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Allana A, Tavares W, Pinto AD, Kuluski K. Designing and Governing Responsive Local Care Systems - Insights from a Scoping Review of Paramedics in Integrated Models of Care. Int J Integr Care 2022; 22:5. [PMID: 35509960 PMCID: PMC9009364 DOI: 10.5334/ijic.6418] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 03/28/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction Programs that fill gaps in fractured health and social services in response to local needs can provide insight on enacting integrated care. Grassroots programs and the changing roles of paramedics within them were analyzed to explore how the health workforce, organizations and governance could support integrated care. Methods A study was conducted following Arksey and O'Malley's method for scoping reviews, using Valentijn's Rainbow Model of Integrated Care as an organizing framework. Qualitative content analysis was done on clinical, professional, organizational, system, functional and normative aspects of integration. Common patterns, challenges and gaps were documented. Results After literature search and screening, 137 documents with 108 unique programs were analysed. Paramedics bridge reactive and preventative care for a spectrum of population needs through partnerships with hospitals, social services, primary care and public health. Programs encountered challenges with role delineation, segregated organizations, regulation and tensions in professional norms. Discussion Five concepts were identified for fostering integrated care in local systems: single point-of-entry care pathways; flexible and mobile workforce; geographically-based cross-cutting organizations; permissive regulation; and assessing system-level value. Conclusion Integrated care may be supported by a generalist health workforce, through cross-cutting organizations that work across silos, and legislation that balances standardization with flexibility.
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Affiliation(s)
- Amir Allana
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- McNally Project for Paramedicine Research, CA
- Upstream Lab, MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, CA
| | - Walter Tavares
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- McNally Project for Paramedicine Research, CA
- The Wilson Centre and Temerty Faculty of Medicine, University of Toronto|University Health Network, CA
- York Region Paramedic Services, Community and Health Services Department, The Regional Municipality of York, CA
| | - Andrew D. Pinto
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- Upstream Lab, MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, CA
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, CA
| | - Kerry Kuluski
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, CA
- Institute for Better Health, Trillium Health Partners, CA
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Abstract
Purpose
In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.
Design/methodology/approach
This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.
Findings
Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.
Originality/value
The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.
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Hooshmand E, Tourani S, Ravaghi H, Vafaee Najar A, Meraji M, Ebrahimipour H. Validating and determining the weight of items used for evaluating clinical governance implementation based on analytic hierarchy process model. Int J Health Policy Manag 2015; 4:645-51. [PMID: 26673174 PMCID: PMC4594104 DOI: 10.15171/ijhpm.2015.79] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 04/04/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The purpose of implementing a system such as Clinical Governance (CG) is to integrate, establish and globalize distinct policies in order to improve quality through increasing professional knowledge and the accountability of healthcare professional toward providing clinical excellence. Since CG is related to change, and change requires money and time, CG implementation has to be focused on priority areas that are in more dire need of change. The purpose of the present study was to validate and determine the significance of items used for evaluating CG implementation. METHODS The present study was descriptive-quantitative in method and design. Items used for evaluating CG implementation were first validated by the Delphi method and then compared with one another and ranked based on the Analytical Hierarchy Process (AHP) model. RESULTS The items that were validated for evaluating CG implementation in Iran include performance evaluation, training and development, personnel motivation, clinical audit, clinical effectiveness, risk management, resource allocation, policies and strategies, external audit, information system management, research and development, CG structure, implementation prerequisites, the management of patients' non-medical needs, complaints and patients' participation in the treatment process. The most important items based on their degree of significance were training and development, performance evaluation, and risk management. The least important items included the management of patients' non-medical needs, patients' participation in the treatment process and research and development. CONCLUSION The fundamental requirements of CG implementation included having an effective policy at national level, avoiding perfectionism, using the expertise and potentials of the entire country and the coordination of this model with other models of quality improvement such as accreditation and patient safety.
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Affiliation(s)
- Elaheh Hooshmand
- Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sogand Tourani
- Hospital Management Research Center, Iran University of Medical Sciences, Tehran, Iran
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Ravaghi
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Vafaee Najar
- Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Marziye Meraji
- Department of Medical Records and Health Information Technology, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Ebrahimipour
- Health Sciences Research Center, Department of Health and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
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Farokhzadian J, Dehghan Nayeri N, Borhani F. Assessment of Clinical Risk Management System in Hospitals: An Approach for Quality Improvement. Glob J Health Sci 2015; 7:294-303. [PMID: 26156927 PMCID: PMC4803839 DOI: 10.5539/gjhs.v7n5p294] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/01/2015] [Accepted: 01/08/2015] [Indexed: 11/17/2022] Open
Abstract
Background: Clinical risks have created major problems in healthcare system such as serious adverse effects on patient safety and enhancing the financial burden for the healthcare. Thus, clinical risk management (CRM) system has been introduced for improving the quality and safety of services to health care. The aim of this study was to assess the status of CRM in the hospitals. Methods: A cross-sectional study was conducted on 200 nursing staff from three teaching hospitals affiliated with the Kerman University of Medical Sciences in southeast of Iran. Data were collected from the participants using questionnaire and observational checklist in quality improvement offices and selected wards. The data were analyzed using SPSS version 20. Results: Almost, 57% of persons participated in at least one of training sessions on CRM. The status of CRM system was rated from weak to moderate (2.93±0.72- 3.18±0.66). Among the six domains of CRM system, the highest mean belonged to domain the monitoring of analysis, evaluation and risk control (3.18±0.72); the lowest mean belonged to domain the staff’s knowledge, recognition and understanding of CRM (2.93±0.66). There were no integrated electronic systems for recording and analyzing clinical risks and incidents in the hospitals. Conclusion: Attempts have been made to establish CRM through improvement quality approach such as clinical governance and accreditation, but not enough, however, health care should move toward quality improvement and safe practice through the effective integration of CRM in organizational process.
