Bridging language barriers in developing valid health policy research tools: insights from the translation and validation process of the SHEMESH questionnaire

BACKGROUND

The use of research tools developed and validated in one cultural and linguistic context to another often faces challenges. One major challenge is poor performance of the tool in the new context. This potentially impact the legitimacy of health policy research conducted with informal adaptations of existing tools which have not been subjected to formal validation. Best practices exist to guide researchers in adapting and validating research tools effectively. We present here, as an extended example, our validation of the SHEMESH questionnaire ('Organizational Readiness to Change Assessment'; In Hebrew: 'SHE'elon Muchanut Ergunit le'SHinuy'), a Hebrew-language version of the Organizational Readiness to Change Assessment (ORCA). SHEMESH is tailored to support implementation science projects, whose aim is to promote a more rapid and complete adoption of evidence-based health policies and practices.

METHODS

The SHEMESH included originally eleven questions from the Evidence (item 1-4) and Context (items 5-11) domains. We validated SHEMESH through the following steps: 1. Professional translation to Hebrew and discussion of the translation by multidisciplinary committee; 2. Back-translation into English by a different translator to detect discrepancies; 3. Eleven cognitive interviews with psychiatric emergency department physicians and nurses; and 4. Pilot testing and psychometric analyses, including Cronbach's alpha for subscales and factor analyses.

RESULTS

Following translation and cognitive interviews, SHEMESH was administered to 222 psychiatrists and nurses. Pearson correlation showed significant and strong correlations of items 1-4 to the Evidence construct and items 6-11 to the Context construct. Item 5 did not correlate with the other items, and therefore was removed from the other psychometric procedures and eventually from the SHEMESH. Factor analysis with the remaining 10 items yielded two factors, which together explained a total of 69.7% of variance. Cronbach's Alpha scores for the two subscales were high (Evidence, 0.887, and Context, 0.852).

CONCLUSIONS

This multi-step validation process of the SHEMESH questionnaire may serve as a comprehensive guideline for others who are willing to adapt research tools that were developed in other languages. Practically, SHEMESH has been validated for use in implementation science research projects in Israel.

The district operation centres in one of the largest local health authorities in Italy to manage COVID-19 surveillance and homecare: first implementation and results of a survey addressed to general practitioners

BACKGROUND

COVID-19 pandemic represented a shock for healthcare systems. Italy was one of the first country to deal with a huge number of patients to be diagnosed, isolated, and treated with scarce evidence-based guidelines and resources. Several organizational and structural changes were needed to face the pandemic at local level. The article aims at studying the perceived impact of the newly implemented District Operation Centres (DOCs) of Local Health Authority (LHA) Roma 1 in managing active surveillance and home care of COVID-19 patients and their close contacts in cooperation with general practitioners (GPs).

METHODS

A questionnaire, developed according to Delphi methodology, was validated by 7 experts and administered to a randomized sample of GPs and family paediatricians (FPs). All medical doctors selected received a phone interview between December 2020 and January 2021. The questionnaire investigated general characteristics of the sample, relations with DOC and its usefulness, and potential developments. A descriptive analysis was performed and inferential statistical tests were used to assess differences.

RESULTS

In April 2020 the LHA Roma 1 implemented one DOCs in each local health district. 215 medical doctors were interviewed, reaching the sample target for health districts (80% CL and 10% MOE) and the whole LHA (90% CL and 5% MOE). Several aspects in the management of COVID-19 cases and close contacts of COVID-19 cases, and of the support of DOCs to GPs/FPs were investigated. More than 55% of the GPs and FPs interviewed found the DOCs useful and more than 78% would recommend a service DOC-like to other LHAs. The medical professionals interviewed would use DOCs in the future as support in treating vulnerable patients, utilizing digital health tools, enlisting specialist doctors, establishing networks, and facilitating professional counselling by nurses.

CONCLUSIONS

This study is an attempt to evaluate an organizational change happened during COVID-19 pandemic. DOCs were created to support GPs and FPs as a link between primary healthcare and public health. Although several difficulties were disclosed, DOCs' experience can help to overcome the fragmentation of the systems and the duality between primary care and public health and make the system more resilient.

Addressing anti-black racism in an academic preterm birth initiative: perspectives from a mixed methods case study

BACKGROUND

Growing recognition of racism perpetuated within academic institutions has given rise to anti-racism efforts in these settings. In June 2020, the university-based California Preterm Birth Initiative (PTBi) committed to an Anti-Racism Action Plan outlining an approach to address anti-Blackness. This case study assessed perspectives on PTBi's anti-racism efforts to support continued growth toward racial equity within the initiative.

METHODS

This mixed methods case study included an online survey with multiple choice and open-ended survey items (n = 27) and key informant interviews (n = 8) of leadership, faculty, staff, and trainees working within the initiative. Survey and interview questions focused on perspectives about individual and organizational anti-racism competencies, perceived areas of initiative success, and opportunities for improvement. Qualitative interview and survey data were coded and organized into common themes within assessment domains.

RESULTS

Most survey respondents reported they felt competent in all the assessed anti-racism skills, including foundational knowledge and responding to workplace racism. They also felt confident in PTBi's commitment to address anti-Blackness. Fewer respondents were clear on strategic plans, resources allocated, and how the anti-racism agenda was being implemented. Suggestions from both data sources included further operationalizing and communicating commitments, integrating an anti-racism lens across all activities, ensuring accountability including staffing and funding consistent with anti-racist approaches, persistence in hiring Black faculty, providing professional development and support for Black staff, and addressing unintentional interpersonal harms to Black individuals.

