Early Discharge and Patient-Initiated Follow-Up in Hand Surgery: A New Norm Following Simple Hand Surgery?

AIMS

The demand for elective hand surgery has increased substantially over the last 10 years. With COVID-19 providing an added challenge of restrictions on face-to-face consultations, already overflowing follow-up clinics will be stressed further. Our aim is to assess the viability, effectiveness, and safety of an early discharge directly from the operating theatre following common hand surgery procedures with the safety net of open-access follow-up.

METHODS

All eligible patients undergoing open-hand surgery under local anaesthesia between February 2019 and December 2020 were offered early discharge. Informed consent was obtained in the clinic, and they were counselled on rehabilitation immediately prior to surgery. Patients were given a custom-made "open-access business card" with clear post-operative instructions and hand exercises, along with information on how to get in touch to request clinic follow-up. A review was completed at a minimum of two months following surgery. Administrative support staff were briefed beforehand to minimise any delays in follow-up requests and either book patients who requested follow-up into a routine elective clinic or utilise ring-fenced emergency elective clinic slots depending on the patient's individual requirements.

RESULTS

A total of 105 patients were included in this study, with an average age of 60 years. The average interval between surgery and review was 20 weeks. Eighty-nine patients had a successful early discharge, with 16 patients requesting clinic follow-up. The average time to follow up in the clinic was 35 weeks (range: four to 84 weeks). There were no complications that we were made aware of, and the most common reason for returning to the clinic was a new complaint, unrelated to the surgery.

CONCLUSIONS

Although virtual follow-up is now well established in both the fracture and elective clinic settings, early discharge is largely uncharted water. Our pilot demonstrates that early discharge and patient-initiated follow-up for common elective hand surgical procedures under local anaesthesia are efficient, safe, and viable.

Service design activities in health services: A systematic literature review based on ecosystem perspective and transformative approach

Service Design (SD) represents a breakthrough in searching for solutions to health systems challenges, but the activities that support these solutions remain underexplored. This research investigates how SD has been applied in the healthcare sector based on two conceptual models: multilevel ecosystem perspective and SD transformative approach. First, we conducted a systematic literature review in eight comprehensive databases in March 2021. Eligibility criteria returned 990 articles filtered by a search protocol, resulting in 47 studies. After this, we identified 23 studies (49%) with a transformative approach through a thematic analysis. Also, the analysis of these 23 studies allowed the identification of five key aspects necessary for enabling a transformative character of SD initiatives: (1) identification of all the actors that make up the provision of healthcare services, (2) identification of users by ecosystem level, (3) knowledge about the SD tools arsenal, (4) use of technology, and (5) applying the Experience-Based Design and Co-Design (EBD/EBCD) approach. The study underlines the role of management for the success of SD in the health sector and suggests an instrument (checklist) to help managers implement SD initiatives successfully.

Health System Transformation Playbook and Unified Care Model: an integrated design, systems & complexity thinking approach to health system transformation

Health system transformation is a complex journey that often results in unintended consequences. Existing methods to drive health system transformation have intrinsic limitations which impede successful implementation in local contexts. The Health System Transformation Playbook is a design-, systems-, and complexity-thinking enabled methodology to systematically design, prioritize and test health system and services transformation actions, anchored on iterative story telling, model building and pathfinding processes that tackles the scale of socially and technologically complex adaptive systems through time. The Unified Care Model and its associated cascade of models are examples of ongoing application of Health System Transformation Playbook in a regional population health system in Singapore. Use of Health System Transformation Playbook enables stewards of health systems to gain a more systematic and coherent understanding of health systems and services planning and organization development, to accelerate transformation towards people-centered, integrated and value-driven health systems.

