprising the institutions. Method-A quantitative study was conducted in which data were collected through questionnaires from various sources to better understand and characterize the factors related to organizations, professionals, and patients (470 health professionals and 768 patients). To test the integrated evaluation model for health organizations, path analysis was used. Results-The results reveal that the organizational culture (OC) presents a positive relationship between the professional's quality of life (QL) and the performance management (PM) of the professionals, along with a negative relationship with the psychosocial work risks (PWR). There is also a relationship between the OC and patient satisfaction (PS), professional job satisfaction (PJS), and economic and financial results (EFR). In the relationship between the processes and the results, there are significant relationships between PM and PJS and PWR and PJS. In terms of the results, there is a significant relationship between the EFR and the PS. Conclusions-This study contributes to a deeper knowledge of the factors that influence the quality of health organizations and their results and produces recommendations for health organizations to address the current challenges.

An international systems-theoretic comparison of hospital accreditation: developing an implementation typology

OBJECTIVE

The integration of quality indicators into the accreditation process has been recognized as a promising strategy worldwide. This study was to explore the implementation patterns of hospital accreditation through the lens of a systems-theory based model, and determine an international accreditation implementation typology.

DESIGN

A qualitative comparative study of five established international hospital accreditation systems was undertaken based on a systems-theoretic holistic healthcare systems relationship model. A set of key attributes relevant to three systems-theoretic model relationships guided data collection, comparison and synthesis.

SETTING

Hospital accreditation systems in five countries: America, Canada, Australia, Taiwan and France.

RESULTS

An accreditation implementation typology was developed based on the data synthesis of the similarities and differences among the relationships. A typology including five implementation types of hospital accreditation systems (TYPE I-V) was induced. TYPE I is a basic stand-alone accreditation system. The higher types represent stronger relationships among accreditation system, healthcare organizations and quality measurement systems. The five settings have shifted their accreditation approaches from the basic type (TYPE I).

CONCLUSIONS

The implementation typology of hospital accreditation could serve as a roadmap for refining hospital accreditation systems toward an integrative approach for continuous quality improvement.

Improvement attributes in healthcare: implications for integrated care

Purpose Healthcare quality improvement is a key concern for policy makers, regulators, carers and service users. Despite a contemporary consensus among policy makers that integrated care represents a means to substantially improve service outcomes, progress has been slow. Difficulties achieving sustained improvement at scale imply that methods employed are not sufficient and that healthcare improvement attributes may be different when compared to prior reference domains. The purpose of this paper is to examine and synthesise key improvement attributes relevant to a complex healthcare change process, specifically integrated care. Design/methodology/approach This study is based on an integrative literature review on systemic improvement in healthcare. Findings A central theme emerging from the literature review indicates that implementing systemic change needs to address the relationship between vision, methods and participant social dynamics. Practical implications Accommodating personal and professional network dynamics is required for systemic improvement, especially among high autonomy individuals. This reinforces the need to recognise the change process as taking place in a complex adaptive system where personal/professional purpose/meaning is central to the process. Originality/value Shared personal/professional narratives are insufficiently recognised as a powerful change force, under-represented in linear and rational empirical improvement approaches.

Mapping for Conceptual Clarity: Exploring Implementation of Integrated Community-Based Primary Health Care from a Whole Systems Perspective

Introduction

Studying implementation of integrated models of community-based primary health care requires a "whole systems" multidisciplinary approach to capture micro, meso and macro factors. However, there is, as yet, no clear operationalization of a "whole systems" approach to guide multidisciplinary research programs. Theoretical frameworks and approaches from diverse academic traditions specify different aspects of the health system in more depth. Enabling analysis across the system, when data and ideas are captured using different taxonomies, requires that we map terms and constructs across the models.