CONCLUSIONS

This case study contributes key lessons which move beyond individual-level and theoretical approaches towards transparency and accountability in academic institutions aiming to address anti-Black racism. Even with PTBi's strong commitment and efforts towards racial equity, these case study findings illustrate that actions must have sustained support by the broader institution and include leadership commitment, capacity-building via ongoing coaching and training, broad incorporation of anti-racism practices and procedures, continuous learning, and ongoing accountability for both short- and longer-term sustainable impact.

Impact of a specific consultation for patients with progressive forms of multiple sclerosis on the response to their unmet care needs: a cross-sectional study

BACKGROUND

As their disease evolves, most patients with progressive forms of multiple sclerosis (MS) develop particular healthcare needs that are not always addressed with usual follow-up. To adapt neurological care to these patients, we created a specific consultation for patients with progressive MS in our centre in 2019.

OBJECTIVES

To explore the main unmet care needs of patients with progressive MS in our setting, and to establish the usefulness of the specific consultation to address them.

METHODS

Literature review and interviews with patients and healthcare professionals were conducted to identify the main unmet needs in routine follow-up. Two questionnaires were developed, assessing the importance of the unmet needs identified and the usefulness of the consultation to meet them, for patients under follow-up in the specific consultation and their informal caregivers.

RESULTS

Forty-one patients and nineteen informal caregivers participated. The most important unmet needs were the information about the disease, access to social services and coordination between specialists. A positive correlation was found between the importance of these unmet needs and the responsiveness to each of them in the specific consultation.

CONCLUSIONS

The creation of a specific consultation may improve attention to the healthcare needs of patients with progressive MS.

Review of science and technology innovation policies in major innovative-oriented countries in response to the COVID-19 pandemic

Since the coronavirus disease 2019 (COVID-19) pandemic, major innovative-oriented countries have adopted various science and technology innovation (STI) policies to address global public health challenges. Using data from the Organization for Economic Co-operation and Development STI Database, this study analyzed international STI policies in response to the COVID-19 pandemic. The findings revealed that the pandemic has dramatically stimulated the application of STI policies, and there are commonalities and differences in the STI policies of different countries. Meanwhile, COVID-19 has disrupted planning for allocating resources for STIs, leading to duplication and inefficiency. Based on the findings, this study recommends increasing research investment to address the long-term challenges of major infectious diseases, strengthening support for enterprises, promoting data sharing and openness, enhancing the internationalization of scientific research, strengthening scientific consultation and communication, and devoting more policy attention to vulnerable groups.

Lean, agile, resilient, and green human resource management: the impact on organizational innovation and organizational performance

There are four paradigms of lean, agile, resilient, and green (LARG) which can promote human resource culture to create novel ideas and increase performance in organizations. This study aims to conceptualize, develop, and validate four lean, agile, resilient, and green paradigms in human resource management (HRM) context and investigates how different LARG HRM elements can affect organizational innovation and performance. In this way, a conceptual model for investigating the LARG concept in HRM is proposed. A new tool to measure lean, agile, resilient, and green indicators in service industry has been developed. Using convenience sampling method, an online survey questionnaire is managed to collect data from 102 service sector organizations, including banking and financial services, transportation, hotel, telecom, and insurance, having more than 50 employees in Iran. The collected data are analyzed by partial least squares-structural equation modeling (PLS-SEM). The results indicate that the LARG HRM significantly and positively influences organizational performance. In addition, the LARG HRM indirectly affects organizational performance through organizational innovation. The findings also showed that employee's ability to perform several different jobs from the lean paradigm, paying attention to employee's ideas in decision-making from the agile paradigm, increasing the ability of staff to change rules in different situations from the resilient paradigm, and having employees with a full understanding of environmental policies from the green paradigm, is the most effective elements among the LARG paradigms factors. This study provides valuable insights into recognizing the most effective LARG elements and factors for implementing the LARG HRM in organizations and how it contributes to enhancing organizational performance and organizational innovation in order to achieve competitive advantage.

European food banks and COVID-19: Resilience and innovation in times of crisis

This paper examines the impact of the COVID-19 crisis on the functioning of European food banks and how resilient European food banks were in coping with the pandemic in 2020. We apply a multiple case study to assess how the first year of the pandemic affected European food banks' operations and the amount of redistributed food. We further investigate innovation practices that have been developed to cope with the new situation, hoping to draw lessons for imminent future waves of the pandemic and other social crises. Our study finds that, compared to 2019, in 2020 food banks were able to redistribute a significantly higher amount of food despite numerous social restrictions and other challenges associated with the pandemic. To explain this, we delve into the organizational innovations implemented by the studied food banks and find that the introduction of new strategies and new internal structures, as well as the establishment of new types of external network relations with other firms and/or public organizations, proved to be particularly important, enabling food banks to respond quickly and effectively to the new emergency. The study thus highlights the role of food banks in food redistribution and food waste reduction in times of crisis.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

Background

COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia.

Methods

We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models.

Results

We identified and analyzed six organizational innovations. Four of these – centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics.

Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations.

Conclusion

COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08140-w.

A qualitative study of the adoption of Value Stream Mapping in breast cancer centers

PURPOSE

In order to design a patient-centered discharge process, the entire process is visualized in Value Stream Mapping. The duration of the process steps and waiting times are measured and presented. As a team, health professionals discuss problems and agree on suitable solutions.