Co-designing health services for people living with HIV who have multimorbidity: a feasibility study

This study explored the feasibility of using an experience-based co-design service improvement methodology to develop a new approach to managing multimorbidity in people living with HIV. Patients with HIV and multimorbidity and staff were recruited from five hospital departments and general practice. Staff and patient experiences were gathered through semi-structured interviews, filmed patient interviews, non-participant observation and patient diaries. A composite film developed from interviews illustrated the touchpoints in the patient journey, and priorities for service improvement were identified by staff and patients in focus groups. Twenty-two people living with HIV and 14 staff took part. Four patients completed a diary and 10 a filmed interview. Analysis identified eight touchpoints, and group work pinpointed three improvement priorities: medical records and information sharing; appointment management; and care co-ordination and streamlining. This study demonstrates that experience-based co-design is feasible in the context of HIV and can inform healthcare improvement for people with multimorbidity.

Co-designing an intervention to improve the process of deprescribing for older people living with frailty in the United Kingdom

BACKGROUND

In older people living with frailty, polypharmacy can lead to preventable harm like adverse drug reactions and hospitalization. Deprescribing is a strategy to reduce problematic polypharmacy. All stakeholders should be actively involved in developing a person-centred deprescribing process that involves shared decision-making.

OBJECTIVE

To co-design an intervention, supported by a logic model, to increase the engagement of older people living with frailty in the process of deprescribing.

DESIGN

Experience-based co-design is an approach to service improvement, which uses service users and providers to identify problems and design solutions. This was used to create a person-centred intervention with the potential to improve the quality and outcomes of the deprescribing process. A 'trigger film' showing older people talking about their healthcare experiences was created and facilitated discussions about current problems in the deprescribing process. Problems were then prioritized and appropriate solutions were developed. The review located the solutions in the context of current processes and procedures. An ideal care pathway and a complex intervention to deliver better care were developed.

SETTING AND PARTICIPANTS

Older people living with frailty, their informal carers and professionals living and/or working in West Yorkshire, England, UK. Deprescribing was considered in the context of primary care.

RESULTS

The current deprescribing process differed from an ideal pathway. A complex intervention containing seven elements was required to move towards the ideal pathway. Three of these elements were prototyped and four still need development. The complex intervention responded to priorities about (a) clarity for older people about what was happening at all stages in the deprescribing process and (b) the quality of one-to-one consultations.

CONCLUSIONS

Priorities for improving the current deprescribing process were successfully identified. Solutions were developed and structured as a complex intervention. Further work is underway to (a) complete the prototyping of the intervention and (b) conduct feasibility testing.

PATIENT OR PUBLIC CONTRIBUTION

Older people living with frailty (and their informal carers) have made a central contribution, as collaborators, to ensure that a complex intervention has the greatest possible potential to enhance the experience of deprescribing medicines.

Economic Viability and Efficacy of Day Case Versus Inpatient Tonsillectomy in Southern Iran

OBJECTIVES

Day case tonsillectomy compared with inpatient tonsillectomy has increasingly become a trend for many patients undergoing elective surgeries. Unjustified stays of tonsillectomy can be avoided by day case surgery, which consequently reduces treatment costs. The aim of this study was therefore to determine the cost and effectiveness of day case tonsillectomy compared with inpatient tonsillectomy.

METHODS

This cost-effectiveness study was performed on 300 patients from May 2017 to April 2018. Patients were randomly divided into 2 groups: day case (n = 150) and inpatient (n = 150). Consequences used in model included incidence of bleeding, blood transfusion, and reoperation frequency within 2 weeks after surgery and also the patients' pain during 24 hours after surgery. Costs were collected from societal perspective, so the costs included direct medical and nonmedical costs as well as indirect costs. One-way sensitivity analysis was conducted to measure the uncertainty effects of the parameters. The collected data were analyzed using software TreeAge and Excel 2016.

RESULTS

Day case tonsillectomy was more cost-effective than inpatient. Mean total costs in day case and inpatient were $915.1 and $1227.9, respectively. Besides, the mean effectiveness was 0.921 and 0.914 percent, respectively. Also, 1-way sensitivity analysis proved the robustness of the results of study.

CONCLUSIONS

Day case tonsillectomy is a cost-effective strategy and can be suggested as a good alternative for a wide range of patients after tonsillectomy. Supporting day case surgery for tonsillectomy cases can significantly reduce the financial burden.

