The challenges of evaluating health systems networks: lessons learned from an early evaluation of the Child Health Network for the Greater Toronto Area

This article describes the first system-wide evaluation of the Child Health Network (CHN) for the Greater Toronto Area (GTA), a partnership of 29 community and hospital care providers. The CHN performance evaluation sought to identify the impact of the network on the delivery of maternal, newborn and child health services in the GTA. CHN members identified seven criteria to be evaluated (appropriate care, accessibility, effectiveness, satisfaction, integrated and coordinated care, accountability and affordability) and then collaborated in selecting measurable indicators for each criterion. Data were compiled from administrative data sets, or collected as needed. This undertaking succeeded in providing a comprehensive assessment of the network's performance, identification of strategies to improve outcomes and network sustainability, as well as practical information that will inform the important new field of network evaluation.

Relationship building for research: the Southern Saskatchewan/Urban Aboriginal Health Coalition

The Southern Saskatchewan/Urban Aboriginal Health Coalition is an interdisciplinary, intersectoral team of researchers and communities dedicated to exploring what 'culturally respectful' care means in Aboriginal communities. Although the purpose of the research project was to examine this concept in an effort to improve health care service delivery and education for health professions, the members of the Coalition realized early in the process that one of the primary factors related to the success of the project would be the building and sustaining of relationships. This paper describes a relational process that was used to initiate, facilitate, and support a research partnership with the Aboriginal communities. Through a community-based process, two communities and the Coalition used sharing circles and workshops as a method to create relationships and begin a discussion about what constitutes key elements of culturally respectful health care and education. These elements have not yet been determined as the Coalition and community members have focused on fostering relationships which have been critical to building the partnership with the Aboriginal communities.

Critical cultural perspectives and health care involving Aboriginal peoples

Despite a growing body of critical scholarship in nursing, the concept of culture continues to be applied in ways that diminish the significance of power relations and structural constraints on health and health care. In this paper, we take a critical look at how assumptions and ideas underpinning conceptualizations of culture and cultural sensitivity can influence nurses' perceptions of Aboriginal peoples and Aboriginal health. Drawing on examples from our research, we examine how popularized assumptions about culture can shape nurses' views of Aboriginal patients. These assumptions and perceptions require closer scrutiny because of their potential to influence nurses' practice with Aboriginal patients. Our specific aims are to: (a) consider some of the limitations of cultural sensitivity in relation to health care involving Aboriginal peoples; (b) explore how ideas about culture have the potential to become problematic in nursing practice with Aboriginal peoples; and (c) explore the relevance of a 'critical cultural approach' in extending our understanding of culture in relation to Aboriginal peoples' health. We discuss a critical cultural perspective as one way of broadening nurses' understandings about the complexities of culture and the many facets of culture that require critical consideration. In relation to Aboriginal health, this will require nurses to develop greater critical awareness of culture as a relational process, and as necessarily influenced by issues of racism, colonialism, historical circumstances, and the current political climate in which we live.

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme

BACKGROUND

Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited.

OBJECTIVE

To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP).

HYPOTHESIS

Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety.

DESIGN, SETTING AND PARTICIPANTS

Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia.

OUTCOME MEASURES

Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired.

RESULTS

No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training.

CONCLUSIONS

RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

Work performance among Australians with depression and anxiety disorders: a population level second order analysis

At a population level, little is known about how anxiety and depression impact on work performance. We investigated the first and second order correlates of work accomplishment and care taken at work among people with International Statistical Classification of Diseases and Related Health Problems, 10th Revision, affective and anxiety disorders in comparison to healthy community residents. Australian Bureau of Statistics multistage sampling strategies obtained a household sample of 37,580 working age individuals. A secondary analysis was conducted using multiple binary logistic regression. The first order correlates of work performance were the extent of employment restrictions, mental health status, age, sex, and whether or not treatment was received. At the second order level, the effects of mental health status on work performance depended on age, sex, and receiving treatment. The effect of employment restrictions on work performance depended on age and sex only.

One hundred years of telemedicine: does this new technology have a place in paediatrics?

100 years of telemedicine

Fetal Listing for Organ Transplantation in Canada

This article presents an ethical and legal examination of whether a fetus should be listed to receive a transplanted organ. To date, relatively little discussion of this question has found its way into either the clinical or ethics literature. This article is divided into four sections. The first section analyzes the most common reasons against fetal listing offered by the nonclinicians with whom the author spoke. The two reasons involve the legal concepts of rights and best interests. Pivotal ethical foundations of the Canadian health system are also discussed so as to help develop a compatible allocation process for Canadian transplant programs. The second section analyzes common concerns raised in the author's discussions with clinicians. The third section presents four cardiac transplant scenarios to illustrate how relevant and sequential criteria for deciding whether, and in what circumstances, an available heart can be defensibly allocated to a fetus. The last section summarizes the decision process that reflects the preceding sections' analysis. Recognizing that the four scenarios do not exhaust the likely situations wherein a fetus and an infant might qualify for the same organ, the article closes with a recommendation that it be considered a catalyst for further analysis.