METHODS

After applying Value Stream Mapping, we conducted eight interviews in 2018, four with physicians and four with breast care nurses. We used the Consolidated Framework for Implementation Research to develop the interview guide and to identify categories for content analysis. To identify the differences in attitude and experience between the occupational groups, we conducted a framework analysis.

RESULTS

Each team of health professionals developed action steps to optimize the discharge process. Obstacles became apparent in the implementation of these action steps. The lack of adequate staff and complex structures were identified as the main factors. These hierarchical structures also prevented a patient-centered discharge process independent of patient-centered care by health professionals. Self-efficacy varied more among breast care nurses than physicians. The group of physicians perceives standardization in the discharge process critically and therefore assumes limitations in transferring Value Stream Mapping to hospitals. The breast care nurses were open in their attitude. Financial incentives contribute to the acceptance of the method.

CONCLUSION

Value Stream Mapping is a simple way to uncover waste and develop applicable action steps. Since the implementation of the action steps was hindered by hierarchical problems and a lack of resources, management involvement and a hospital-wide approach could be beneficial.

A prognostic information system for real-time personalized care: Lessons for embedded researchers

Embedded researchers could play a central role in developing tools to personalize care using electronic medical records (EMRs). However, few studies have described the steps involved in developing such tools, or evaluated the key factors in success and failure. This case study describes how we used an EMR-derived data warehouse to develop a prototype informatics tool to help oncologists counsel patients with pancreatic cancer about their prognosis. The tool generated real-time prognostic information based on tumor type and stage, age, comorbidity status and lab tests. Our multidisciplinary team included embedded researchers, application developers, user experience experts, and an oncologist leader.This prototype succeeded in establishing proof of principle, but did not reach adoption into actual practice. In pilot testing, oncologists succeeded in generating prognostic information in real time. A few found it helpful in patient encounters, but all identified critical areas for further development before implementation. Generalizable lessons included the need to (1) include a wide range of potential use cases and stakeholders when selecting use cases for such tools; (2) develop talking points for clinicians to explain results from predictive tools to patients; (3) develop ways to reduce lag time between events and data availability; and (4) keep the options presented in the user interface very simple. This case demonstrates that embedded researchers can lead collaborations using EMR-derived data to create systems for real-time personalized patient counseling, and highlights challenges that such teams can anticipate.

Enhancing innovation speed through trust: a case study on reframing employee defensive routines

Trust in organizations plays an essential role for efficient innovation implementation. However, trust between managers and employees is under-communicated in relation to innovation speed. Innovation speed is related to innovation adoption, concerning new ways of performing laboratory services within the health sector. The purpose of this case study is to investigate how trust mechanisms may enhance innovation speed by reducing employee decisions to perform defensive routines. The focus is related to trust as a social condition for enhancing innovation acceptance in the context of management and organizing styles subject to the Norwegian Work Life Model. The study found that a lack of employee participation and involvement may result in emotional tension, a sense of uncertainty, disconnect, and various defensive mechanisms towards management and the innovation. Consequently, employees' attention, loyalty, and responsibility might be redirected away from the innovation.

Typology of organizational innovation components: building blocks to improve access to primary healthcare for vulnerable populations

BACKGROUND

Achieving equity of access to primary healthcare requires organizations to implement innovations tailored to the specific needs and abilities of vulnerable populations. However, designing pro-vulnerable innovations is challenging without knowledge of the range of possible innovations tailored to vulnerable populations' needs. To better support decision-makers, we aimed to develop a typology of pro-vulnerable organizational innovation components - akin to "building blocks" that could be combined in different ways into new complex innovations or added to existing organizational processes to improve access to primary healthcare.

METHODS

To develop the typology, we used data from a previously conducted a) scoping review (2000-2014, searched Medline, Embase, CINAHL, citation tracking, n = 90 articles selected), and b) environmental scan (2014, online survey via social networks, n = 240 innovations). We conducted a typological analysis of the data. Our initial typology yielded 48 components, classified according to accessibility dimensions from the Patient-Centred Accessibility Framework. The initial typology was then field-tested for relevance and usability by health system stakeholders and refined from 2014 to 2018 (e.g., combined similar components, excluded non-organizational components).

RESULTS

The selected articles (n = 90 studies) and survey responses (n = 240 innovations) were mostly from the USA, Canada, Australia and the UK. Innovations targeted populations with various vulnerabilities (e.g., low income, chronic illness, Indigenous, homeless, migrants, refugees, ethnic minorities, uninsured, marginalized groups, mental illness, etc.). Our final typology had 18 components of organizational innovations, which principally addressed Availability & Accommodation (7/18), Approachability (6/18), and Acceptability (3/18). Components included navigation & information, community health worker, one-stop-shop, case management, group visits, defraying costs, primary healthcare brokerage, etc. CONCLUSIONS: This typology offers a comprehensive menu of potential components that can help inform the design of pro-vulnerable organizational innovations. Component classification according to the accessibility dimensions of the Patient-Centred Accessibility Framework is useful to help target access needs. Components can be combined into complex innovations or added to existing organizational processes to meet the access needs of vulnerable populations in specific contexts.

Promises of artificial intelligence in neuroradiology: a systematic technographic review

PURPOSE

To conduct a systematic review of the possibilities of artificial intelligence (AI) in neuroradiology by performing an objective, systematic assessment of available applications. To analyse the potential impacts of AI applications on the work of neuroradiologists.

METHODS

We identified AI applications offered on the market during the period 2017-2019. We systematically collected and structured information in a relational database and coded for the characteristics of the applications, their functionalities for the radiology workflow and their potential impacts in terms of 'supporting', 'extending' and 'replacing' radiology tasks.

