A value-based taxonomy of improvement approaches in healthcare

Networks for healthcare delivery: a systematic literature review

PURPOSE

Network configurations have been proposed as an efficient form of organisation and a promising area of research; however, a lack of conceptual clarity can be noted. The purpose of this review is to allow for a broad appreciation of network configurations and provide guidance for future studies of the concept.

DESIGN/METHODOLOGY/APPROACH

A systematic literature review was conducted based on the PRISMA method; Scopus, Web of Science, PubMed and the Cochrane Library were searched for conference proceedings and journal articles describing organisational networks to integrate resources aimed at care delivery. Around 80 articles were included in the final review and analysed thematically and by use of bibliographic coupling.

FINDINGS

The last decades have seen an increase in the frequency of articles describing networks for healthcare delivery. The most common contexts are care for multiple and/or long-term conditions. Three clusters of articles were found, corresponding to different conceptualisations of networks in healthcare: efficiency-enhancing cooperation, efficiency-enhancing integration and involvement for cocreation.

RESEARCH LIMITATIONS/IMPLICATIONS

To increase conceptual clarity and allow the research on network configurations in healthcare to produce meta-learnings and guidance to practice, scholars are advised to provide ample descriptions of studied networks and relate them to established network classifications.

ORIGINALITY/VALUE

The current review has only included articles including networks as a key concept, which provides a focused overview of the use of network configurations but limits the insights into similar approaches not described explicitly as networks.

A taskforce for national improvement of innovation implementation in radiotherapy

BACKGROUND AND PURPOSE

Previous research among Dutch radiotherapy centres (RTCs) showed that 69% of innovations was simultaneously implemented in 7/19 centres, with a success rate of 51%. However, no structure to share lessons learned about the implementation process existed. Therefore, a national Taskforce Implementation (TTI) was raised to stimulate efficient implementation of innovations. The aim of the current study was to develop and pilot-evaluate a website for facilitating mutual learning on implementation issues.

MATERIAL AND METHODS

First, we made an inventory in all Dutch RTCs on their 10 most valuable innovations between 2019 and 2022. In-depth interviews, structured according to the Consolidated Framework for Implementation Research, were performed on the four most mentioned topics. A website was built, and pilot evaluated 1 year after the launch, using a qualitative survey amongst the TTI members.

RESULTS

In 13/18 centres, 19 interviews were conducted on 1) automation, 2) patient participation, 3) adaptive radiotherapy 4) surface guided radiotherapy and tracking. Most innovations (13/16) were implemented with a delay, with many comparable challenges: e.g. shortage of personnel (7/16) and prioritization of projects (9/16). The website allows users to upload and search for projects, including implementation experiences. After 1 year, 14 projects were uploaded. The qualitative evaluation was largely positive with room for improvement, i.e.75 % would recommend the website to others.

CONCLUSION

This study showed that RTCs experience comparable challenges when implementing innovations, thereby underlining the need for a platform to share implementation-lessons learned. The first concept of this platform was evaluated positively.

Efficiency Improvement Strategies for Public Health Systems: Developing and Evaluating a Taxonomy in the Australian Healthcare System

INTRODUCTION

As demand for healthcare continues to grow, public health systems are increasingly required to drive efficiency improvement (EI) to address public service funding challenges. Despite this requirement, evidence of EI strategies that have been successful applied at the whole-of-system level is limited. This study reports the development, implementation and evaluation of a novel taxonomy of EI strategies used in public health systems to inform systemwide EI models.

MATERIALS AND METHODS

The public health system in New South Wales, Australia, operates a centralised EI model statewide and was the setting for this study. An audit of EI strategies implemented in the NSW Health system between July 2016 and June 2019 was used to identify all available EI strategies within the study timeframe. A content management approach was applied to audit the strategies, with each strategy coded to an EI focus area. Codes were clustered according to similarity, and category names were assigned to each cluster to form a preliminary taxonomy. Each category was defined and examples were provided. The resulting taxonomy was distributed and evaluated by user feedback survey and pre-post study to assess the impact on EI strategy distribution.