Cancer Care Ontario and integrated cancer programs: portrait of a performance management system and lessons learned

PURPOSE

A performance management system has been implemented by Cancer Care Ontario (CCO). This system allows for the monitoring and management of 11 integrated cancer programs (ICPs) across the Province of Ontario. The system comprises of four elements: reporting frequency, reporting requirements, review meetings and accountability and continuous improvement activities. CCO and the ICPs have recently completed quarterly performance review exercises for the last two quarters of the fiscal year 2004-2005. The purpose of this paper is to address some of the key lessons learned.

DESIGN/METHODOLOGY/APPROACH

The paper provides an outline of the CCO performance management system.

FINDINGS

These lessons included: data must be valid and reliable; performance management requires commitments from both parties in the performance review exercises; streamlining performance reporting is beneficial; technology infrastructure which allows for cohesive management of data is vital for a sustainable performance management system; performance indicators need to stand up to scrutiny by both parties; and providing comparative data across the province is valuable. Critical success factors which would help to ensure a successful performance management system include: corporate engagement from various parts of an organization in the review exercises; desire to focus on performance improvement and avoidance of blaming; and strong data management systems.

PRACTICAL IMPLICATIONS

The performance management system is a practical and sustainable system that allows for performance improvement of cancer care services. It can be a vital tool to enhance accountability within the health care system.

ORIGINALITY/VALUE

The paper demonstrates that the performance management system supports accountability in the cancer care system for Ontario, and reflects the principles of the provincial governments commitment to continuous improvement of healthcare.

Knowledge transfer & exchange through social networks: building foundations for a community of practice within tobacco control

Background

Health services and population health innovations advance when knowledge transfer and exchange (KTE) occurs among researchers, practitioners, policy-makers and consumers using high-quality evidence. However, few KTE models have been evaluated in practice. Communities of practice (CoP) – voluntary, self-organizing, and focused groups of individuals and organizations – may provide one option. This paper outlines an approach to lay the foundation for a CoP within the area of Web-assisted tobacco interventions (WATI). The objectives of the study were to provide a data-driven foundation to inform decisions about organizing a CoP within the geographically diverse, multi-disciplinary WATI group using evaluation and social network methodologies.

Methods

A single-group design was employed using a survey of expectations, knowledge, and interpersonal WATI-related relationships administered prior to a meeting of the WATI group followed by a 3-week post-meeting Web survey to assess short-term impact on learning and networking outcomes.

Results

Twenty-three of 27 WATI attendees (85%) from diverse disciplinary and practice backgrounds completed the baseline survey, with 21 (91%) of those participants completing the three-week follow-up. Participants had modest expectations of the meeting at baseline. A social network map produced from the data illustrated a centralized, yet sparse network comprising of interdisciplinary teams with little trans-sectoral collaboration. Three-week follow-up survey results showed that participants had made new network connections and had actively engaged in KTE activities with WATI members outside their original network.

Conclusion

Data illustrating both the shape and size of the WATI network as well as member's interests and commitment to KTE, when shared and used to frame action steps, can positively influence the motivation to collaborate and create communities of practice. Guiding KTE planning through blending data and theory can create more informed transdisciplinary and trans-sectoral collaboration environments.

Medical workforce policy-making in Canada, 1993-2003: reconnecting the disconnected

The authors set out to review Canadian medical workforce policies for 1993 to 2003 and assess if data existed in the 1990s that could have reversed the policy decision to curtail the supply of physicians from Canada's medical schools just as Canada was about to experience a developing shortage. The authors reviewed existing descriptive data sources regarding Canadian physician workforce size and activity from 1986 to 2003, including the Canadian Medical Association workforce database. The review indicated that a significant loss of physicians to retirement was imminent. Physician workforce productivity had started to fall by the early 1990s. Emigration to the United States had risen above traditional levels in the early 1990s and remained higher into the late 1990s. Despite these existing findings, an integrated adjustment to physician workforce policies taken in 1993-94 only occurred after 1999. The authors recommend that policy makers and managers must monitor the numbers from existing sources. To optimize these sources, planned data tracking and linkages are essential. The period in question demonstrated major disconnects in coordinating implementation, wherein subject experts monitoring data trends were not adequately utilized by policy makers. Finally, in complex systems with regional differences, policy decisions based on normative data are insufficient.

Mental illness and employment discrimination

PURPOSE OF REVIEW

Work is a major determinant of mental health and a socially integrating force. To be excluded from the workforce creates material deprivation, erodes self-confidence, creates a sense of isolation and marginalization and is a key risk factor for mental disability. This review summarizes recent evidence pertaining to employment-related stigma and discrimination experienced by people with mental disabilities. A broad understanding of the stigmatization process is adopted, which includes cognitive, attitudinal, behavioural and structural disadvantages.

RECENT FINDINGS

Stigma is both a proximate and a distal cause of employment inequity for people with a mental disability who experience direct discrimination because of prejudicial attitudes from employers and workmates and indirect discrimination owing to historical patterns of disadvantage, structural disincentives against competitive employment and generalized policy neglect. Against this background, modern mental health rehabilitation models and legislative philosophies, which focus on citizenship rights and full social participation, are to be welcomed. Yet, recent findings demonstrate that the legislation remains vulnerable to the very prejudicial attitudes they are intended to abate.

SUMMARY

Research conducted during the past year continues to highlight multiple attitudinal and structural barriers that prevent people with mental disabilities from becoming active participants in the competitive labour market.