RESULTS

We identified 37 AI applications in the domain of neuroradiology from 27 vendors, together offering 111 functionalities. The majority of functionalities 'support' radiologists, especially for the detection and interpretation of image findings. The second-largest group of functionalities 'extends' the possibilities of radiologists by providing quantitative information about pathological findings. A small but noticeable portion of functionalities seek to 'replace' certain radiology tasks.

CONCLUSION

Artificial intelligence in neuroradiology is not only in the stage of development and testing but also available for clinical practice. The majority of functionalities support radiologists or extend their tasks. None of the applications can replace the entire radiology profession, but a few applications can do so for a limited set of tasks. Scientific validation of the AI products is more limited than the regulatory approval.

Civil Society and Social Mobilizations in the Context of the Rio Doce Socioenvironmental Disaster

To explain how social movements and organizations changed in the context of the Rio Doce, Brazil socioenvironmental disaster, this article identifies a process of organizational innovation. The research is based on documental data and interviews with activists over the 3 y of the disaster. The main argument is that organizational innovation consists of changes in organizational forms and repertoires of collective action, based on existing organizational models and tactics. On the one hand, the innovation occurred through the territorialization of novel organizational forms, intermediated by social movements that act as incubators. On the other hand, it consisted of the combination among extrainstitutional, institutional, and multiscalar repertoires and in the innovation in tactics and performances. Mechanisms of adaptation, imitation, and negotiated diffusion are identified which operated in this innovation process. It is argued that the organizational innovation of social movements was propelled by political constraints of disaster governance, which pushed them to innovation, in addition to the role of preexisting organizations. Integr Environ Assess Manag 2020;16:681-690. © 2020 SETAC.

Creating the conditions for change: an NHS perspective

PURPOSE

Improving early diagnosis of cancer through system change initiatives is endemic in England's NHS cancer services. These initiatives, however, often fail to gain traction due to the complexities of health system structures. The purpose of this paper is to explore whether using a change framework grounded in systems thinking could be of help to system leaders.

DESIGN/METHODOLOGY/APPROACH

A portfolio of geographically independent projects, all implementing cancer service changes as part of the Accelerate, Coordinate, Evaluate Programme, was used for the study. Eight projects were purposively selected to give a varied case-mix. Two semi-structured interviews were conducted with each project. Analysis of interviews was carried out using the Framework Method.

FINDINGS

Processes working for (growth processes) and against (limiting processes) change were evident in and common across all eight projects. Projects commonly encountered challenges of relevance, time and bounded thinking. Having a network of committed people was vital for both initiating and sustaining change. Furthermore, understanding stakeholders' emotional responses to change helped mitigate emergent challenges.

PRACTICAL IMPLICATIONS

Leaders should pay constant attention to the dynamics of change, taking time to anticipate and diffuse challenges whilst simultaneously working to create the conditions that help change flourish. A change framework rooted in complex systems theory can help leaders understand the contradictory and non-linear processes inherent in transformational change.

ORIGINALITY/VALUE

Few studies seek to understand change dynamics by comparing the experiences of separate change initiatives implemented contemporaneously. The findings offer leaders practical insights on how to implement transformation.

Organizational Factors and Quality Improvement Strategies Associated With Lower Radiation Dose From CT Examinations

PURPOSE

The aim of this study was to identify organizational factors and quality improvement strategies associated with lower radiation doses from abdominal CT.

METHODS

Cross-sectional survey was administered to radiology leaders, along with simultaneous measurement of CT radiation dose among 19 health care organizations with 100 imaging centers throughout the United States, Europe, and Japan, using a common dose management software system. After adjusting for patient age, gender, and size, quality improvement strategies were tested for association with mean abdominal CT radiation dose and the odds of a high-dose examination.

RESULTS

Completed surveys were received from 90 imaging centers (90%), and 182,415 abdominal CT scans were collected during the study period. Radiation doses varied considerably across organizations and centers. Univariate analyses identified eight strategies and systems that were significantly associated with lower average doses or lower frequency of high doses for abdominal CT examinations: tracking patient safety measures, assessing the impact of CT changes, identifying areas for improvement, setting specific goals, organizing improvement teams, tailoring decisions to sites, testing process changes before full implementation, and standardizing workflow. These processes were associated with an 18% to 37% reduction in high-dose examinations (P < .001-.03). In multivariate analysis, having a tracking system for patient safety measures, supportive radiology leaders, and obtaining clear images were associated with a 47% reduction in high-dose examinations.

CONCLUSIONS

This documentation of the relation between quality improvement strategies and radiation exposure from CT examinations has identified important information for others interested in reducing the radiation exposure of their patients.

Current status of integrating oncology and palliative care in Japan: a nationwide survey

BACKGROUND

Palliative care (PC) is increasingly recognized as essential for oncology care, and several academic societies strongly recommend integrating oncology and palliative care (IOP) in daily practice. Similarly, the Japanese government encouraged the implementation of IOP through the Cancer Control Act of 2007; however, its detailed progress remains unclear. Therefore, this cross-sectional nationwide survey was conducted to investigate the current status and hospital executive physicians' perception of IOP.

METHODS

The questionnaire was developed based on IOP indicators with international consensus. It was distributed to executive physicians at all government-designated cancer hospitals (DCHs, n = 399) and matched non-DCHs (n = 478) in November 2017 and the results were compared.