Theory and methods

This paper uses concept mapping techniques to compare and contrast the theoretical frameworks and approaches used in the iCOACH project including: Ham's Ten Characteristics of the High-Performing Chronic Care System (capturing patient/carer and provider perspectives), the Organizational Context and Capabilities for Integrating Care framework (capturing the organizational perspective), and the Health Policy Monitor framework (capturing the policy system perspective). The aim of the paper is to link concepts across different theoretical framework to guide the iCOACH study.

Results

A concept map was developed that identifies 8 overarching concepts across the heuristic models. A preliminary analysis of one of these overarching concepts, care coordination, demonstrates how different perspectives will assign different meanings, values, and drivers of seemingly similar ideas. For patients and carers care coordination is about having a responsive team of health care providers. Building relationships in teams that exist within and across different organizations is essential for providers to achieve care coordination, where managers and policy makers see care coordination as being more about creating linkages and addressing systems gaps.

Discussion and conclusion

This work represents a first step towards development of a fully formed conceptual framework that includes key domains, concepts, and mechanisms of implementing integrated community-based primary health care.

The Impact of Applying Quality Management Practices on Patient Centeredness in Jordanian Public Hospitals: Results of Predictive Modeling

Targeting the patient's needs and preferences has become an important contributor for improving care delivery, enhancing patient satisfaction, and achieving better clinical outcomes. This study aimed to examine the impact of applying quality management practices on patient centeredness within the context of health care accreditation and to explore the differences in the views of various health care workers regarding the attributes affecting patient-centered care. Our study followed a cross-sectional survey design wherein 4 Jordanian public hospitals were investigated several months after accreditation was obtained. Total 829 clinical/nonclinical hospital staff members consented for study participation. This sample was divided into 3 main occupational categories to represent the administrators, nurses, as well as doctors and other health professionals. Using a structural equation modeling, our results indicated that the predictors of patient-centered care for both administrators and those providing clinical care were participation in the accreditation process, leadership commitment to quality improvement, and measurement of quality improvement outcomes. In particular, perceiving the importance of the hospital's engagement in the accreditation process was shown to be relevant to the administrators (gamma = 0.96), nurses (gamma = 0.80), as well as to doctors and other health professionals (gamma = 0.71). However, the administrator staff (gamma = 0.31) was less likely to perceive the influence of measuring the quality improvement outcomes on the delivery of patient-centered care than nurses (gamma = 0.59) as well as doctors and other health care providers (gamma = 0.55). From the nurses' perspectives only, patient centeredness was found to be driven by building an institutional framework that supports quality assurance in hospital settings (gamma = 0.36). In conclusion, accreditation is a leading factor for delivering patient-centered care and should be on a hospital's agenda as a strategy for continuous quality improvement.

A systematic review of hospital accreditation: the challenges of measuring complex intervention effects

Background

The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness.

Methods

We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies.

Results

The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized.

Conclusion

Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0933-x) contains supplementary material, which is available to authorized users.

The impact of hospital accreditation on quality measures: an interrupted time series analysis

Background

Developing countries frequently use hospital accreditation to guarantee quality and patient safety. However, implementation of accreditation standards is demanding on organisations. Furthermore, the empirical literature on the benefits of accreditation is sparse and this is the first empirical interrupted time series analysis designed to examine the impact of healthcare accreditation on hospital quality measures.

Methods

The study was conducted in a 150-bed multispecialty hospital in Abu Dhabi, United Arab Emirates. The quality performance outcomes were observed over a 48 month period. The quality performance differences were compared across monthly intervals between two time segments, 1 year pre- accreditation (2009) and 3 years post-accreditation (2010, 2011 and 2012) for the twenty-seven quality measures. The principal data source was a random sample of 12,000 patient records drawn from a population of 50,000 during the study period (January 2009 to December 2012). Each month (during the study period), a simple random sample of 24 percent of patient records was selected and audited, resulting in 324,000 observations. The measures (structure, process and outcome) are related to important dimensions of quality and patient safety.