Just regionalisation: rehabilitating care for people with disabilities and chronic illnesses

BACKGROUND

Regionalised models of health care delivery have important implications for people with disabilities and chronic illnesses yet the ethical issues surrounding disability and regionalisation have not yet been explored. Although there is ethics-related research into disability and chronic illness, studies of regionalisation experiences, and research directed at improving health systems for these patient populations, to our knowledge these streams of research have not been brought together. Using the Canadian province of Ontario as a case study, we address this gap by examining the ethics of regionalisation and the implications for people with disabilities and chronic illnesses. The critical success factors we provide have broad applicability for guiding and/or evaluating new and existing regionalised health care strategies.

DISCUSSION

Ontario is in the process of implementing fourteen Local Health Integration Networks (LHINs). The implementation of the LHINs provides a rare opportunity to address systematically the unmet diverse care needs of people with disabilities and chronic illnesses. The core of this paper provides a series of composite case vignettes illustrating integration opportunities relevant to these populations, namely: (i) rehabilitation and services for people with disabilities; (ii) chronic illness and cancer care; (iii) senior's health; (iv) community support services; (v) children's health; (vi) health promotion; and (vii) mental health and addiction services. For each vignette, we interpret the governing principles developed by the LHINs - equitable access based on patient need, preserving patient choice, responsiveness to local population health needs, shared accountability and patient-centred care - and describe how they apply. We then offer critical success factors to guide the LHINs in upholding these principles in response to the needs of people with disabilities and chronic illnesses.

SUMMARY

This paper aims to bridge an important gap in the literature by examining the ethics of a new regionalisation strategy with a focus on the implications for people with disabilities and chronic illnesses across multiple sites of care. While Ontario is used as a case study to contextualize our discussion, the issues we identify, the ethical principles we apply, and the critical success factors we provide have broader applicability for guiding and evaluating the development of - or revisions to - a regionalised health care strategy.

The devil is in the details: trends in avoidable hospitalization rates by geography in British Columbia, 1990-2000

Background

Researchers and policy makers have focussed on the development of indicators to help monitor the success of regionalization, primary care reform and other health sector restructuring initiatives. Certain indicators are useful in examining issues of equity in service provision, especially among older populations, regardless of where they live. AHRs are used as an indicator of primary care system efficiency and thus reveal information about access to general practitioners. The purpose of this paper is to examine trends in avoidable hospitalization rates (AHRs) during a period of time characterized by several waves of health sector restructuring and regionalization in British Columbia. AHRs are examined in relation to non-avoidable and total hospitalization rates as well as by urban and rural geography across the province.

Methods

Analyses draw on linked administrative health data from the province of British Columbia for 1990 through 2000 for the population aged 50 and over. Joinpoint regression analyses and t-tests are used to detect and describe trends in the data.

Results

Generally speaking, non-avoidable hospitalizations constitute the vast majority of hospitalizations in a given year (i.e. around 95%) with AHRs constituting the remaining 5% of hospitalizations. Comparing rural areas and urban areas reveals that standardized rates of avoidable, non-avoidable and total hospitalizations are consistently higher in rural areas. Joinpoint regression results show significantly decreasing trends overall; lines are parallel in the case of avoidable hospitalizations, and lines are diverging for non-avoidable and total hospitalizations, with the gap between rural and urban areas being wider at the end of the time interval than at the beginning.

Conclusion

These data suggest that access to effective primary care in rural communities remains problematic in BC given that rural areas did not make any gains in AHRs relative to urban areas under recent health sector restructuring initiatives. It remains important to continue to monitor the discrepancy between them as a reflection of inequity in service provision. In addition, it is important to consider alternative explanations for the observed trends paying particular attention to the needs of rural and urban populations and the factors influencing local service provision.

Mental health and related disability among workers: a population-based study

BACKGROUND

In past decades, the nature of work has undergone significant changes including increased psychological demands and job instability. A stressful psychosocial work environment has been shown to have adverse effects on workers' mental and physical health. This goal of this study is to estimate the prevalence of psychiatric syndromes and related disability in a population-based sample of employed adults and investigate associations between psychiatric syndromes and related disability.

METHODS

A random-digit dial provincial wide mental health survey was conducted in Alberta, Canada (n = 5,383). The telephone interview included the Mini International Neuropsychiatric Interview (MINI) and the World Health Organization's Disability Assessment Schedule (WHO-DAS-II). In this analysis, participants who were currently employed were included (n = 4,149).

RESULTS

In this population, 6.2% had had at least one MINI-defined psychiatric diagnosis with clinically significant interference. Without consideration of the clinical interference criterion, the prevalence of psychiatric syndromes was higher (33.5%). Psychiatric syndromes were strongly associated with disability. A dose-response relationship between the number of diagnoses and disability was found.

CONCLUSIONS

Interventional strategies in the workplace should focus on mental disorders at both the clinical and sub-clinical levels.

Morbidity in expatriates--a prospective cohort study

BACKGROUND

Expatriates comprise an important, but rarely studied subset of international travellers. This study was performed to assess the incidence of health events in an expatriate group and to evaluate factors affecting this incidence.

METHODS

A cohort of 2020 Foreign and Commonwealth Office (FCO) staff and partners living abroad were followed-up over 1 year. The main outcome measure was incidence of illness or injury serious enough to require consultation with a doctor. Data collection was by means of a self-administered questionnaire. Poisson regression was used to estimate the rates of health events and to test for association between health events and a number of independent variables.