RESULTS

In total, 269 (67.4%) DCHs and 259 (54.2%) non-DCHs responded. The number of PC resources in DCHs was significantly higher than those in non-DCHs (e.g., full-time PC physicians and nurses, 52.8% vs. 14.0%, p < 0.001; availability of outpatient PC service ≥3 days per week, 47.6% vs. 20.7%, p < 0.001). Routine symptom screening was more frequently performed in DCHs than in non-DCHs (65.1% vs. 34.7%, p < 0.001). Automatic trigger for PC referral availability was limited (e.g., referral using time trigger, 14.9% vs. 15.3%, p = 0.700). Education and research opportunities were seriously limited in both types of hospitals. Most executive physicians regarded IOP as beneficial for their patients (95.9% vs. 94.7%, p = 0.163) and were willing to facilitate an early referral to PC services (54.7% vs. 60.0%, p < 0.569); however, the majority faced challenges to increase the number of full-time PC staff, and < 30% were planning to increase the staff members.

CONCLUSIONS

This survey highlighted a considerable number of IOP indicators met, particularly in DCHs probably due to the government policy. Further efforts are needed to address the serious research/educational gaps.

Implementation of pharmaceutical care for older adults in the brazilian public health system: a case study and realistic evaluation

BACKGROUND

Pharmaceutical care services have been recognized as the most highly regarded professional pharmacy practice model that allows the identification, intervention, and resolution of drug related problems. This practice provides significant clinical outcomes and can reduce direct and indirect costs for health systems. However, its implementation can be complex and challenging, needing study experiences that aims at overcoming obstacles, especially in free and universal healthcare systems. The objective of this study is to evaluate the implementation of Ambulatory Care Pharmacy services for older adults at Paulista Institute of Geriatrics and Gerontology (IPGG), which is recognized in the city of São Paulo for offering pharmaceutical care services for over 10 years continuously. This initiative and process is independent of external academic interventions or educational institutions. It is hoped that the results may also contribute to advancing the implementation of pharmaceutical care service in similar health systems.

DESIGN

This is a case study using multiple sources of data. Qualitative and quantitative data were collected from institutional documents, by participant observation and interviews. Initial themes were identified by content analysis and analyzed under the context-mechanism-outcome configurations (CMO Configurations) in realistic evaluation.

SETTING

Geriatrics and Gerontology Institute of São Paulo (known as IPGG).

PARTICIPANTS

Eleven health professionals and three pharmaceutical care service users.

RESULTS

Three CMO configurations were identified and accepted: "Scenario Construction mediated by educational processes", "Contribution to complex needs resolution", and "Organizational Visibility". The CMO (Context-Mechanism-Outcomes) configuration "Logistic activities discourage clinical pharmaceutical services implantation" was denied due to the influence of accepted CMOs.

CONCLUSIONS

Educational processes which value transdisciplinary knowledge exchanges provide resources required to overcome important obstacles present during pharmaceutical care implementation. Thus, providing and seeking knowledge to build and offer context-consistent clinical health services as well as fulfilling organizational environment requirements can be the key to implement pharmaceutical care service.

Partnering for change

Purpose

Despite many calls to strengthen connections between health systems and communities as a way to improve primary healthcare, little is known about how new collaborations can effectively alter service provision. The purpose of this paper is to explore how a health authority, municipal leaders and physicians worked together in the process of transforming primary healthcare.

Design/methodology/approach

A longitudinal qualitative case study was conducted to explore the processes of change at the regional level and within seven communities across Northern British Columbia (BC), Canada. Over three years, 239 interviews were conducted with physicians, municipal leaders, health authority clinicians and leaders and other health and social service providers. Interviews and contextual documents were analyzed and interpreted to articulate how ongoing transformation has occurred.

Findings

Four overall strategies with nine approaches were apparent. The strategies were partnering for innovation, keeping the focus on people in communities, taking advantage of opportunities for change and encouraging experimentation while managing risk. The strategies have bumped the existing system out of the status quo and are achieving transformation. Key components have been a commitment to a clear end-in-view, a focus on patients, families, and communities, and acting together over time.

Originality/value

This study illuminates how partnering for primary healthcare transformation is messy and complicated but can create a foundation for whole system change.

Dataset on organizational innovation and its determinants in the SMEs hotels

The aim of the study is to identify the factors that influence innovation activities associated with business management, known in the academic world as organizational innovation. Data was gathered by administering a survey on the managers or owners of hotels in the province of Santa Elena, Ecuador. Three components of organizational innovation were analyzed: methods of organizing job positions, work organization practices and management of external relations; all of which were tested with both internal variables (individual and structural characteristics) and variables external to the firms.

Early assessment of innovation in a healthcare setting

OBJECTIVES

Early assessment can assist in allocating resources for innovation effectively and produce the most beneficial technology for an institution. The aim of the present study was to identify methods and discuss the analytical approaches applied for the early assessment of innovation in a healthcare setting.

METHODS

Knowledge synthesis based on a structured search (using the MEDLINE, Embase, and Cochrane databases) and thematic analysis was conducted. An analytical framework based on the stage of innovation (developmental, introduction, or early diffusion) was applied to assess whether methods vary according to stage. Themes (type of innovation, study, analysis, study design, method, and main target audience) were then decided among the authors. Identified methods and analysis were discussed according to the innovation stage.

RESULTS

A total of 1,064 articles matched the search strategy. Overall, thirty-nine articles matched the inclusion criteria. The use of methods has a tendency to change according to the stage of innovation. Stakeholder analysis was a prominent method in the innovation stages and particularly in the developmental stage, as the introduction and early diffusion stage has more availability of data and may apply more complex methods. Barriers to the identified methods were also discussed as all of the innovation stages suffered from lack of data and substantial uncertainty.