RESULTS

A total of 1127 EI strategies were identified and coded into 263 unique strategies, which were clustered into nine categories to form the taxonomy of EI strategies. Categories included the following: non-clinical contracts and supplies; avoided and preventable activity; clinical service delivery and patient outcomes; finance and operations; recruitment, vacancies and FTE; staffing models; leave management; staff engagement and development; premium staffing; and clinical contracts and supplies. Evaluative findings revealed a perceived reduction in the duplication of EI work, improved access to EI knowledge and improved engagement with EI processes when using the taxonomy. The taxonomy was also associated with wider use of EI strategies.

CONCLUSIONS

Whole-of-system EI is an increasing requirement. Using a taxonomy to guide systemwide practice appears to be advanta-geous in reducing duplication and guiding practice, with implications for use in health systems internationally.

Implementing value-based healthcare using a digital health exchange platform to improve pregnancy and childbirth outcomes in urban and rural Kenya

Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of the United Nations Sustainable Development Goal 3. Value-based healthcare (VBHC) has the potential to outperform traditional supply-driven approaches in changing this dismal situation, and significantly improve maternal, neonatal and child health (MNCH) outcomes. We developed a theory of change and used a cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated in Kenya. At the core of the approach was a value-based care bundle for maternity care, with predefined cost and quality of care using WHO guidelines and adjusted to the risk profile of the pregnancy. The care bundle was implemented using a digital exchange platform that connects pregnant women, clinics and payers. The platform manages financial transactions, enables bi-directional communication with pregnant women via SMS, collects data from clinics and shares enriched information via dashboards with payers and clinics. While the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a predictable cost per enrolled person. This community case study shows that implementation of the VBHC framework in an LMIC setting is possible for MNCH. The incremental, cohort-based approach enabled iterative learning processes. This can support the restructuring of health systems in low resource settings from an output-driven model to a value based financing-driven model.

Driving Efficiency Improvement (EI): Exploratory Analysis of a Centralised Model in New South Wales

Introduction

Public healthcare systems face rising demand coupled with reducing funding growth rates, necessitating ongoing approaches to efficiency improvement (EI). Centrally coordinated EI approaches l may support EI leaders, yet few such approaches exist internationally. This study provides evidence to inform system-wide EI by harnessing understanding of the perceptions, role demands and support requirements of key EI stakeholders in the centralised EI model implemented in New South Wales.

Methods

A purposive sample of key informants within NSW Health with responsibility for EI in their organisation were invited to participate. Semi-structured interviews were conducted, recorded and transcribed. A thematic analysis was undertaken using a theoretical deductive approach.

Results

Seventeen respondents participated who occupied EI leadership roles in metro (8) and rural (6) health services as well as non-clinical support (3) services. Four primary themes emerged on the perceptions and experiences of participants in 1. holding a unique skillset which enables them to undertake EI; 2. inheriting EI accountabilities as additional duties rather than holding dedicated EI roles; 3. the importance of senior support for EI success; and 4. feelings of isolation in undertaking EI. An additional underpinning theme that EI is not well conceptualized in public health systems also emerged, whereby EI planners felt that frontline staff generally do not consider efficiency as a component of their duties.

Conclusion

EI leaders provide points of authority, experience and influence across organisations within public health systems. This study finds that EI planners possess a unique skillset, can feel isolated both within their health organisation and within the broader public health system and believe that EI is poorly conceptualized amongst health staff. Centralised support for EI stakeholders across a public health system can promote knowledge sharing and capability development. Addressing the role and support requirements of key EI stakeholders is essential.

[Practical considerations for implementing health outcomes measurement projects within a healthcare organization: Delphi Expert Consensus Study]

INTRODUCTION

Measuring health outcomes and costs per patient is an essential element of value-based healthcare (VBHC). The aim of the study was to generate expert consensus on the activities required to implement it.

METHODS

A two-round modified Delphi study with healthcare professionals, quality and clinical management methodologists and managers with academic and/or practical experience in outcome measurement projects. A median equal to or greater than 4 and a relative interquartile range (RIQR) equal to or greater than 25% were established as consensus criteria.

