Talking it better: conversations and normative complexity in healthcare improvement

Patient and Clinician Perspectives: To Create a Better Future for Chronic Kidney Disease, We Need to Talk About Our Kidneys

Chronic kidney disease (CKD) affects more than one in ten people worldwide. However, results from the REVEAL-CKD study suggest that it is often not diagnosed. Many patients are therefore unaware that they have CKD, putting them at increased risk of disease progression and complications. Empowering patients with knowledge about CKD will allow them to become active participants in their own care, driving improvements in diagnosis rates and changing patient outcomes for the better. In this article, we provide patient and clinician perspectives on the importance of early CKD diagnosis and management. We present an overview of the tests commonly used to diagnose CKD in clinical practice, as well as actionable suggestions for patients, clinicians, and health policymakers that could help improve disease detection and treatment. Navdeep Tangri, a nephrologist and epidemiologist at the University of Manitoba, and Jane DeMeis, a patient living with chronic kidney disease, discuss how results from the REVEAL-CKD study highlight the need for change to improve management of chronic kidney disease. Video Abstract (MP4 141866 KB).

What factors influence a Quality Improvement Collaborative in improving contraceptive services for foreign-born women? A qualitative study in Sweden

BACKGROUND

Improved contraceptive services could reduce the unmet need for contraception and unintended pregnancies globally. This is especially true among foreign-born women in high-income countries, as the health outcomes related to unmet need of contraception disproportionally affect this group. A widely used quality improvement approach to improve health care services is Quality Improvement Collaborative (QIC). However, evidence on to what extent, how and why it is effective and what factors influence a QIC in different healthcare contexts is limited. The purpose of this study was to analyse what factors have influenced a successful QIC intervention that is aimed to improve contraceptive service in postpartum care, mainly targeting foreign-born women in Sweden.

METHODS

A qualitative, deductive design was used, guided by the Consolidated Framework for Implementation Research (CFIR). The study triangulated secondary data from four learning seminars as part of the QIC, with primary interview data with four QIC-facilitators. The QIC involved midwives at three maternal health clinics in Stockholm County, Sweden, 2018-2019.

RESULTS

Factors from all five CFIR domains were identified, however, the majority of factors that influenced the QIC were found inside the QIC-setting, in three domains: intervention characteristics, inner setting and process. Outside factors and those related to individuals were less influential. A favourable learning climate, emphasizing co-creation and mutual learning, facilitated reflections among the participating midwives. The application of the QIC was facilitated by adaptability, trialability, and a motivated and skilled project team. Our study further suggests that the QIC was complex because it required a high level of engagement from the midwives and facilitators. Additionally, it was challenging due to unclear roles and objectives in the initial phases.

CONCLUSIONS

The application of the CFIR framework identified crucial factors influencing the success of a QIC in contraceptive services in a high-income setting. These factors highlight the importance of establishing a learning climate characterised by co-creation and mutual learning among the participating midwives as well as the facilitators. Furthermore, to invest in planning and formation of the project group during the QIC initiation; and to ensure adaptability and trialability of the improvement activities.

Social and health vulnerability of homeless people

The objective is to conduct a theoretical reflection on the social and health vulnerability of homeless people, from the perspective of complexity thinking. Study with a theoretical and reflective approach that accessed bibliographical sources of contemporary authors who seek to understand the phenomenon of homeless populations and, at the same time, attribute theoretical support from the reference of complexity, under a critical and analytical bias. Health is conceived as a subsystem of the social system that transcends any linear and punctual diagnostic perspective. Theoretical reflection on the social and health vulnerability of homeless people sparks a unique and multidimensional apprehension of the human being - a complex unit par excellence, which demands equally complex interventions.

Toward a Values-Informed Approach to Complexity in Health Care: Hermeneutic Review

Policy Points The concept of value complexity (complexity arising from differences in people's worldviews, interests, and values, leading to mistrust, misunderstanding, and conflict among stakeholders) is introduced and explained. Relevant literature from multiple disciplines is reviewed. Key theoretical themes, including power, conflict, language and framing, meaning-making, and collective deliberation, are identified. Simple rules derived from these theoretical themes are proposed.