Developing a prototype for integrated dental and diabetes care: understanding needs and priorities

BACKGROUND

Periodontal treatment may be a useful adjunct to medical management of diabetes; however, oral health has not been integrated into multidisciplinary diabetes care in Australia. This study aimed to understand the needs of patients and staff at a diabetes clinic to inform a prototype of integrated dental and diabetes care.

METHODS

Quantitative and qualitative data were collected from patients and staff at West Moreton Diabetes Clinic (WMDC) between September-October 2019. Clinical information, survey responses and dental screening results were analysed for 41 patients. Semi-structured interviews were held with six patients and a focus group with seven staff.

RESULTS

Most patients (83%) had not seen a dentist in the previous year. Of the 37 patients with remaining natural teeth, 84% required periodontal assessment and 46% had multiple carious lesions. Unmet treatment needs and rates of access were similar for private and public dental patients. Staff and patients reported high levels of support for incorporation of dental care at WMDC.

CONCLUSIONS

Integrating oral health into diabetes management is well-supported by patients and staff to address significant unmet dental needs for both public and private dental patients. Incorporating dental screening/services within diabetes clinics may increase uptake and improve awareness of its importance in diabetes management.

Creating pre-conditions for change in clinical practice: the influence of interactions between multiple contexts and human agency

Purpose

The purpose of this paper is to explore what happens when changes to clinical practice are proposed and introduced in healthcare organisations. The authors use the implementation of Treatment Escalation Plans to explore the dynamics shaping the translational journey of a complex intervention from research into the everyday context of real-world healthcare settings.

Design/methodology/approach

A qualitative instrumental collective case study design was used. Data were gathered using qualitative interviews (n = 36) and observations (n = 46) in three English acute hospital trusts. Normalisation process theory provided the theoretical lens and informed data collection and analysis.

Findings

While each organisation faced the same translational problem, there was variation between settings regarding adoption and implementation. Successful change was dependent on participants' ability to manage and shape contexts and the work this involved was reliant on individual capacity to create a new, receptive context for change. Managing contexts to facilitate the move from research into clinical practice was a complex interactive and iterative process.

Practical implications

The paper advocates a move away from contextual factors influencing change and adoption, to contextual patterns and processes that accommodate different elements of whole systems and the work required to manage and shape them.

Originality/value

The paper addresses important and timely issues of change in healthcare, particularly for new regulatory and service-oriented processes and practices. Insights and explanations of variations in implementation are revealed which could contribute to conceptual generalisation of context and implementation.

Same-day discharge protocol for laparoscopic treatment of adnexal disease: management and acceptance

OBJECTIVE

Develop a 'same-day discharge' setting for laparoscopic treatment of adnexal disease.

SETTING

Preventive Gynecology, European Institute of Oncology, Milan, Italy.

POPULATION

Two hundred patients undergoing laparoscopic procedures.

MATERIAL AND METHODS

Data were retrospectively collected through clinical, surgical and laboratory reports. After discharge patients were contacted by phone and e-mail.

MAIN OUTCOME MEASURES

The rate of discharge, adverse events and readmission was measured. The need for adjunctive care provided by our on-call service or by a primary care physician and the acceptability of the same-day discharge protocol were also investigated.

RESULTS

One hundred and sixty-five patients out of 200 were discharged on the same day. Of the 35 patients hospitalized, the most frequent causes for overnight admission were: uncontrolled pain, surgical length or complexity of the procedure in nine patients, nausea/vomit in four patients. One hundred and one out of 200 patients answered the mailed questionnaire. None of the discharged patients were readmitted. Eighty-five percent of the answering patients evaluated the length of their hospital stay as adequate or moderately adequate. Ninety-two percent of the patients would recommend the day surgery to other patients.

CONCLUSIONS

our experience demonstrates that the same-day discharge protocol for laparoscopic treatment of adnexal disease is safe and acceptable.

Experience-based co-design-Adapting the method for a researcher-initiated study in a multi-site setting

Background

Experience‐based co‐design (EBCD) brings patients and staff together to co‐design services. It is normally conducted in one organization which initiates and implements the process. We used the traditional EBCD method with a number of adaptations as part of a larger research study in the British National Health Service.