RESULTS

The incidence of health events was 21%. Trauma (incidence 5%), musculoskeletal disorders (incidence 4%) and infectious disease (incidence 3%) were the principal causes of morbidity. The incidence of psychological disorders was low (1%). Of significance, employees were at increased risk of morbidity when compared to partners, with a higher incidence of health events [incidence rate ratio (IRR) 1.4, 95% CI 1.1-1.9] and psychological disorders (IRR 5.9, 95% CI 1.0-34.1). Moreover, unaccompanied employees were at increased risk of health events (IRR 1.3, 95% CI 1.0-1.7), and of traumatic injury (IRR 2.3, 95% CI 1.3-4.3) when compared to accompanied employees.

CONCLUSION

While the morbidity in FCO personnel is low in comparison to other expatriate groups, the higher risk of morbidity in employees and unaccompanied individuals merits further research, particularly to ascertain whether work demands, isolation or risk-taking behaviour are contributory factors.

Health promotion for frail older home care clients

AIM

This paper reports a study evaluating the comparative effects and costs of a proactive nursing health promotion intervention in addition to usual home care for older people compared with usual home care services alone.

BACKGROUND

An ageing population, budget constraints and technological advances in many countries have increased the pressure on home care resources. The result is a shift in nursing services from health promotion to meet the more pressing need for postacute care. For frail older people with long-term needs, these changes combine to create a fragmented system of health service delivery, characterized by providing nursing on demand rather than proactively.

METHODS

A two-armed, single-blind, randomized controlled trial was carried out with older people > or =75 years and eligible for personal support services through a home care programme in Ontario, Canada. Participants were randomly allocated either to usual home care (control) or to a nursing (experimental) group. In addition to usual home care, the nursing group received a health assessment combined with regular home visits or telephone contacts, health education about management of illness, coordination of community services, and use of empowerment strategies to enhance independence. The data were collected in 2001-2002.

RESULTS

Of the 288 older people who were randomly allocated at baseline, 242 (84%) completed the study (120 nursing group; 122 control group). Proactively providing older people with nursing health promotion, compared with providing nursing services on-demand, resulted in better mental health functioning (P = 0.009), a reduction in depression (P = 0.009), and enhanced perceptions of social support (P = 0.009) at no additional cost from a societal perspective.

CONCLUSIONS

Home based nursing health promotion, proactively provided to frail older people with chronic health needs, enhances quality of life while not increasing the overall costs of health care. The results underscore the need to re-invest in nursing services for health promotion for older clients receiving home care.

A critical policy analysis of an emerging agenda for home care in one Canadian province

Amidst projections of the increased care demands and expectations for home care, policy in this area demands urgent attention. Home care is inherently complex as it challenges us to deliberate fundamental issues of responsibility for care, and the limits of care for people in their most immediate contexts and needs. This research takes the form of a critical policy analysis of the interaction of the context, process and content of policy proposals in home care in a regional health system in one Canadian province. The method of study includes thematic and comparative analyses of perspectives derived from policy documents, and interviews with policy actors (decision-makers, healthcare providers, public advocates) regarding their perspectives of policy problems and processes. The content and process of policy in home care interact in important ways with political, economic, social and historical contexts. This critical analysis revealed that the emerging policy agenda in regional home care is one of medicalisation, which stands in contrast to the principles of primary health care, and potentially leads to further marginalisation of the most vulnerable. This contrast is characterised by tensions between the fundamental values of equity and efficiency, choice and universality, and public vis-à-vis individual responsibility for the provision of care.

Applying Evidence-Based Medicine to Traditional Chinese Medicine: Debate and Strategy

Drawing on recent paper published literature in both English and Chinese, this explores reactions to the evaluation of Chinese medicine using randomized controlled trials (RCTs) and the standards of evidence-based medicine (EBM). The literature review revealed a few sources which contend that Chinese medicine should not be evaluated on the basis of RCTs, but a far greater number which advocate for applying RCT and EBM standards to Chinese medicine. This paper describes the position of the detractors and points out ways in which their arguments contain oversimplified representations of Chinese medicine, biomedicine, EBM, and RCTs. In describing the position of the proponents, the analysis outlines some of the numerous innovative techniques they are developing for dealing with issues of control and standardization in efficacy research. Overall, the analysis indicates that important refinements are being generated in Chinese medicine research and clinical trial design in response to the challenges posed by the forced encounter of these two paradigms.

Policy conflicts: gene patents and health care in Canada

Several recent gene patent controversies have energized and refocused the human gene patent debate in Canada. These include the use of the Myriad test for breast cancer by the provinces, patenting of the Severe Acute Respiratory Syndrome virus and a recent Supreme Court decision rejecting the patenting of 'higher life forms'. These cases place the emerging policy conflicts between the innovation and commercialization agenda of the government and the desire to provide equitable access to health care in sharp focus. Another challenge faced by Canada is the powerful influence of the United States in policy decisions. Although these issues have raised awareness about the possibility of reforming the patent system, Parliament has yet to consider any of the suggested reforms of the Canadian patent system and there are no formal proposals pending.