CONCLUSIONS

Although this review has identified applicable approaches for early assessment in different innovation stages, research is required regarding the value of the available data and methods and tools to enhance interactions between different parties at different stages of innovation.

Beginning with high value care in mind: A scoping review and toolkit to support the content, delivery, measurement, and sustainment of high value care

OBJECTIVE

To create a shared vision for the content, delivery, measurement, and sustainment of patient-centered high value care.

METHODS

We performed a scoping review and translated findings into toolkit for system leaders. For our scoping review, we searched Medline, 2005-November 2015, for literature on patient-centered care (PCC) and its relationship to a high value care change model. We supplemented searches with key author, Google Scholar, and key website searches. One author reviewed all titles, abstracts, and articles for inclusion; another reviewed a random 20%. To develop our toolkit, we translated evidence into simple, actionable briefs on key topics and added resources. We then iteratively circulated briefs and the overall toolkit to potential users, making updates as needed.

RESULTS

In our scoping review, we found multiple interventions and measures to support the components of PCC and our change model. We found little on the overall effects of PCC or how PCC creates value. Potential users reported our toolkit was simple, understandable, thorough, timely, and likely to be globally useful.

CONCLUSIONS

Considerable evidence supports patient-centered high value care and a toolkit garnered enthusiasm.

PRACTICE IMPLICATIONS

The toolkit is ready for use, but needs comparison to other approaches.

[Effective implementation of the Quadruple Helix-Based Innovation Model for active ageing]

This paper shows an experience of the practical implementation of the Quadruple Helix-Based Innovation Model of Reference Sites of the European Commission through the Design Thinking method. This method establishes that, in order to successfully achieve the design of a digital solution, five unavoidable phases must be covered: empathize, define, ideate, prototype and test. The process was approached using the research action design. Qualitative data collection and analysis techniques were applied in each phase: qualitative meta-synthesis, focus groups, biographical interviews, professional and community forums and techniques of prototyping and testing with users. The systematic application of this method has facilitated the consolidation of a cooperative work model in which the main key agents in active and healthy ageing interact. Thus, products and services have been developed to better meet the needs of the users, making them an active part of the creation process.

What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study

PURPOSE

The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented.

DESIGN/METHODOLOGY/APPROACH

A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments.

FINDINGS

The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people.

RESEARCH LIMITATIONS/IMPLICATIONS

Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input.

PRACTICAL IMPLICATIONS

The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems.

ORIGINALITY/VALUE

This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience

Background

Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various ‘new models of care’, including general practice offering ‘additional availability’ appointments during evenings and at weekends. In Greater Manchester, six ‘demonstrator sites’ were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes.

Methods

Semi-structured interviews, with the data subjected to thematic analysis.

Results

Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants.

Conclusions

The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

Telemonitoring in-home complex chronic patients from primary care in routine clinical practice: Impact on healthcare resources use

Background: Recent evidence indicates that home telemonitoring of chronic patients reduces the use of healthcare resources. However, further studies exploring this issue are needed in primary care.

Objectives: To assess the impact of a primary care-based home telemonitoring intervention for highly unstable chronic patients on the use of healthcare resources.

Methods: A one-year follow-up before and after exploratory study, without control group, was conducted. Housebound patients with heart failure or chronic lung disease, with recurrent hospital admissions, were included. The intervention consisted of patient’s self-measurements and responses to a health status questionnaire, sent daily from smartphones to a web-platform (aided by an alert system) reviewed by healthcare professionals. The primary outcome measure was the number of hospital admissions occurring 12 months before and after the intervention. Secondary outcomes were length of hospital stay and number of emergency department attendances. Primary care nurses were mainly in charge of the telemonitoring process and were assisted by the general practitioners when required.

Results: For the 28 patients who completed the follow-up (out of 42 included, 13 patients died and 1 discontinued the intervention), a significant reduction in hospitalizations, from 2.6 admissions/patient in the previous year (standard deviation, SD: 1.6) to 1.1 (SD: 1.5) during the one-year telemonitoring follow-up (P <0.001), and emergency department attendances, from 4.2 (SD: 2.6) to 2.1 (SD: 2.6) (P <0.001) was observed. The length of hospital stay was reduced non-significantly from 11.4 to 7.9 days.

Conclusion: In this small exploratory study, the primary care-based telemonitoring intervention seemed to have a positive impact decreasing the number of hospital admissions and emergency department attendances.

Experiences of primary care physicians and staff following lean workflow redesign

BACKGROUND

In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members.

METHODS

The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses.

RESULTS

We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign.

CONCLUSIONS

Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.

Health system innovations: adapting to rapid change

This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries.

Care delivery and compensation system changes: a case study of organizational readiness within a large dental care practice organization in the United States

Background

Dental care delivery systems in the United States are consolidating and large practice organizations are becoming more common. At the same time, greater accountability for addressing disparities in access to care is being demanded when public funds are used to pay for care. As change occurs within these new practice structures, attempts to implement change in the delivery system may be hampered by failure to understand the organizational climate or fail to prepare employees to accommodate new goals or processes. Studies of organizational behavior within oral health care are sparse and have not addressed consolidation of current delivery systems. The objective of this case study was to assess organizational readiness for implementing change in a large dental care organization consisting of staff model clinics and affiliated dental practices and test associations of readiness with workforce characteristics and work environment.