Methods

The primary aim was to assess the feasibility and acceptability of conducting research‐initiated EBCD, to enhance intervention development prior to testing. As well as embedding the method in a research study, there were 3 further key adaptations: (a) working across primary and secondary care sectors, (b) working on multiple sites and (c) incorporating theory‐informed analysis.

Results

We recruited four sites (covering both primary and secondary care) and, on each site, conducted the initial traditional EBCD meetings, with separate staff and patient groups—followed by a single joint patient‐staff event, where four priority areas for co‐design were agreed. This event was driven by theory‐informed analysis, as well as the traditional trigger film of patient experiences. Each site worked on one priority area, and the four co‐design groups met over 2‐3 months to design prototype tools. A second joint event was held (not usually undertaken in single‐site EBCD) where they shared and compared outputs. The research team combined elements of these outputs to create an intervention, now being tested in a cluster randomized controlled trial.

Conclusions

EBCD can be successfully adapted for use across an entire patient pathway with multiple organizations and as part of a research process to identify an intervention for subsequent testing in a randomized trial. Our pragmatic approach used the patient experience to identify areas for improvement and co‐designed an intervention which directly reflected patient priorities.

The evolution of New Zealand's health workforce policy and planning system: a study of workforce governance and health reform

INTRODUCTION

While considerable attention has been given to improving health workforce planning practice, few articles focus on the relationship between health workforce governance and health reform. By outlining a sequence of health reforms, we reveal how New Zealand's health workforce governance and practices came under pressure, leading to a rethink and the introduction of innovative approaches and initiatives.

CASE DESCRIPTION

New Zealand's health system was quite stable up to the late 1980s, after which 30 years of structural and system reform was undertaken. This had the effect of replacing the centralised medically led health workforce policy and planning system with a market-driven and short-run employer-led planning approach. The increasing pressures and inconsistencies this approach produced ultimately led to the re-centralisation of some governance functions and brought with it a new vision of how to better prepare for future health needs. While significant gain has been made implementing this new vision, issues remain for achieving more effective innovation diffusion and improved integrated care orientations.

DISCUSSION AND EVALUATION

The case reveals that there was a failure to consider the health workforce in almost all of the reforms. Health and workforce policy became increasingly disconnected at the central and regional levels, leading to fragmentation, duplication and widening gaps. New Zealand's more recent workforce policy and planning approach has adopted new tools and techniques to overcome these weaknesses that have implications for the workforce and service delivery, workforce governance and planning methodologies. However, further strengthening of workforce governance is required to embed the changes in policy and planning and to improve organisational capabilities to diffuse innovation and respond to evolving roles and team-based models of care.

CONCLUSION

The case reveals that disconnecting the workforce from reform policy leads to a range of debilitating effects. By addressing how it approaches workforce planning and policy, New Zealand is now better placed to plan for a future of integrated and team-based health care. The case provides cues for other countries considering reform agendas, the most important being to include and consider the health workforce in health reform processes.

Design Thinking in Health Care

Introduction

Applying Design Thinking to health care could enhance innovation, efficiency, and effectiveness by increasing focus on patient and provider needs. The objective of this review is to determine how Design Thinking has been used in health care and whether it is effective.

Methods

We searched online databases (PubMed, Medline, Web of Science, CINAHL, and PyscINFO) for articles published through March 31, 2017, using the terms “health,” “health care,” or “healthcare”; and “Design Thinking,” “design science,” “design approach,” “user centered design,” or “human centered design.” Studies were included if they were written in English, were published in a peer-reviewed journal, provided outcome data on a health-related intervention, and used Design Thinking in intervention development, implementation, or both. Data were collected on target users, health conditions, intervention, Design Thinking approach, study design or sample, and health outcomes. Studies were categorized as being successful (all outcomes improved), having mixed success (at least one outcome improved), or being not successful (no outcomes improved).

Results

Twenty-four studies using Design Thinking were included across 19 physical health conditions, 2 mental health conditions, and 3 systems processes. Twelve were successful, 11 reported mixed success, and one was not successful. All 4 studies comparing Design Thinking interventions to traditional interventions showed greater satisfaction, usability, and effectiveness.