Integrating Swedish massage therapy with primary health care initiatives as part of a holistic nursing approach

Nursing has long embraced a holistic approach to health care. Providing such an approach is also a goal embodied within many complementary therapy (CT) practices, such as Swedish massage therapy (SMT). Primary health care (PHC) reform initiatives as well often support a holistic approach to patient/client management. Presently, amongst the practices of nursing, a potential synergy between CTs and PHC domains has not as yet been adequately explored within the humanities and social/scientific literature. The purpose of this review is to address the potential of such a collaboration, as made feasible by incorporating an integrative medicine approach to enhance comprehensiveness of care, and in turn, holistic nursing.

Error or “act of God”? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure

BACKGROUND

Calls abound for a culture change in health care to improve patient safety. However, effective change cannot proceed without a clear understanding of perceptions and beliefs about error. In this study, we describe and compare operative team members' and patients' perceptions of error, reporting of error, and disclosure of error.

METHODS

Thirty-nine interviews of team members (9 surgeons, 9 nurses, 10 anesthesiologists) and patients (11) were conducted at 2 teaching hospitals using 4 scenarios as prompts. Transcribed responses to open questions were analyzed by 2 researchers for recurrent themes using the grounded-theory method. Yes/no answers were compared across groups using chi-square analyses.

RESULTS

Team members and patients agreed on what constitutes an error. Deviation from standards and negative outcome were emphasized as definitive features. Patients and nurse professionals differed significantly in their perception of whether errors should be reported. Nurses were willing to report only events within their disciplinary scope of practice. Although most patients strongly advocated full disclosure of errors (what happened and how), team members preferred to disclose only what happened. When patients did support partial disclosure, their rationales varied from that of team members.

CONCLUSIONS

Both operative teams and patients define error in terms of breaking the rules and the concept of "no harm no foul." These concepts pose challenges for treating errors as system failures. A strong culture of individualism pervades nurses' perception of error reporting, suggesting that interventions are needed to foster collective responsibility and a constructive approach to error identification.

Breast Cancer in Limited-Resource Countries: Health Care Systems and Public Policy

As the largest cancer killer of women around the globe, breast cancer adversely impacts countries at all levels of economic development. Despite major advances in the early detection, diagnosis, and treatment of breast cancer, health care ministries face multitiered challenges to create and support health care programs that can improve breast cancer outcomes. In addition to the financial and organizational problems inherent in any health care system, breast health programs are hindered by a lack of recognition of cancer as a public health priority, trained health care personnel shortages and migration, public and health care provider educational deficits, and social barriers that impede patient entry into early detection and cancer treatment programs. No perfect health care system exists, even in the wealthiest countries. Based on inevitable economic and practical constraints, all health care systems are compelled to make trade-offs among four factors: access to care, scope of service, quality of care, and cost containment. Given these trade-offs, guidelines can define stratified approaches by which economically realistic incremental improvements can be sequentially implemented within the context of resource constraints to improve breast health care. Disease-specific "vertical" programs warrant "horizontal" integration with existing health care systems in limited-resource countries. The Breast Health Global Initiative (BHGI) Health Care Systems and Public Policy Panel defined a stratified framework outlining recommended breast health care interventions for each of four incremental levels of resources (basic, limited, enhanced, and maximal). Reallocation of existing resources and integration of a breast health care program with existing programs and infrastructure can potentially improve outcomes in a cost-sensitive manner. This adaptable framework can be used as a tool by policymakers for program planning and research design to make best use of available resources to improve breast health care in a given limited-resource setting.

Long-term care in the St. John's region: impact of single entry and prediction of bed need

In 1996, the St. John's region had a population of 8,435 > or = 75 years, with 996 nursing home (NH) beds and 550 supervised care (SC) beds. A single entry system to these institutions was implemented in 1995. To determine the impact of the single entry system, the demographic and clinical characteristics of NH residents were assessed in 1997 (N = 1,044) and in 2003 (N = 963). To determine the efficiency of placement and the need for long-term care beds, two incident cohorts requesting placement were studied in 1995/96 (N = 467) and in 1999/2000 (N = 464). Degree of disability was determined using the Residents Utilization Groups III classification (RUG-III) and the Alberta Resident Classification Score (ARCS), and time to placement and to death was measured. In prevalent NH residents, the percentage without RUGS-III disability decreased from 18.5% in 1997 and to 9.9% in 2003. The proportion recommended for NH was 75% in 1995/96 and 72% in 1999/2000, despite the fact that the proportion with RUGS-III disability was 64% in both periods. Using a decision tree, optimal placement for the 1999/2000 cohort was 36% to SC, 20% to SC for the cognitively impaired, and 44% to NH. Predicted need for long-term care beds in 2004 matched poorly with current provision of NH and SC beds, and the mismatch will be worse in 2014. It was concluded that the single entry system was associated with improved appropriateness of NH bed utilization. However, there was a mismatch in need for and provision of institutional long-term care. Investment in the reconfiguration of long-term care beds by case mix and by geography is necessary.

Labour force activity by people with depression and anxiety disorders: a population-level second-order analysis

OBJECTIVE

To identify the population-level first- and second-order effects among candidate correlates of labour force activity by people with ICD-10 depression and anxiety disorders.

METHOD

Australian Bureau of Statistics multistage sampling strategies obtained a household sample of 37,580 individuals. Analyses were conducted using multiple binary logistic regression.