RESULTS

Consensus was obtained on 91% of the items (N=74/81). In terms of feasibility, the items that received the highest score and consensus were the existence of data protection guarantees (median=5; mean=4.8; RIQR=0%), the vision and motivation of healthcare professionals (median=5; mean=4.7; RIQR=20%), the existence and availability of ICT tools (or systems) for data recording (median=5; mean=4.5; RIQR=20%), and having sufficient funding to undertake the project (median=5; mean=4.2; RIQR=20%). The most highly rated factors adding complexity were the number of units or departments involved in the care process for the clinical condition (median=5; mean=4.4; RIQR=20%), having an accepted set of monitoring indicators for the condition (median=5; mean=4.4; RIQR=20%), and the involvement of several levels of care in the project (median=5; mean=4.3; RIQR=20%).

CONCLUSIONS

We describe practical aspects for the application of systematic outcomes measurement in routine clinical practice. These results can serve as a tool for prioritising, sizing, resource planning, and estimating implementation costs.

Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review

Introduction: Healthcare systems increasingly move toward “value-based healthcare” (VBHC), aiming to further improve quality and performance of care as well as the sustainable use of resources. Evidence about healthcare professionals' contributions to VBHC, experienced job demands and resources as well as employee well-being in VBHC is scattered. This systematic review synthesizes this evidence by exploring how VBHC relates to the healthcare professional, and vice versa.

Method: Seven databases were systematically searched for relevant studies. The search yielded 3,782 records, of which 45 were eligible for inclusion based on a two-step screening process using exclusion criteria performed by two authors independently. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (MMAT). Based on inductive thematic analysis, the Job Demands-Resources (JD-R) model was modified. Subsequently, this modified model was applied deductively for a second round of thematic analysis.

Results: Ten behaviors of healthcare professionals to enhance value in care were identified. These behaviors and associated changes in professionals' work content and work environment impacted the experienced job demands and resources and, in turn, employee well-being and job strain. This review revealed 16 constructs as job demand and/or job resource. Examples of these include role strain, workload and meaning in work. Four constructs related to employee well-being, including engagement and job satisfaction, and five constructs related to job strain, including exhaustion and concerns, were identified. A distinction was made between job demands and resources that were a pure characteristic of VBHC, and job demands and resources that resulted from environmental factors such as how care organizations shaped VBHC.

Conclusion and Discussion: This review shows that professionals experience substantial job demands and resources resulting from the move toward VBHC and their active role therein. Several job demands are triggered by an unsupportive organizational environment. Hence, increased organizational support may contribute to mitigating or avoiding adverse psychosocial factors and enhance positive psychosocial factors in a VBHC context. Further research to estimate the effects of VBHC on healthcare professionals is warranted.

A Standardized Framework for Evaluating Surgical Enhanced Recovery Pathways: A Recommendations Statement from the TDABC in Health-care Consortium

Background: Innovative methodologies to redesign care delivery are being applied to increase value in health care, including the creation of enhanced recovery pathways (ERPs) for surgical patients. However, there is a lack of standardized methods to evaluate ERP implementation costs. Objectives: This Recommendations Statement aims to introduce a standardized framework to guide the economic evaluation of ERP care-design initiatives, using the Time-Driven Activity-Based Costing (TDABC) methodology. Methods: We provide recommendations on using the proposed framework to support the decision-making processes that incorporate ERPs. Since ERPs are usually composed of activities distributed throughout the patient care pathway, the framework can demonstrate how the TDABC may be a valuable method to evaluate the incremental costs of protocol implementation. Our recommendations are based on the review of available literature and expert opinions of the members of the TDABC in Healthcare Consortium. Results: The ERP framework, composed of 11 steps, was created describing how the techniques and methods can be applied to evaluate the economic impact of an ERP and guide health-care leaders to optimize the decision-making process of incorporating ERPs into health-care settings. Finally, six recommendations are introduced to demonstrate that using the suggested framework could increase value in ERP care-design initiatives by reducing variability in care delivery, educating multidisciplinary teams about value in health, and increasing transparency when managing surgical pathways. Conclusions: Our proposed standardized framework can guide decisions and support measuring improvements in value achieved by incorporating the perioperative redesign protocols.