Conclusion

Design Thinking is being used in varied health care settings and conditions, although application varies. Design Thinking may result in usable, acceptable, and effective interventions, although there are methodological and quality limitations. More research is needed, including studies to isolate critical components of Design Thinking and compare Design Thinking–based interventions with traditionally developed interventions.

Prospective sensemaking of a national quality register in health care and elderly care

Purpose The purpose of this paper is to examine how external change agents (ECAs) engaged to disseminate a national quality register (NQR) called Senior alert nationwide in the Swedish health care and elderly care sectors interpret their work. To study this, sensemaking theories are used. Design/methodology/approach This is a qualitative inductive interview study including eight ECAs. To analyze the data, a thematic analysis is carried out. Findings Well-disseminated NQRs support health care organizations' possibility to work with quality improvement and to improve care for patient groups. NQRs function as artifacts that can influence how health care professionals make sense of their work. In this paper, a typology depicting how the ECAs make sense of their dissemination work has been developed. The ECAs are engaged in prospective sensemaking. They describe their work as being about creating future good results, both for patients and affiliated organizations, and they can balance different quality aspects. Originality/value The number of NQRs increased markedly in Sweden and elsewhere, but there are few reports on how health care professionals working with the registers interpret their work. The use of ECAs to disseminate NQRs is a novel approach. This paper describes how the ECAs are engaged in prospective sensemaking - an under-researched perspective of the sensemaking theory.

Practical Methods for Extracting Explicit Design Rules Grounded in the Experience of Organizational Managers

The concept of design rules, an element of design science, helps convert the tacit knowledge of organizational change agents into explicit, actionable knowledge. Design rules are heuristic statements in the form: If you want to achieve outcome Y in situation S, something like X might help. Research suggests that experts tend to think using such heuristic rules, and the authors propose that this is also true for organizational managers leading successful change programs. Although design science approaches aim to build a body of design rules applicable in a variety of settings, little has been done to explore how design rules are elaborated from particular change efforts. The authors describe experience in testing four methods for extracting explicit design rules from existing programs of organizational change. They found this to be both a promising field of research and a potentially valuable methodology for practicing managers and change leaders in organizations.

What a Design Approach Offers to Organization Development

In this article, the authors describe characteristics of design science as a type of organization development (OD) intervention and as an approach to actionable theorizing. The authors discuss ways that design science approaches are typically but not necessarily consistent with OD’s values as well as the types of intervention motors they typically use. That is, they often reflect humanistic values, but they need not necessarily do so. Design science typically uses action research and participation intervention motors but does not include as much self-reflection as is the case in much OD work. Design approaches focus much more on action than do most current OD interventions; thus they add an important dimension to OD practice. In addition, they suggest ways of linking this focus on action with hypothesis testing and theorizing more than do most current OD interventions. Thus, they offer the possibility of revitalizing OD.

Having Relevance and Impact

This introductory article argues building intentional design capabilities is a primary approach to bridging theory and practice. To address the complexity and challenges of today’s organizational environments, the organizational development (OD) profession’s focus on humanistic development should be complemented by equally strong attention to bringing expertise to help design solutions to thorny problems. This requires attention to management as design and development of a design science to provide content and methodological knowledge to guide the design process. Treatments of organizational design science, just as other design sciences such as architecture, must juxtapose development of the guiding knowledge of the field with the descriptions of designing processes that bring to bear the perspectives, aspirations, and experiences of varied participants. The combination of the perspectives of organizational development and organization design science is critical to provide a knowledge foundation to build organizations that are sustainable and meet the needs of their stakeholders.

Development of a web-based and mobile app to support physical activity in individuals with rheumatoid arthritis: results from the second step of a co-design process

Background

Long-term adherence to physical activity recommendations remains challenging for most individuals with rheumatoid arthritis (RA) despite evidence for its health benefits.

Objective

The aim of this study was to provide basic data on system requirement specifications for a Web-based and mobile app to self-manage physical activity. More specifically, we explored the target user group, features of the future app, and correlations between the system requirements and the established behavior change techniques (BCTs).