RESULTS

The impact of depression and anxiety on labour force activity depended on the extent of employment restrictions, age and country of birth. Background second-order effects help explain labour force participation and employment in the wider and predominantly healthy community. A significantly greater proportion of those receiving mental health treatment for anxiety and depression were not in the labour force.

CONCLUSION

These second-order effects reveal the substantial impact of depression and anxiety disorders on labour force activity across the working life. Those with more severe employment restrictions appear to need more intensive and continuous forms of assistance.

International nursing leadership related to the drugs phenomenon: a case study of the partnership experience between the Inter-American Drug Abuse Control Commission (CICAD) and the University of Alberta - Faculty of Nursing

In this article, the authors discuss the value of international health in advancing the nursing profession through the development of strong leadership in the area of drug demand reduction. Paradigms for nursing leadership are briefly reviewed and linked to the development of the "International Nursing Leadership Institutes" organized by the Inter-American Commission for the Control of Drug Abuse (CICAD). The "International Nursing Leadership Institutes" have facilitated the implementation of Phase III of the CICAD Schools of Nursing Project: a) planning and implementing the first "International Research Capacity-Building Program for Nurses to Study the Drug Phenomenon in Latin America", b) development of Regional and National Strategic Plans for Nursing Professionals in the Area of Demand Reduction in Latin America, and c) preparation of a document that provides guidelines on how to include drug content into undergraduate and graduate nursing curricula. The article also brings reflections directly from several of the participants in the first International Research Capacity-Building Program for Nurses to Study the Drug Phenomenon in the Americas, offered in collaboration with the Faculty of Nursing at the University of Alberta in Edmonton, Canada. These reflections demonstrate the multiplicity of ways in which this capacity-building program has made it easier for these members of Latin American Schools of Nursing to show leadership in the area of drug demand reduction.

Providing integrated mental health services: a policy and management perspective

OBJECTIVE

To review the challenge of providing integrated mental health services from a policy and health management perspective.

CONCLUSIONS

The provision of integrated mental health services involving specialist mental health services, general practitioners, psychiatric disability and rehabilitation services and public community health services is a major challenge in the Australian health care context and is increasingly an expectation of the community. Government, Divisions of General Practice and public community health policy and many Government, State and local initiatives have attempted to address this challenge. However, much remains to be done, including culture change within services and professions and the development of technology to support integrated service provision.

Consumer involvement in Quality Use of Medicines (QUM) projects - lessons from Australia

Background

It is essential that knowledge gained through health services research is collated and made available for evaluation, for policy purposes and to enable collaboration between people working in similar areas (capacity building). The Australian Quality Use of Medicine (QUM) on-line, web-based project database, known as the QUMmap, was designed to meet these needs for a specific sub-section of health services research related to improving the use of medicines. Australia's National Strategy for Quality Use of Medicines identifies the primacy of consumers as a major principle for quality use of medicines, and aims to support consumer led research. The aim of this study was to determine how consumers as a group have been represented in QUM projects in Australia. A secondary aim was to investigate how the projects with consumer involvement fit into Australia's QUM policy framework.

Method

Using the web-based QUMmap, all projects which claimed consumer involvement were identified and stratified into four categories, projects undertaken by; (a) consumers for consumers, (b) health professionals for consumers, (c) health professionals for health professionals, and (d) other. Projects in the first two categories were then classified according to the policy 'building blocks' considered necessary to achieve QUM.

Results

Of the 143 'consumer' projects identified, the majority stated to be 'for consumers' were either actually by health professionals for health professionals (c) or by health professionals for consumers (b) (47% and 40% respectively). Only 12 projects (9%) were directly undertaken by consumers or consumer groups for consumers (a). The majority of the health professionals for consumers (b) projects were directed at the provision of services and interventions, but were not focusing on the education, training or skill development of consumers.

Conclusion

Health services research relating to QUM is active in Australia and the projects are collated and searchable on the web-based interactive QUMmap. Healthcare professionals appear to be dominating nominally 'consumer focussed' research, with less than half of these projects actively involving the consumers or directly benefiting consumers. The QUMmap provides a valuable tool for policy analysis and for provision of future directions through identification of QUM initiatives.

Experience With Providing Drugs for Seniors in Canada

The provincial and territorial governments in Canada are responsible for the provision of health care to all Canadians and, as part of this mandate, they provide drug coverage to all hospitalized patients regardless of age, and to seniors and patients with certain diagnoses, dependent on some forms of means testing. The federal government is responsible for regulation and setting standards for health care. It provides financial subsidies to the provincial programs as well as direct funding for specific groups of individuals. This article reviews the roles of each level of government in the provision of pharmaceuticals to seniors in Canada.

Experiences of workplace bullying in a rural area

Employed people spend most of their waking hours in workplaces, but sometimes workplaces are made unbearable by bullying. This study examined how 21 people experienced workplace bullying in a rural and small city context and explored strategies for stopping workplace abuse. The research method of the learning circle was used because of its potential to reduce the isolation typically experienced by targets of workplace bullying, and its potential for peer dialogue and learning. This paper focuses on signs and experiences of workplace bullying, a phenomenon which produces both physical and emotional symptoms and often requires counseling.

