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Vesel T, Covaleski A, Burkarth V, Ernst E, Vesel L. Leadership's Perceptions of Palliative Care During the COVID-19 Pandemic: A Qualitative Study. J Pain Symptom Manage 2024; 68:105-114.e4. [PMID: 38643955 DOI: 10.1016/j.jpainsymman.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/06/2024] [Accepted: 04/10/2024] [Indexed: 04/23/2024]
Abstract
CONTEXT Palliative care (PC) played a leading role in the COVID-19 pandemic. However, little is known regarding health system leadership's perceptions. BACKGROUND This study aimed to explore the perceptions, understanding, and utilization of PC before compared to during the COVID-19 pandemic among health system leadership. METHODS Semi-structured, in-depth interviews were conducted with leaders in a large healthcare system based in Massachusetts, United States. RESULTS A total of 22 in-depth interviews were completed at four facilities. Emerging themes included the role of PC before compared to during the COVID-19 pandemic, facilitators and barriers to PC delivery, and recommendations for future practice. Participants reported that the COVID-19 pandemic increased PC utilization, reinforced positive perceptions of the specialty, and emphasized its role in maximizing healthcare efficiency. Many participants found PC financing to be a barrier to delivery; some had an inaccurate understanding of how PC is reimbursed. When asked about their recommendations for improving future practice, participants noted improvements in coordination within the healthcare system and education of healthcare providers and future physicians in primary PC skills. CONCLUSIONS Our findings suggest that healthcare leadership increasingly understands the value of PC and its critical role within the health system and during future public health emergencies; this was further reinforced during the COVID-19 pandemic. Healthcare leadership recognizes and highlights the need to increase investments in this specialty, both financially and educationally. In doing so, healthcare costs will be lowered, patient satisfaction will increase, and care will be better coordinated.
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Affiliation(s)
- Tamara Vesel
- Division of Palliative Care, Tufts Medical Center (T.V., V.B.), Tufts University School of Medicine, Boston, Massachusetts, USA.
| | - Audrey Covaleski
- Department of Community Health (A.C.), Tufts University, Medford, Massachusetts, USA
| | - Veronica Burkarth
- Division of Palliative Care, Tufts Medical Center (T.V., V.B.), Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emma Ernst
- Department of Family Medicine (E.E.), University of Michigan, Ann Arbor, Michigan, USA
| | - Linda Vesel
- Ariadne Labs (L.V.), Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Rusoja E, Chad Swanson R, Swift M. Using Systems Thinking and Complexity Theory to understand and improve Emergency Medicine: Lessons from COVID-19 in a safety net health system. J Eval Clin Pract 2024; 30:330-336. [PMID: 37723831 DOI: 10.1111/jep.13920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/03/2023] [Indexed: 09/20/2023]
Abstract
RATIONALE COVID-19 has fundamentally changed the practice of Emergency Medicine (EM). Care delivery on the front lines has historically depended upon ostensibly reliable input-output models for staffing, supplies, policies, and therapies. Challenged by the complexity of healthcare during the pandemic, the fallibility of these reductionist models was quickly revealed. Providers and systems quickly had to reconceptualize their dependence on the wider, complex system in which healthcare operates and find adaptive solutions to rapid changes. AIMS/METHOD This papers seeks to review and describe how Systems Thinking and Complexity Theory (ST/CT)-concepts, principles, and tools that can be used to understand and impact our constantly evolving health system-can be applied to better understand and enact change in complex settings such as during COVID-19. Some of these ST/CT are described through the real world example of the Alameda Health System Vaccine Taskforce. RESULTS ST/CT concepts such as Unintended Consequences, Interrelationships, Emergent Behavior, Feedback Loops, and Path Dependence can help EM providers and planners understand the context in which their system operates. Key principles such as Collaboration, Iterative Learning, and Transformational Leadership can help these actors respond to current and future challenges. The integration of these concepts and principles into the Learning Health System offers a model for tying these key concepts and principles together into an adaptive, cross-sectoral organizational approach. CONCLUSION By integrating ST/CT into the practice of EM, we can not only improve our ability to care for patients but also our capacity to understand and strengthen our wider systems of care.
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Affiliation(s)
- Evan Rusoja
- Alameda Health System, Oakland, California, USA
| | | | - Mini Swift
- Alameda Health System, Oakland, California, USA
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Truppa C, Yaacoub S, Valente M, Celentano G, Ragazzoni L, Saulnier D. Health systems resilience in fragile and conflict-affected settings: a systematic scoping review. Confl Health 2024; 18:2. [PMID: 38172918 PMCID: PMC10763433 DOI: 10.1186/s13031-023-00560-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Health systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS. METHODS We used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al. RESULTS: Thirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services. CONCLUSIONS Our review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.
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Affiliation(s)
- Claudia Truppa
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy.
- International Committee of the Red Cross, Geneva, Switzerland.