Results

The study findings showed that preparation for the accreditation survey results in significant improvement as 74% of the measures had a significant positive pre-accreditation slope. Accreditation had a larger significant negative effect (48% of measures) than a positive effect (4%) on the post accreditation slope of performance. Similarly, accreditation had a larger significant negative change in level (26%) than a positive change in level (7%) after the accreditation survey. Moreover, accreditation had no significant impact on 11 out of the 27 measures. However, there is residual benefit from accreditation three years later with performance maintained at approximately 90%, which is 20 percentage points higher than the baseline level in 2009.

Conclusions

Although there is a transient drop in performance immediately after the survey, this study shows that the improvement achieved from accreditation is maintained during the three year accreditation cycle.

The impact of hospital accreditation on clinical documentation compliance: a life cycle explanation using interrupted time series analysis

OBJECTIVE

To evaluate whether accredited hospitals maintain quality and patient safety standards over the accreditation cycle by testing a life cycle explanation of accreditation on quality measures. Four distinct phases of the accreditation life cycle were defined based on the Joint Commission International process. Predictions concerning the time series trend of compliance during each phase were specified and tested.

DESIGN

Interrupted time series (ITS) regression analysis of 23 quality and accreditation compliance measures.

SETTING

A 150-bed multispecialty hospital in Abu Dhabi, UAE.

PARTICIPANTS

Each month (over 48 months) a simple random sample of 24% of patient records was audited, resulting in 276,000 observations collected from 12,000 patient records, drawn from a population of 50,000.

INTERVENTIONS

The impact of hospital accreditation on the 23 quality measures was observed for 48 months, 1 year preaccreditation (2009) and 3-year postaccreditation (2010-2012).

MAIN OUTCOME MEASURES

The Life Cycle Model was evaluated by aggregating the data for 23 quality measures to produce a composite score (YC) and fitting an ITS regression equation to the unweighted monthly mean of the series.

RESULTS

The four phases of the life cycle are as follows: the initiation phase, the presurvey phase, the postaccreditation slump phase and the stagnation phase. The Life Cycle Model explains 87% of the variation in quality compliance measures (R(2)=0.87). The ITS model not only contains three significant variables (β1, β2 and β3) (p≤0.001), but also the size of the coefficients indicates that the effects of these variables are substantial (β1=2.19, β2=-3.95 (95% CI -6.39 to -1.51) and β3=-2.16 (95% CI -2.52 to -1.80).

CONCLUSIONS

Although there was a reduction in compliance immediately after the accreditation survey, the lack of subsequent fading in quality performance should be a reassurance to researchers, managers, clinicians and accreditors.

Application of case classification in healthcare quality assessment in China

The purpose of this study was to build a healthcare quality assessment system with disease category as the basic unit of assessment based on the principles of case classification, and to assess the quality of care in a large hospital in Shanghai. Using the Delphi method, four quality indicators were selected. The data of 124,125 patients discharged from a large general hospital in Shanghai, from October 1, 2004 to September 30, 2007, were used to establish quality indicators estimates for each disease. The data of 51,760 discharged patients from October 1, 2007 to September 30, 2008 were used as the testing sample, and the standard scores of each quality indicator for each clinical department were calculated. Then the total score of various clinical departments in the hospital was calculated based on the differences between the practical scores and the standard. Based on quality assessment scores, we found that the quality of healthcare in departments of thyroid and mammary gland surgery, obstetrics and gynaecology, stomatology, dermatology, and paediatrics was better than in other departments. Implementation of the case classification for healthcare quality assessment permitted the comparison of quality among different healthcare departments.

Reconceptualizing children's complex discharge with health systems theory: novel integrative review with embedded expert consultation and theory development

AIM

To report a novel review to develop a health systems model of successful transition of children with complex healthcare needs from hospital to home.

BACKGROUND

Children with complex healthcare needs commonly experience an expensive, ineffectual and prolonged nurse-led discharge process. Children gain no benefit from prolonged hospitalization and are exposed to significant harm. Research to enable intervention development and process evaluation across the entire health system is lacking.