Methods

A dental care organization implemented a multifaceted quality improvement program, called PREDICT, in which community-based mobile and clinic-based dental services were integrated and the team compensated based in part on meeting performance targets. Dental care providers and supporting staff members (N = 181) were surveyed before program implementation and organizational readiness for implementing change (ORIC) was assessed by two 5-point scales: change commitment and efficacy.

Results

Providers and staff demonstrated high organizational readiness for change. Median change commitment was 3.8 (Interquartile range [IQR]: 3.3-4.3) and change efficacy was 3.8 (IQR: 3.0-4.2). In the adjusted regression model, change commitment was associated with organizational climate, support for methods to arrest tooth decay and was inversely related to office chaos. Change efficacy was associated with organizational climate, support for the company’s mission and was inversely related to burnout. Each unit increase in the organizational climate scale predicted 0.45 and 0.8-unit increases in change commitment and change efficacy.

Conclusions

The survey identified positive readiness for change and highlighted weaknesses that are important cautions for this organization and others initiating change. Future studies will examine how organizational readiness to change, workforce characteristics and work environment influenced successful implementation within this organization.

Electronic supplementary material

The online version of this article (10.1186/s12903-017-0448-4) contains supplementary material, which is available to authorized users.

Implementing technology in healthcare: insights from physicians

BACKGROUND

Technology has significantly changed the way health organizations operate. However, the role it plays in healthcare systems remains unclear. This aim of this study was to evaluate the opinion of physicians regarding e-health and determine what factors influence their opinion and describe the advantages, inconveniences and threats they may perceive by its use.

METHODS

A cross-sectional questionnaire-based study. A questionnaire which had been previously designed and validated by the authors was used to interview physicians from the Barcelona Medical Association. 930 physicians were contacted by phone to participate in the study.

RESULTS

Seven hundred sixty physicians responded to the questionnaire (response rate: 82%). The usefulness of telemedicine scored 7.4 (SD 1.8) on a scale from 1-10 (from the lowest to the highest) and the importance of the Internet in the workplace was 8.2 points (SD 1.8). Therapeutic compliance (7.0 -SD 1.8-) and patient health (7.0 -SD 1.7-) showed the best scores, and there were differences between professionals who had and had not previously participated in a telemedicine project (p < 0.05). The multivariate regression model explained the 41% of the variance for 7 factors: participation in telemedicine project (p < 0.001), quality of clinical practice (p < 0.001), patient health (p < 0.001), professional workload (p = 0.005), ease-of-use of electronic device (p = 0.007), presence of incentives for telemedicine (p = 0.011) and patient preference for in-person visits (p = 0.05).

CONCLUSIONS

Physicians believe in the usefulness of e-health. Professionals with previous experience with it are more open to its implementation and consider that the benefits of technology outweigh its possible difficulties and shortcomings. Physicians demanded projects with appropriate funding and technology, as well as specific training to improve their technological abilities. The relationship of users with technology differs according to their personal or professional life. Although a 2.0 philosophy has been incorporated into many aspects of our lives, healthcare systems still have a long way to go in order to adapt to this new understanding of the relationship between patients and their health.

Pediatric eMental healthcare technologies: a systematic review of implementation foci in research studies, and government and organizational documents

Background

Researchers, healthcare planners, and policymakers convey a sense of urgency in using eMental healthcare technologies to improve pediatric mental healthcare availability and access. Yet, different stakeholders may focus on different aspects of implementation. We conducted a systematic review to identify implementation foci in research studies and government/organizational documents for eMental healthcare technologies for pediatric mental healthcare.

Methods

A search of eleven electronic databases and grey literature was conducted. We included research studies and documents from organization and government websites if the focus included eMental healthcare technology for children/adolescents (0–18 years), and implementation was studied and reported (research studies) or goals/recommendations regarding implementation were made (documents). We assessed study quality using the Mixed Methods Appraisal Tool and document quality using the Appraisal of Guidelines for Research & Evaluation II. Implementation information was grouped according to Proctor and colleagues’ implementation outcomes—acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability—and grouped separately for studies and documents.

Results

Twenty research studies and nine government/organizational documents met eligibility criteria. These articles represented implementation of eMental healthcare technologies in the USA (14 studies), United Kingdom (2 documents, 3 studies), Canada (2 documents, 1 study), Australia (4 documents, 1 study), New Zealand (1 study), and the Netherlands (1 document). The quality of research studies was excellent (n = 11), good (n = 6), and poor (n = 1). These eMental health studies focused on the acceptability (70%, n = 14) and appropriateness (50%, n = 10) of eMental healthcare technologies to users and mental healthcare professionals. The quality of government and organizational documents was high (n = 2), medium (n = 6), and low (n = 1). These documents focused on cost (100%, n = 9), penetration (89%, n = 8), feasibility (78%, n = 7), and sustainability (67%, n = 6) of implementing eMental healthcare technology.

Conclusion

To date, research studies have largely focused on acceptability and appropriateness, while government/organizational documents state goals and recommendations regarding costs, feasibility, and sustainability of eMental healthcare technologies. These differences suggest that the research evidence available for pediatric eMental healthcare technologies does not reflect the focus of governments and organizations. Partnerships between researchers, healthcare planners, and policymakers may help to align implementation research with policy development, decision-making, and funding foci.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-017-0608-6) contains supplementary material, which is available to authorized users.