Value-based healthcare logics and their implications for Nordic health policies

Value-based healthcare (VBHC) is a widely approved logic for financing services, using innovative care models and evaluating healthcare outcomes. It is consistent with the Triple Aim framework of simultaneously improving population health, patient experience and the costs of care. In Nordic countries, VBHC has been mainly implemented as a strategic concept in developing hospitals. Despite the evident interest in VBHC as a management trend in healthcare organisations, the studies concerning the implications of VBHC logics on health policies have been scant. This study aimed to fill this gap by building a conceptual bridge between national health policy and value-based care. Through the Triple Aim framework, we explored how VBHC goals have evolved in Finnish Government Programmes from 1995 to 2015 by using qualitative document analysis and interviews. The study addresses the evolution and national impacts of VBHC. Our results show that the goals of Triple Aim gradually become evident at the Finnish health policies. All three Triple Aim goals were present, though the equal prioritisation of these goals only emerged in 2015, also highlighting patient experience. We argue that VBHC logics have indeed affected Nordic welfare policies, not only at the organisational level but also concerning performance measurement and care delivery. This may imply that the diffusion of VBHC logics evolves from healthcare organisations to policymaking instead of top-down. Particularly in publicly financed systems, VBHC indicates a transformation to a new public governance ideology, accelerating policy goals that promote customer responsiveness and value creation for citizens.

Identifying the Value of an eHealth Intervention Aimed at Cognitive Impairments: Observational Study in Different Contexts and Service Models

BACKGROUND

Value is one of the central concepts in health care, but it is vague within the field of summative eHealth evaluations. Moreover, the role of context in explaining the value is underexplored, and there is no explicit framework guiding the evaluation of the value of eHealth interventions. Hence, different studies conceptualize and operationalize value in different ways, ranging from measuring outcomes such as clinical efficacy or behavior change of patients or professionals to measuring the perceptions of various stakeholders or in economic terms.

OBJECTIVE

The objective of our study is to identify contextual factors that determine similarities and differences in the value of an eHealth intervention between two contexts. We also aim to reflect on and contribute to the discussion about the specification, assessment, and relativity of the "value" concept in the evaluation of eHealth interventions.

METHODS

The study concerned a 6-month eHealth intervention targeted at elderly patients (n=107) diagnosed with cognitive impairment in Italy and Sweden. The intervention introduced a case manager role and an eHealth platform to provide remote monitoring and coaching services to the patients. A model for evaluating the value of eHealth interventions was designed as monetary and nonmonetary benefits and sacrifices, based on the value conceptualizations in eHealth and marketing literature. The data was collected using the Mini-Mental State Examination (MMSE), the clock drawing test, and the 5-level EQ-5D (EQ-5D-5L). Semistructured interviews were conducted with patients and health care professionals. Monetary data was collected from the health care and technology providers.

RESULTS

The value of an eHealth intervention applied to similar types of populations but differed in different contexts. In Sweden, patients improved cognitive performance (MMSE mean 0.85, SD 1.62, P<.001), reduced anxiety (EQ-5D-5L mean 0.16, SD 0.54, P=.046), perceived their health better (EQ-5D-5L VAS scale mean 2.6, SD 9.7, P=.035), and both patients and health care professionals were satisfied with the care. However, the Swedish service model demonstrated an increased cost, higher workload for health care professionals, and the intervention was not cost-efficient. In Italy, the patients were satisfied with the care received, and the health care professionals felt empowered and had an acceptable workload. Moreover, the intervention was cost-effective. However, clinical efficacy and quality of life improvements have not been observed. We identified 6 factors that influence the value of eHealth intervention in a particular context: (1) service delivery design of the intervention (process of delivery), (2) organizational setup of the intervention (ie, organizational structure and professionals involved), (3) cost of different treatments, (4) hourly rates of staff for delivering the intervention, (5) lifestyle habits of the population (eg, how physically active they were in their daily life and if they were living alone or with family), and (6) local preferences on the quality of patient care.

CONCLUSIONS

Value in the assessments of eHealth interventions need to be considered beyond economic terms, perceptions, or behavior changes. To obtain a holistic view of the value created, it needs to be operationalized into monetary and nonmonetary outcomes, categorizing these into benefits and sacrifices.