| | - Sally Yaacoub
- Center for Research in Epidemiology and StatisticS (CRESS), Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, 75004, Paris, France
| | - Martina Valente
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, 13100, Vercelli, Italy
| | - Giulia Celentano
- ETH Zürich, Institut Für Bau- Und Infrastrukturmanagement, Chair of Sustainable Construction, Zurich, Schweiz
| | - Luca Ragazzoni
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, 13100, Vercelli, Italy
| | - Dell Saulnier
- Division of Social Medicine and Global Health/Department of Clinical Sciences, Lund University, Malmö, Sweden
- Geneva Centre of Humanitarian Studies, Université de Genève, Geneva, Switzerland
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Dudeja N, Sharma D, Maria A, Pawar P, Mukherjee R, Nargotra S, Mohapatra A. Implementing recommended breastfeeding practices in healthcare facilities in India during the COVID-19 pandemic: a scoping review of health system bottlenecks and potential solutions. Front Nutr 2023; 10:1142089. [PMID: 37583462 PMCID: PMC10423995 DOI: 10.3389/fnut.2023.1142089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 07/14/2023] [Indexed: 08/17/2023] Open
Abstract
Background Breastfeeding practices in institutional settings got disrupted during the COVID-19 pandemic. We reviewed the challenges faced and the "work-around" solutions identified for implementing recommended breastfeeding practices in institutionalized mother-newborn dyads in resource constrained settings during the pandemic with the aim to identify learnings that could be potentially adapted to the Indian and relatable contexts, for building resilient health systems. Methods We conducted a scoping review of literature using the PRISMA ScR Extension guidelines. We searched the Medline via PubMed and Web of Science databases for literature published between 1st December 2019 and 15th April 2022. We included original research, reviews, and policy recommendations published in English language and on India while others were excluded. Further, we searched for relevant gray literature on Google (free word search), websites of government and major professional bodies in India. Three reviewers independently conducted screening and data extraction and the results were displayed in tabular form. Challenges and potential solutions for breastfeeding were identified and were categorized under one or more suitable headings based on the WHO building blocks for health systems. Results We extracted data from 28 papers that were deemed eligible. Challenges were identified across all the six building blocks. Lack of standard guidelines for crisis management, separation of the newborn from the mother immediately after birth, inadequate logistics and resources for infection prevention and control, limited health workforce, extensive use of formula and alternative foods, inconsistent quality of care and breastfeeding support, poor awareness among beneficiaries about breastfeeding practices (and especially, about its safety during the pandemic) were some of the challenges identified. The solutions primarily focused on the development of standard guidelines and operating procedures, restricted use of formula, use of telemedicine services for counseling and awareness and improving resource availability for risk mitigation through strategic mobilization. Conclusion The COVID-19 pandemic has provided rich learning opportunities for health system strengthening in India. Countries must strengthen learning mechanisms to identify and adapt best practices from within their health systems and from other relatable settings.
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Affiliation(s)
- Nonita Dudeja
- Generating Research Insights for Development (GRID) Council, Executive Office, Noida, Uttar Pradesh, India
| | - Divita Sharma
- Generating Research Insights for Development (GRID) Council, Executive Office, Noida, Uttar Pradesh, India
| | - Arti Maria
- Department of Neonatology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Priyanka Pawar
- Generating Research Insights for Development (GRID) Council, Executive Office, Noida, Uttar Pradesh, India
| | - Ritika Mukherjee
- Generating Research Insights for Development (GRID) Council, Executive Office, Noida, Uttar Pradesh, India
| | - Shikha Nargotra
- Generating Research Insights for Development (GRID) Council, Executive Office, Noida, Uttar Pradesh, India
| | - Archisman Mohapatra
- Generating Research Insights for Development (GRID) Council, Executive Office, Noida, Uttar Pradesh, India
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Borghi J, Ismail S, Hollway J, Kim RE, Sturmberg J, Brown G, Mechler R, Volmink H, Spicer N, Chalabi Z, Cassidy R, Johnson J, Foss A, Koduah A, Searle C, Komendantova N, Semwanga A, Moon S. Viewing the global health system as a complex adaptive system - implications for research and practice. F1000Res 2022; 11:1147. [PMID: 37600221 PMCID: PMC10432894 DOI: 10.12688/f1000research.126201.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 08/22/2023] Open
Abstract
The global health system (GHS) is ill-equipped to deal with the increasing number of transnational challenges. The GHS needs reform to enhance global resilience to future risks to health. In this article we argue that the starting point for any reform must be conceptualizing and studying the GHS as a complex adaptive system (CAS) with a large and escalating number of interconnected global health actors that learn and adapt their behaviours in response to each other and changes in their environment. The GHS can be viewed as a multi-scalar, nested health system comprising all national health systems together with the global health architecture, in which behaviours are influenced by cross-scale interactions. However, current methods cannot adequately capture the dynamism or complexity of the GHS or quantify the effects of challenges or potential reform options. We provide an overview of a selection of systems thinking and complexity science methods available to researchers and highlight the numerous policy insights their application could yield. We also discuss the challenges for researchers of applying these methods and for policy makers of digesting and acting upon them. We encourage application of a CAS approach to GHS research and policy making to help bolster resilience to future risks that transcend national boundaries and system scales.
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Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Sharif Ismail
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - James Hollway
- Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Rakhyun E. Kim
- Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | - Joachim Sturmberg
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Garrett Brown
- School of Politics and International Studies, University of Leeds, Leeds, UK
| | - Reinhard Mechler
- International Institute for Applied Systems Analysis, Laxenberg, Austria
| | - Heinrich Volmink
- Division of Health Systems and Public Health, Stellenbosch University, Stellenbosch, South Africa
| | - Neil Spicer
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Zaid Chalabi
- Institute for Environmental Design and Engineering, University College London., London, UK
| | - Rachel Cassidy
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Jeff Johnson
- Faculty of Science, Technology, Engineering & Mathematics, The Open University, Milton Keynes, UK
| | - Anna Foss
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Augustina Koduah
- Department of Pharmacy Practice and Clinical Pharmacy, University of Ghana, Accra, Ghana
| | - Christa Searle
- Edinburgh Business School, Heriot Watt University, Edinburgh, UK
| | | | - Agnes Semwanga
- Health Informatics Research Group, Makerere University, Kampala, Uganda
| | - Suerie Moon
- Graduate Institute of International and Development Studies, Geneva, Switzerland
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