An international comparison of information in adverse events

PURPOSE

Aims to describe the growing importance of information and its governance within public services. The paper starts by considering how scandals in three national public health systems have focused public attention on information issues. It describes a theoretical framework for improving information governance, and its practical implementation as a management tool. The paper concludes with a discussion of the benefits of the approach, and the consequences of not improving information governance.

DESIGN/METHODOLOGY/APPROACH

The framework brings together a number of existing methodological approaches, principally the maturity model approach to process improvement, first described in the Software Engineering Institute's capability maturity model, and the novice-to-expert approach to competency.

FINDINGS

The paper describes how these approaches can be synthesised into an integrated framework to manage organisational change and how that can be used to improve information governance within public sector organisations.

RESEARCH IMPLICATIONS

The paper compares the framework and its practical implementation with existing solutions, arguing that existing solutions provide only partial solutions.

ORIGINALITY/VALUE

Considers how plans for future service improvements will be restricted unless information governance issues can be addressed.

The Common Drug Review: a NICE start for Canada?

Prescription drugs are one of the fastest growing cost components of modern health care systems. Efforts to control escalating costs while simultaneously maximizing population health outcomes have led many countries to implement restrictive criteria on the funding of certain drugs. While drugs are licensed for sale based on evidence of safety and efficacy versus a placebo, many funders now require evidence of clinical- and cost-effectiveness compared to existing drugs as part of their reimbursement criteria. In some countries, concerns about duplication of drug assessment and administrative effort across different jurisdictions have led to experimentation with various forms of centralized drug review processes. Centralized drug reviews strive to standardize, inform, and improve drug reimbursement decisions through critical assessments of comparative clinical- and cost-effectiveness. The ultimate objective is to inform formulary listing decisions that both maximize health outcomes and achieve good "value for money". This paper describes the Common Drug Review (CDR), a uniquely Canadian version of a centralized drug review process, and compares it with the much-studied National Institute for Health and Clinical Excellence (NICE) in the United Kingdom. Through this analysis, which draws on prior critiques and experiences of NICE, we highlight several critical issues for pharmaceutical priority setting that must be considered in the operation and appraisal of centralized drug review processes. These include the selection of drugs for review, centralized versus decentralized decision-making, receptor capacity at local decision making levels, and public participation.

Teorizando sobre sistemas: uma tarefa ecológica para as pesquisas na área de segurança do paciente

Com o movimento global atual sobre segurança na área da saúde, pesquisadores tem chamado a atenção para o referencial da abordagem do sistema como um meio de melhorar a segurança dos ambientes e pacientes. Entretanto, quais tipos de teorias do sistema devem guiar as pesquisas sobre a segurança de pacientes? Nesse artigo, argumenta-se que enfermeiros e outros profissionais podem usar as teorias e princípios da restauração ecológica, ou seja da reparação de ecossistemas danificados, para estudar e fortalecer a segurança de ambientes. Usando a ciência da restauração para teorizar sobre sistemas de saúde, serão desenvolvidas habilidades para pensar ecologicamente sobre nossas relações com o outro e com os ambientes que dividimos, entre eles o ambiente hospitalar. A aplicação do conhecimento da ciência da restauração em conjunto ao da enfermagem e área da saúde, pode fortalecer a criação de sistemas seguros para todos a custos adequados.

Promoting mental well-being in the workplace: a European policy perspective

The nature of the workplace continues to change as Europe adapts to the challenges of competing in a global marketplace. Across the European Union there is a trend of increasing absenteeism and early retirement due to mental health problems, particularly stress and depression. The social and economic costs of lost productivity in Europe are substantial. Moreover, the sustainability of social protection systems may be challenged further by increases in the levels of disability benefits paid to people who have left work on grounds of poor mental health. Yet despite these significant consequences, at both national and pan-European levels, decision-makers have been slow to recognise the importance of promoting mental health within the workplace, although recently there have been some positive developments. This paper outlines some of the socio-economic arguments for the promotion of good mental well-being in the labour force and identifies how they link with different national and European policy agendas around four key issues: economic growth and development, the promotion of a high level of public health, sustainability of social welfare systems and social inclusion. The role and activities to promote mental well-being in the workplace undertaken by both national and international organizations in Europe are outlined along with important gaps and challenges that need to be addressed.

Prescription drug benefits and Canada's uninsured

The Canada Health Act provides a framework for the Canadian health system and a mechanism for federal healthcare funds to flow to the provinces. Presently, the Canada Health Act covers medically necessary hospital, physician and surgical-dental as well as limited long-term care services, but not prescription medication. Though not mandated, each province has chosen to also develop a prescription drug benefit plan. These plans differ with respect to the groups that are covered and the type of coverage provided. In this paper, we describe the key structural elements of the various provincial plans. In addition, using a population-based national health and mental healthcare survey of 33,000 Canadians, we explore the characteristics of the population currently not covered by prescription drug benefits. Finally, we look at a sub-population of Canadians with mental illness with regard to their insurance coverage and use of prescription drugs. Our findings suggest that drug coverage within provinces is working for individuals with chronic physical conditions only. The findings herein reaffirm the need for a national strategy, support the notion that prescription drug coverage is important, and raise questions about the role of employers in providing these benefits.