The implementation of change model adds value to value-based healthcare: a qualitative study

Background

Value-based healthcare (VBHC) is a concept that focuses on outcome measurement to contribute to quality improvement. However, VBHC does not offer a systematic approach for implementing improvement as implementation science does. The aim is to, firstly, investigate the implementation of improvement initiatives in the context of VBHC and secondly, to explore how implementation science could be of added value for VBHC and vice versa.

Methods

A case study with two cases in heart care was conducted; one without the explicit use of a systematic implementation method and the other one with the use of the Implementation of Change Model (ICM). Triangulation of data from document research, semi-structured interviews and a focus group was applied to evaluate the degree of method uptake. Interviews were held with experts involved in the implementation of Case 1 (N = 4) and Case 2 (N = 7). The focus group was held with experts also involved in the interviews (N = 4). A theory-driven qualitative analysis was conducted using the ICM as a framework.

Results

In both cases, outcome measures were seen as an important starting point for the implementation and for monitoring change. Several themes were identified as most important: support, personal importance, involvement, leadership, climate and continuous monitoring. Success factors included intrinsic motivation for the change, speed of implementation, complexity and continuous evaluation.

Conclusion

Application of the ICM facilitates successful implementation of quality- improvement initiatives within VBHC. However, the practical use of the ICM shows an emphasis on processes. We recommend that monitoring of outcomes be added as an essential part of the ICM. In the discussion, we propose an implementation model that integrates ICM within VBHC.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4498-y) contains supplementary material, which is available to authorized users.

Value-based healthcare translated: a complementary view of implementation

BACKGROUND

Interest in the implementation of various innovations (e.g. medical interventions and organizational approaches) has increased rapidly, and management innovations (MIs) are considered particularly complex to implement. In contrast to a traditional view that innovations are implemented, some scholars have promoted the view that innovations are translated into contexts, a view referred to as translation theory. The aim of this paper is to investigate how a translation theory perspective can inform the Consolidated Framework of Implementation Research (CFIR) to increase understanding of the complex process of putting MIs into practice. The empirical base is a two-year implementation of the MI Value-Based Health Care (VBHC) to a psychiatric department in a large Swedish hospital.

METHODS

In this longitudinal case study, a qualitative approach was applied using an insider researcher with unique access to data, who followed the implementation starting in 2015. Data sources includes field notes, documents, and audio recordings of meetings and group reflections which were abridged into an event data file structured by CFIR domains. In a joint analysis, an outsider researcher was added to strengthen the analysis and mitigate potential bias.

RESULTS

Two themes were identified, for which CFIR did not satisfactorily explain the findings. First, the intervention characteristics (i.e. the content of the MI) were modified along the process and, second, the process did not follow predefined plans. However, the project was still perceived to be successful by internal and external stakeholders.

CONCLUSIONS

The paper proposes three ways in which translation theory can inform CFIR when applied to MIs: 1) strength of evidence is not as important for MIs as for medical and technical innovations; 2) adaptability of the MI can be emphasized more strongly, and 3) it can be more fruitful to view implementation as a dynamic process rather than seeing it as a matter of planning and execution. For managers, this implies encouragement to seize the opportunity to translate MIs to fit their organization, rather than to aim to be true to an original concept.

From one-sized to over-individualized? Service logic's value creation

Purpose There is a current trend in healthcare management away from produced and standardized one-size-fits-all processes toward co-created and individualized services. The purpose of this paper is to increase understanding of the value concept in healthcare organization and management by recognizing different levels of value (private, group and public) and the interconnectedness among these levels. Design/methodology/approach The paper uses social constructionism as a lens to problematize the individualization of service logic's value concept. Theories from consumer culture theory/transformative service research and public management add group and public levels of value to the private level. Findings An intersubjective (rather than subjective) approach to value creation entails the construction and sharing of value perceptions among groups of people. Such an approach also implies that group members may face similar barriers in their value creation efforts. Practical implications Healthcare management should be aware of the inherent individualism of service logic and, consequently, the need to balance private value with group and public levels of value. Social implications Identifying and addressing disadvantaged groups and the reasons for their disadvantaged positions is important in order to enhance the individual's value creation prerequisites as well as to address public and societal values, such as equal/equitable health(care). Originality/value It is important to complement service logic's value creation with group and public levels in order to understand the complexity and interconnectedness of value and the creation thereof.