Methods

We used a participatory action research design. Qualitative data were collected using multiple methods in four workshops. Participants were 5 individuals with RA, a clinical physiotherapist, an officer from the Swedish Rheumatism Association, a Web designer, and 2 physiotherapy researchers. A taxonomy was used to determine the degree of correlation between the system requirements and established BCTs.

Results

Participants agreed that the future Web-based and mobile app should be based on two major components important for maintaining physical activity: (1) a calendar feature for goal setting, planning, and recording of physical activity performance and progress, and (2) a small community feature for positive feedback and support from peers. All system requirements correlated with established BCTs, which were coded as 24 different BCTs.

Conclusions

To our knowledge, this study is the first to involve individuals with RA as co-designers, in collaboration with clinicians, researchers, and Web designers, to produce basic data to generate system requirement specifications for an eHealth service. The system requirements correlated to the BCTs, making specifications of content and future evaluation of effectiveness possible.

Improvements in neonatal care; using experience-based co-design

Purpose

– The purpose of this paper is to identify and improve patient care processes by collaborating patients, relatives and healthcare professionals.

Design/methodology/approach

– To identify and improve patient care processes by collaborating patients, relatives and healthcare professionals.

Findings

– Healthcare problems captured from collaboration between patients and healthcare professionals fall into simple, complicated and complex problems. Healthcare staff and patient experiences with patient processes differ, and a collaborative approach is needed to capture all areas needing improvement.

Research limitations/implications

– The conclusions are drawn from a project with few participants in a context that probably influenced the results. In contrast, other studies in the same area confirm the results.

Practical implications

– The study outcomes have direct implications for healthcare professionals who can learn from patients involved in quality improvements such as this experience-based co-design (EBCD) project.

Originality/value

– The paper contributes to limited studies on EBCD involving patients in healthcare quality improvements.

The socio-materiality of designing organizational change

Purpose

– The purpose of this paper is to examine the managerial implications of adopting a design attitude to organizational change.

Design/methodology/approach

– Based on an ethnographic study of a merger, the paper investigates the intricate interplay between architectural design and organizational change in the context of physically relocating an organization to a new office building. Emphasis is given to the socio-materiality of this double design process.

Findings

– The data suggests that taking a design attitude toward managing organizational change can allow different actors to participate in organizational design processes, releasing management from its traditional role as the keeper of the design solution.

Research limitations/implications

– Although based on a single case, the paper provides insights into the socio-materiality of organizational change that is relevant in other settings where developing new collective understandings of change processes are needed.

Practical implications

– A design attitude allows for multiple contributions to organizational change processes that can help reduce anxiety among those involved. The approach calls for openness, experimentation and the ability to balance different concerns. It can provide new ways of attending to resistance and produce valuable inputs to shaping organizations.

Originality/value

– This study contributes to the growing research on the role of material artifacts in organizational studies by providing a detailed account of organizational change as a socio-material achievement.

Lead users' ideas on core features to support physical activity in rheumatoid arthritis: a first step in the development of an internet service using participatory design

BACKGROUND

Despite the growing evidence of the benefits of physical activity (PA) in individuals with rheumatoid arthritis (RA), the majority is not physically active enough. An innovative strategy is to engage lead users in the development of PA interventions provided over the internet. The aim was to explore lead users' ideas and prioritization of core features in a future internet service targeting adoption and maintenance of healthy PA in people with RA.

METHODS

Six focus group interviews were performed with a purposively selected sample of 26 individuals with RA. Data were analyzed with qualitative content analysis and quantification of participants' prioritization of most important content.

RESULTS

Six categories were identified as core features for a future internet service: up-to-date and evidence-based information and instructions, self-regulation tools, social interaction, personalized set-up, attractive design and content, and access to the internet service. The categories represented four themes, or core aspects, important to consider in the design of the future service: (1) content, (2) customized options, (3) user interface and (4) access and implementation.

CONCLUSIONS

This is, to the best of our knowledge, the first study involving people with RA in the development of an internet service to support the adoption and maintenance of PA.Participants helped identifying core features and aspects important to consider and further explore during the next phase of development. We hypothesize that involvement of lead users will make transfer from theory to service more adequate and user-friendly and therefore will be an effective mean to facilitate PA behavior change.