Integrating System Dynamics and Action Research: Towards a Consideration of Normative Complexity Comment on "Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research"

Holmström and co-authors argue for the value of integrating system dynamics into action research to deal with increasing complexity in healthcare. We argue that despite merits, the authors overlook the key aspect of normative complexity, which refers to the existence of multiple, often conflicting values that actors in healthcare systems have to pragmatically develop responses to in their daily practices. We argue that a better theoretical and empirical understanding of the multiplicity of values and how actors deal with value conflicts in daily practices can enrich discussions about complexity in healthcare. We introduce the alternative methodology of 'value exnovation' for action researchers to broaden the scope of system-based thinking and action research in healthcare.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative

BACKGROUND

The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact.

OBJECTIVE

We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada.

METHODS

The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents.

RESULTS

Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes.

CONCLUSION

The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.

Am I safe? An Interpretative Phenomenological Analysis of Vulnerability as Experienced by Patients With Complications Following Surgery

Abdominal surgery carries with it risks of complications. Little is known about patients' experiences of post-surgical deterioration. There is a real need to understand the psychosocial as well as the biological aspects of deterioration in order to improve care and outcomes for patients. Drawing on in-depth interviews with seven abdominal surgery survivors, we present an idiographic account of participants' experiences, situating their contribution to safety within their personal lived experiences and meaning-making of these episodes of deterioration. Our analysis reveals an overarching group experiential theme of vulnerability in relation to participants' experiences of complications after abdominal surgery. This encapsulates the uncertainty of the situation all the participants found themselves in, and the nature and seriousness of their health conditions. The extent of participants' vulnerability is revealed by detailing how they made sense of their experience, how they negotiated feelings of (un)safety drawing on their relationships with family and staff and the legacy of feelings they were left with when their expectations of care (care as imagined) did not meet the reality of their experiences (care as received). The participants' experiences highlight the power imbalance between patients and professionals in terms of whose knowledge counts within the hospital context. The study reveals the potential for epistemic injustice to arise when patients' concerns are ignored or dismissed. Our data has implications for designing strategies to enable escalation of care, both in terms of supporting staff to deliver compassionate care, and in strengthening patient and family involvement in rescue processes.

InspirE5: a participatory, internationally informed framework for health humanities curricula in health professions education

BACKGROUND

Reporting on the effect of health humanities teaching in health professions education courses to facilitate sharing and mutual exchange internationally, and the generation of a more interconnected body of evidence surrounding health humanities curricula is needed. This study asked, what could an internationally informed curriculum and evaluation framework for the implementation of health humanities for health professions education look like?

METHODS

The participatory action research approach applied was based on three iterative phases 1. Perspective sharing and collaboration building. 2. Evidence gathering 3. Development of an internationally relevant curriculum and evaluation framework for health humanities. Over 2 years, a series of online meetings, virtual workshops and follow up communications resulted in the production of the curriculum framework.

RESULTS

Following the perspective sharing and evidence gathering, the InspirE5 model of curriculum design and evaluation framework for health humanities in health professions education was developed. Five principal foci shaped the design of the framework.

ENVIRONMENT

Learning and political environment surrounding the program. Expectations: Graduate capabilities that are clearly articulated for all, integrated into core curricula and relevant to graduate destinations and associated professional standards.

EXPERIENCE

Learning and teaching experience that supports learners' achievement of the stated graduate capabilities.

EVIDENCE

Assessment of learning (formative and/or summative) with feedback for learners around the development of capabilities. Enhancement: Program evaluation of the students and teachers learning experiences and achievement. In all, 11 Graduate Capabilities for Health Humanities were suggested along with a summary of common core content and guiding principles for assessment of health humanities learning.

DISCUSSION

Concern about objectifying, reductive biomedical approaches to health professions education has led to a growing expansion of health humanities teaching and learning around the world. The InspirE5 curriculum and evaluation framework provides a foundation for a standardised approach to describe or compare health humanities education in different contexts and across a range of health professions courses and may be adapted around the world to progress health humanities education.