Implementation of eMental Health care: viewpoints from key informants from organizations and agencies with eHealth mandates

Background

The use of technology such as computers, tablets, and smartphones to improve access to and the delivery of mental health care (eMental Health care) is growing worldwide. However, despite the rapidly expanding evidence base demonstrating the efficacy of eMental Health care, its implementation in clinical practice and health care systems remains fragmented. To date, no peer-reviewed, key-informant studies have reported on the perspectives of decision-makers concerned with whether and how to implement eMental Health care.

Methods

From September to November 2015, we conducted 31 interviews with key informants responsible for leadership, policy, research, and/ or information technology in organizations influential in the adoption of technology for eMental Health care. Deductive and inductive thematic analyses of transcripts were conducted using the Behavior Change Wheel as an organizing framework. Frequency and intensity effect sizes were calculated for emerging themes to further explore patterns within the data.

Results

Key informant responses (n = 31) representing 6 developed countries and multiple organizations showed consensus on common factors impacting implementation: individual and organizational capacities (e.g., computer literacy skills [patients and providers], knowledge gaps about cyber security, limited knowledge of available services); motivational drivers of technology-based care (e.g., extending care, data analytics); and opportunities for health systems to advance eMental Health care implementation (e.g., intersectoral research, rapid testing cycles, sustainable funding). Frequency effect sizes showed strong associations between implementation and credibility, knowledge, workflow, patient empowerment, electronic medical record (EMR) integration, sustained funding and intersectoral networks. Intensity effect sizes showed the highest concentration of statements (>10% of all comments) related to funding, credibility, knowledge gaps, and patient empowerment.

Conclusion

This study provides previously unavailable information about key informant perspectives on eMental Health care implementation. The themes that emerged, namely the need to intensify intersectoral research, measure/monitor readiness to implement, define cost-utility benchmarks, raise awareness about available technologies, and test assumptions that ‘proven’ technologies will be easily integrated can inform the design and evaluation of eMental Health care implementation models.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0474-9) contains supplementary material, which is available to authorized users.

IMPROVING THE EFFECTIVENESS AND EFFICIENCY OF EVIDENCE PRODUCTION FOR HEALTH TECHNOLOGY ASSESSMENT

Objectives: Health Technology Assessment (HTA) needs to address the challenges posed by high cost, effective technologies, expedited regulatory approaches, and the opportunities provided by collaborative real-world evaluation of technologies. The Health Technology Assessment International (HTAi) Policy Forum met to consider these issues and the implications for evidence production to inform HTA. This paper shares their discussion to stimulate further debate.

Methods: A background paper, presentations, group discussions, and stakeholder role play at the 2015 HTAi Policy Forum meeting informed this paper.

Results: HTA has an important role to play in helping improve evidence production and ensuring that the health service is ready to adopt effective technologies. It needs to move from simply informing health system decisions to also working actively to align stakeholder expectations about realistic evidence requirements. Processes to support dialogue over the health technology life cycle need to be developed that are mindful of limited resources, operate across jurisdictions and learn from past processes. Collaborations between health technology developers and health systems in different countries should be encouraged to develop evidence that will inform decision making. New analytical techniques emerging for real-world data should be harnessed to support modeling for HTA.

Conclusions: A paradigm shift (to “Health Innovation System 2.0”) is suggested where HTA adopts a more central, proactive role to support alignment within and amongst stakeholders over the whole life cycle of the technology. This could help ensure that evidence production is better aligned with patient and health system needs and so is more effective and efficient.

Use of a national collaborative to improve hospital quality in a low-income setting

Background

Quality improvement collaboratives are a widely used mechanism to improve hospital performance in high-income settings, but we lack evidence about their effectiveness in low-income settings.

Methods

We conducted cross-sectional and longitudinal analysis of data from the Ethiopian Hospital Alliance for Quality, a national collaborative sponsored by Ethiopia's Federal Ministry of Health. We identified hospital strategies associated with more positive patient satisfaction using linear regression and assessed changes in patient experience over a 3-year period (2012–2014) using matched t-tests.

Results

A total of 68 hospitals (response rate 68/120, 56.7%) were included in cross-sectional analysis. Four practices were significantly associated with more positive patient satisfaction (p<0.05): posting a record of cleaning activity in toilets and in patient wards, distributing leaflets in the local language with each prescription, and sharing ideas about patient experience across the hospital. Among hospitals that had complete data for longitudinal analysis (44/68, 65%), we found a 10% improvement in a 10-point measure of patient satisfaction (7.7 vs 8.4, p<0.01) from the start to the end of the study period.

Conclusions

Quality improvement collaboratives can be useful at scale in low-income settings in sub-Saharan Africa, particularly for hospitals that adopt strategies associated with patient satisfaction.

Out-of-hospital follow-up after low risk breast cancer within a care network: 14-year results

The delegation of low-risk breast cancer patients' follow-up to non-hospital practitionners (NHP), including gynaecologists and general practitioners, has been assessed prospectively within a care network in the Paris region. Patients with early stage breast cancer were eligible. The follow-up protocol was built according to international guidelines. By 2012, 289 NHPs were following 2266 patients treated in 11 centres. Median follow-up time was 7.4 years. The mean intervals between two consecutive consultations were 9.5 [9.2-9.8] months for women supposed to be monitored every 6 months and 12.5 [12.2-12.8] for those requiring annual monitoring. The relapse rate was 3.2% [2.1-4.3] at 5 years and 7.8% [5.9-9.7] at 10 years. Seventy one percent of relapses were diagnosed on a scheduled assessment. Only 6% were lost-to-follow-up. Delegating follow-up after low risk breast cancer to NHPs in a care network is feasible, well accepted and provides an alternative to follow-up in specialized centres.