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Hastings SE, Armitage GD, Mallinson S, Jackson K, Suter E. Exploring the relationship between governance mechanisms in healthcare and health workforce outcomes: a systematic review. BMC Health Serv Res 2014; 14:479. [PMID: 25280467 PMCID: PMC4282499 DOI: 10.1186/1472-6963-14-479] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 09/29/2014] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The objective of this systematic review of diverse evidence was to examine the relationship between health system governance and workforce outcomes. Particular attention was paid to how governance mechanisms facilitate change in the workforce to ensure the effective use of all health providers. METHODS In accordance with standard systematic review procedures, the research team independently screened over 4300 abstracts found in database searches, website searches, and bibliographies. Searches were limited to 2001-2012, included only publications from Canada, the United Kingdom, the Netherlands, New Zealand, Australia, and the United States. Peer- reviewed papers and grey literature were considered. Two reviewers independently rated articles on quality and relevance and classified them into themes identified by the team. One hundred and thirteen articles that discussed both workforce and governance were retained and extracted into narrative summary tables for synthesis. RESULTS Six types of governance mechanisms emerged from our analysis. Shared governance, Magnet accreditation, and professional development initiatives were all associated with improved outcomes for the health workforce (e.g., decreased turnover, increased job satisfaction, increased empowerment, etc.). Implementation of quality-focused initiatives was associated with apprehension among providers, but opportunities for provider training on these initiatives increased quality and improved work attitudes. Research on reorganization of healthcare delivery suggests that changing to team-based care is accompanied by stress and concerns about role clarity, that outcomes vary for providers in private versus public organizations, and that co-operative clinics are beneficial for physicians. Funding schemes required a supplementary search to achieve adequate depth and coverage. Those findings are reported elsewhere. CONCLUSIONS The results of the review show that while there are governance mechanisms that consider workforce impacts, it is not to the extent one might expect given the importance of the workforce for improving patient outcomes. Furthermore, to successfully implement governance mechanisms in this domain, there are key strategies recommended to support change and achieve desired outcomes. The most important of these are: to build trust by clearly articulating the organization's goal; considering the workforce through planning, implementation, and evaluation phases; and providing strong leadership.
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Affiliation(s)
| | - Gail D Armitage
- Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
| | - Sara Mallinson
- Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
| | - Karen Jackson
- Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
| | - Esther Suter
- Alberta Health Services, 10301 Southport Lane SW, Calgary, AB T2W 1S7 Canada
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Bahrami MA, Sabahi AA, Montazeralfaraj R, Shamsi F, Ardekani SE. Hospitals' readiness for clinical governance implementation in educational hospitals of yazd, iran. Electron Physician 2014; 6:794-800. [PMID: 25763148 PMCID: PMC4324270 DOI: 10.14661/2014.794-800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/21/2013] [Accepted: 04/27/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Clinical governance is a systematic approach to maintaining and improving the quality of patient care. This study aimed to assess some Iranian educational hospitals' readiness for clinical governance implementation through the organizational climate. METHODS It was a cross-sectional study that used the Clinical Governance Climate Questionnaire (CGCQ) in three educational hospitals in Yazd, a city in central Iran, in 2012. A total of 186 personnel contributed to the study. Data were analyzed using SPSS version 16. Descriptive statistics and the Kruskal-Wallis test were used for data analyses. RESULTS The mean scores of the clinical governance climate in Shahid Sadoughi, Shahid Rahnemoon and Afshar hospitals were 2.63±0.29, 2.58±0.32, and 2.68±0.29. The mean scores of quality improvement planning and change, quality improvement integration and motivation, clinical risk management and climate of blame and punishment, organizational learning, and training and development (T&D) opportunities for learning in the studied hospitals were 2.21±0.49, 2.80±0.40, 2.76±0.40, 2.91±0.54 and 3.06±0.72, respectively. CONCLUSION The results of this study showed that the educational hospitals' climate should be more supportive for successful implementation of clinical governance.
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Affiliation(s)
- Mohammad Amin Bahrami
- Ph.D. in Healthcare Management, Assistant Professor, Healthcare Management Department, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Ph.D. in Healthcare Management, Hospital Management Research Center, Shahid Sadoughi Hospital, Yazd, Iran
| | - Ali Akbar Sabahi
- B.Sc. in Healthcare Management, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Razieh Montazeralfaraj
- Ph.D. in Healthcare Management, Hospital Management Research Center, Shahid Sadoughi Hospital, Yazd, Iran
| | - Farimah Shamsi
- M.Sc. in Biostatistics, Biostatistics and Epidemiology Department, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Provision of clinical forensic medical services in Australia: A qualitative survey 2011/12. J Forensic Leg Med 2014; 21:31-7. [DOI: 10.1016/j.jflm.2013.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 09/20/2013] [Accepted: 10/29/2013] [Indexed: 11/18/2022]
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