Flexible client-driven in-home case management: an option to consider

Changes in health services and care needs have created high demand for case management of in-home services. To address this challenge, several models of case management have been used. Evaluations to date suggest that clients need different approaches for different circumstances at different times to optimize cost-effectiveness. Accordingly, one Canadian home care program adopted flexible client-driven case management engaging clients as partners in flexibly selecting either an integrated team, consumer-managed or brokerage model of case management in keeping with their preferences and abilities. Using an exploratory, multimeasure quasi-experimental design, a generic model of program evaluation, and both quantitative and qualitative methods, researchers identified challenges in implementing this intervention, policy impediments the clients characteristically in each of the three case management models, and client, provider, and caregiver outcomes of flexible, client-driven care. While further longitudinal investigation is needed findings suggest several important considerations for those interested in this option for care management. Alternative case management models do attract different client groups, and having a choice does not alter care costs or outcomes. Flexible client-driven case management may be experienced positively by case managers and other providers.

CAM in Canada: places, practices, research

This paper reflects on the practice and research of complementary and alternative medicine (CAM) in Canada. Although certain trends in use, as well as the regulation and integration of CAM, are mirrored in many other developed countries, some are highlighted as uniquely Canadian with distinct political and economic geographies. Similarly, although like in other countries the research of CAM is growing rapidly, Canadian scholars have been particularly productive in terms of providing unique disciplinary perspectives and the ways in which they have organized their research training and collaborations. CAM is clearly not a fully integrated and researched option in Canadian health care, yet Canada exhibits the foundations for an integrated CAM practice, supported by a growing, wide-ranging and well-articulated research evidence-base.

Evaluating the Effectiveness of Community-Based Dementia Care Networks: The Dementia Care Networks' Study

PURPOSE

The Dementia Care Networks' Study examined the effectiveness of four community-based, not-for-profit dementia networks. The study involved assessing the relationship between the types of administrative and service-delivery exchanges that occurred among the networked agencies and the network members' perception of the effectiveness of these exchanges.

DESIGN AND METHODS

With the use of a case-study method, the evolution, structure, and processes of each network were documented. Social network analysis using a standardized questionnaire completed by member agencies identified patterns of administrative and clinical exchanges among networked agencies.

RESULTS

Differences were found between the four networks in terms of their perceptions of service-delivery effectiveness; perceptions of administrative effectiveness did not factor significantly. Exchanges between groups of agencies (cliques) within each of the four networks were found to be more critical than those between individual agencies within each network.

IMPLICATIONS

Integration-measured by the types of exchanges within as opposed to across networks-differentiated the four networks studied. This research contributes to our understanding of the use of multiple measures to evaluate the inner workings of service delivery and their impact on elder health and elder health care.

An educational intervention to enhance nurse leaders' perceptions of patient safety culture

OBJECTIVE

To design a training intervention and then test its effect on nurse leaders' perceptions of patient safety culture.

STUDY SETTING

Three hundred and fifty-six nurses in clinical leadership roles (nurse managers and educators/CNSs) in two Canadian multi-site teaching hospitals (study and control).

STUDY DESIGN

A prospective evaluation of a patient safety training intervention using a quasi-experimental untreated control group design with pretest and posttest. Nurses in clinical leadership roles in the study group were invited to participate in two patient safety workshops over a 6-month period. Individuals in the study and control groups completed surveys measuring patient safety culture and leadership for improvement prior to training and 4 months following the second workshop.

EXTRACTION METHODS

Individual nurse clinical leaders were the unit of analysis. Exploratory factor analysis of the safety culture items was conducted; repeated-measures analysis of variance and paired t-tests were used to evaluate the effect of the training intervention on perceived safety culture (three factors). Hierarchical regression analyses looked at the influence of demographics, leadership for improvement, and the training intervention on nurse leaders' perceptions of safety culture.

PRINCIPAL FINDINGS

A statistically significant improvement in one of three safety culture measures was shown for the study group (p<.001) and a significant decline was seen on one of the safety culture measures for the control group (p<.05). Leadership support for improvement was found to explain significant amounts of variance in all three patient safety culture measures; workshop attendance explained significant amounts of variance in one of the three safety culture measures. The total R(2) for the three full hierarchical regression models ranged from 0.338 and 0.554.

CONCLUSIONS

Sensitively delivered training initiatives for nurse leaders can help to foster a safety culture. Organizational leadership support for improvement is, however, also critical for fostering a culture of safety. Together, training interventions and leadership support may have the most significant impact on patient safety culture.

Researching income and income distribution as determinants of health in Canada: gaps between theoretical knowledge, research practice, and policy implementation

The research identified gaps in Canadian knowledge and research activity concerning the roles that income and its distribution play in Canadians' population health. 241 Canadian research studies on income and health were considered along eight taxonomies: conceptualization of income or its proxies; theoretical underpinnings; income distribution measures; health measures; who/what was studied, pathways mediating between income and health; complexity of these pathways; research design; and presence of policy implications. The study identified the following areas of weakness: (a) poor conceptualization of income and the means by which it influences health; (b) lack of longitudinal studies of the impact of income-related issues upon health across the life-span; (c) lack of linked data bases that allow complex analyses of how income and related issues contribute to health and well-being, and (d) little inter-disciplinary work in identifying pathways mediating the income and health relationship. Advances in health policy to address the health effects of income and its distribution requires a research infrastructure that draws upon recent theoretical developments in the area and is able to access data sources to test these advanced conceptualizations.