DEVELOPING RADICAL SERVICE INNOVATIONS IN HEALTHCARE — THE ROLE OF DESIGN METHODS

This paper looks at the management of service innovation. In particular, it explores the challenge of public services and argues that there is a need for new approaches to the ways which engage users as more active co-creators within the innovation process. It draws on wider research on radical innovation being carried out as part of a long-term international programme and reports on a series of case studies of experiments in the health sector in the UK using tools like ethnography and prototyping to enable innovation.

The paper argues that a potentially valuable toolkit can be found in the field of design methods. By their nature, design tools are used to help articulate needs and give them shape and form; as such they are critical to the "front end" of any innovation process. Methods like ethnography allow for deep insights into user needs, including those not clearly articulated whilst prototyping provides the possibility of creating a set of "boundary objects" around which design discussions which include users and their perspectives can be carried out.

Large-scale improvement initiatives in healthcare: a scan of the literature

CONTEXT

The goal of this article is to provide a succinct scan of the literature as it relates to the current thinking and practice in large-scale improvement initiatives in healthcare.

METHOD

We employed a scan of the literature using a modified Delphi technique. A standard review form was used. The scan was limited to large-scale spread efforts in hospitals and healthcare systems. Each of the main factors that emerged during the scan was linked to secondary factors and organized using a driver diagram.

FINDINGS

Four primary drivers (factors) emerged during our scan that inform large-scale change initiatives in healthcare: Planning and Infrastructure; Individual, Group, Organizational, and System Factors; The Process of Change; and Performance Measures and Evaluation.

CONCLUSION

Our scan identified a tremendous amount of work being done around the world to improve healthcare. In general, our findings suggest these initiatives tend to be fragmented from an implementation standpoint. We identified primary and secondary drivers (factors) that can be used by those responsible for implementing large-scale improvement initiatives both at a strategy level and in their daily work. These drivers could serve as a "checklist" of ideas to consider in different testing and implementation situations.

Moving from research to large-scale change in child health care

There is a large and persistent failure to achieve widespread dissemination of evidence-based practices in child health care. Too often studies demonstrating evidence for effective child health care practices are not brought to scale and across different settings and populations. This failure is not due to a lack of knowledge, but rather a failure to bring to bear proven methods in dissemination, diffusion, and implementation (DD&I) science that target the translation of evidence-based medicine to everyday practice. DD&I science offers a framework and a set of tools to identify innovations that are likely to be implemented, and provides methods to better understand the capabilities and preferences of individuals and organizations and the social networks within these organizations that help facilitate widespread adoption. Successful DD&I is dependent on making the intervention context sensitive without losing fidelity to the core components of the intervention. The achievement of these goals calls for new research methods such as pragmatic research trials that combine hypothesis testing with quality improvement, participatory research that engages the target community at the beginning of research design, and other quasi-experimental designs. With the advent of health care reform, it will be extremely important to ensure that the ensuing large demonstration projects that are designed to increase integrated care and better control costs can be rapidly brought to scale across different practices settings, and health plans and will be able to achieve effectiveness in diverse populations.

Codesigning as a Discursive Practice in Emergency Health Services: The Architecture of Deliberation

This article addresses the issue of how government agencies are increasingly attempting to involve users in the design of public services. The article examines codesign as a method for fostering new and purposeful interaction among service-delivery staff and their customers. Codesign brings together stakeholders who, in the past, have had limited input into the way public services are experienced. By participating in this emerging discourse practice, codesign stakeholders can construct new ways of relating and deliberating. The data presented in this article are drawn from a codesign study initiated by the New South Wales Department of Health in an effort to improve the experience of staff, patients, and caregivers. The article concludes that codesign presents service consumers, professionals, and government officials with new opportunities as well as new challenges. Its opportunities reside in codesign bringing stakeholders together across previously impervious boundaries, producing new understandings, relationships, and engagements. Its challenges reside in these new understandings, relationships, and engagements only becoming possible and only continuing to be relevant if and when stakeholders are prepared to adopt and adapt to the new discourse needed to realize them, implicating them in what has been referred to as the “design competency spiral.”