DESIGN

Novel mixed-method integrative review informed by health systems theory. DATA 

SOURCES

CINAHL, PsychInfo, EMBASE, PubMed, citation searching, personal contact. REVIEW 

METHODS

Informed by consultation with experts. English language studies, opinion/discussion papers reporting research, best practice and experiences of children, parents and healthcare professionals and purposively selected policies/guidelines from 2002-December 2012 were abstracted using Framework synthesis, followed by iterative theory development.

RESULTS

Seven critical factors derived from thirty-four sources across five health system levels explained successful discharge (new programme theory). All seven factors are required in an integrated care pathway, with a dynamic communication loop to facilitate effective discharge (new programme logic). Current health system responses were frequently static and critical success factors were commonly absent, thereby explaining ineffectual discharge.

CONCLUSION

The novel evidence-based model, which reconceptualizes 'discharge' as a highly complex longitudinal health system intervention, makes a significant contribution to global knowledge to drive practice development. Research is required to develop process and outcome measures at different time points in the discharge process and future trials are needed to determine the effectiveness of integrated health system discharge models.

Using clinical indicators to facilitate quality improvement via the accreditation process: an adaptive study into the control relationship

OBJECTIVE

The aim of the study was to determine accreditation surveyors' and hospitals' use and perceived usefulness of clinical indicator reports and the potential to establish the control relationship between the accreditation and reporting systems. The control relationship refers to instructional directives, arising from appropriately designed methods and efforts towards using clinical indicators, which provide a directed moderating, balancing and best outcome for the connected systems.

DESIGN

Web-based questionnaire survey.

SETTING

Australian Council on Healthcare Standards' (ACHS) accreditation and clinical indicator programmes.

RESULTS

Seventy-three of 306 surveyors responded. Half used the reports always/most of the time. Five key messages were revealed: (i) report use was related to availability before on-site investigation; (ii) report use was associated with the use of non-ACHS reports; (iii) a clinical indicator set's perceived usefulness was associated with its reporting volume across hospitals; (iv) simpler measures and visual summaries in reports were rated the most useful; (v) reports were deemed to be suitable for the quality and safety objectives of the key groups of interested parties (hospitals' senior executive and management officers, clinicians, quality managers and surveyors).

CONCLUSIONS

Implementing the control relationship between the reporting and accreditation systems is a promising expectation. Redesigning processes to ensure reports are available in pre-survey packages and refined education of surveyors and hospitals on how to better utilize the reports will support the relationship. Additional studies on the systems' theory-based model of the accreditation and reporting system are warranted to establish the control relationship, building integrated system-wide relationships with sustainable and improved outcomes.

Healthcare accreditation systems: further perspectives on performance measures

OBJECTIVE

The purpose of this paper is to identify and suggest a number of performance measures to facilitate the evaluation of accreditation programs in healthcare.

METHODS

The paper is based on an exploratory research which has used qualitative methods, including snowball sampling technique, email interview and thematic content analysis.

PARTICIPANTS

Respondents (experts and professionals) were selected from a diverse spectrum ranging from healthcare organizations, universities and accreditation-associated institutions.

RESULTS

The analysis of the data provided key measures to be considered in the evaluation of accreditation programs' impact at macro and micro levels as well as their nature and operations. The measures can be used to, for example, assess the degree of stakeholders' reliance on accreditation results, measure the cost of accreditation for participating organizations and serve as a formal mechanism for accredited organizations to appeal accreditation decisions.

CONCLUSIONS

This paper has brought together a number of generic, yet influential and workable, measures which could be utilized for assessing the overall performance of an accreditation program in healthcare. The application of these measures depends on the features of given accreditation program and the context in which the program operates. Therefore, the next step/steps in the assessment of an accreditation program might be choosing the measures suiting that program.