Decision-making in healthcare as a complex adaptive system

Opioid-specific harm reduction in the emergency department: how staff provide harm reduction and contextual factors that impact their capacity to engage in harm reduction practice

BACKGROUND

Emergency Departments (ED) staff, including nurses and physicians, are most directly involved in the care of people who use unregulated substances, and are ideally positioned to provide harm reduction interventions. Conceptualizing the ED as a complex adaptive system, this paper examines how ED staff experience opioid-specific harm reduction provision and engage in harm reduction practice, including potential facilitators and barriers to engagement.

METHODS

Using a mixed methods approach, ED nurses and physicians completed a self-administered staff survey (n = 99) and one-on-one semi-structured interviews (n = 15). Five additional interviews were completed with clinical leaders. Survey data were analyzed to generate descriptive statistics and to compute scale scores. De-identified interview data were analyzed using a reflexive thematic analysis approach, which was informed by the theory of complex adaptive systems, as well as understandings of harm reduction as both a technical solution and a contextualized social practice. The final analysis involved mixed analysis through integrating both quantitative and qualitative data to generate overarching analytical themes.

RESULTS

Study findings illustrated that, within the context of the ED as a complex adaptive system, three interrelated contextual factors shape the capacity of staff to engage in harm reduction practice, and to implement the full range of opioid-specific harm reduction interventions available. These factors include opportunities to leverage benefits afforded by working collaboratively with colleagues, adequate preparation through receiving the necessary education and training, and support in helping patients establish connections for ongoing care.

CONCLUSIONS

There is a need for harm reduction provision across all health and social care settings where people who use unregulated opioids access public sector services. In the context of the ED, attention to contextual factors including teamwork, preparedness, and connections is warranted to support that ED staff engage in harm reduction practice.

Constructing a Hospital Department Development-Level Assessment Model: Machine Learning and Expert Consultation Approach in Complex Hospital Data Environments

BACKGROUND

Every hospital manager aims to build harmonious, mutually beneficial, and steady-state departments. Therefore, it is important to explore a hospital department development assessment model based on objective hospital data.

OBJECTIVE

This study aims to use a novel machine learning algorithm to identify key evaluation indexes for hospital departments, offering insights for strategic planning and resource allocation in hospital management.

METHODS

Data related to the development of a hospital department over the past 3 years were extracted from various hospital information systems. The resulting data set was mined using neural machine algorithms to assess the possible role of hospital departments in the development of a hospital. A questionnaire was used to consult senior experts familiar with the hospital to assess the actual work in each hospital department and the impact of each department's development on overall hospital discipline. We used the results from this questionnaire to verify the accuracy of the departmental risk scores calculated by the machine learning algorithm.

RESULTS

Deep machine learning was performed and modeled on the hospital system training data set. The model successfully leveraged the hospital's training data set to learn, predict, and evaluate the working and development of hospital departments. A comparison of the questionnaire results with the risk ranking set from the departments machine learning algorithm using the cosine similarity algorithm and Pearson correlation analysis showed a good match. This indicates that the department development assessment model and risk score based on the objective data of hospital systems are relatively accurate and objective.

CONCLUSIONS

This study demonstrated that our machine learning algorithm provides an accurate and objective assessment model for hospital department development. The strong alignment of the model's risk assessments with expert opinions, validated through statistical analysis, highlights its reliability and potential to guide strategic hospital management decisions.

An Exploration of Dutch Dermatologists' Experience and Satisfaction With Teledermatology: Sociotechnical and Complex Adaptive System Perspective

BACKGROUND

Despite the global upscale of teledermatology during the COVID-19 pandemic, persistent barriers, such as the poor anamnesis and photo quality, hinder its effective use in practice. Understanding Dutch dermatologists' experiences and satisfaction with using the teledermatology system in the Dutch health care system is needed. A holistic evaluation may provide valuable insight to understand how barriers interrelate which is deemed necessary for the innovation of teledermatology in practice.

OBJECTIVE

Guided by a complex adaptive system perspective, this study aims to understand Dutch dermatologists' experience and satisfaction with their training, support communication, interaction, and usage of a teledermatology platform of a Dutch digital hospital during the COVID-19 pandemic, uncovering insights to improve teledermatology services for the future.

METHODS

A web-based questionnaire was sent in December 2021 to Dutch dermatologists who (1) had an active teledermatology platform account, and (2) responded to a teledermatology consultation between October 1, 2019, and September 30, 2021. The questionnaire consisted of the validated Store-and-Forward Telemedicine Service User-satisfaction Questionnaire (SAF-TSUQ) questionnaire, and new questions regarding; demographics of teledermatologists, the use of teledermatology during the COVID-19 pandemic, the performance of teledermatology by general practitioners (GP), and the role of dermatologists in the teledermatology process. The open-ended questions were analyzed by a grounded theory approach guided by a sociotechnical model and complemented by a complex adaptive system perspective. A panel discussion with 3 dermatologists was performed to provide additional insight into the responses to the questionnaire.

RESULTS

We obtained responses from 25 out of the 249 (10%) invited dermatologists. Overall, dermatologists had a positive experience with teledermatology. Interestingly, teledermatology use frequency remained unaffected by the COVID-19 pandemic. However, the insufficient quality and incompleteness of the clinical content (photos and anamneses information) of the teledermatology consultation impacted the efficiency of the teledermatology workflow. Dermatologists expressed the need for improvement to avoid time-consuming processes or physical referrals. The panel discussion enriched and confirmed the responses, suggesting solutions like mandatory fields for the GPs for a complete anamnesis.

CONCLUSIONS

Dutch Dermatologists view teledermatology as a valuable tool to provide access to dermatology care. However, improvements regarding the quality and completeness of the provided clinical content are necessary for the effectiveness and efficiency of the complex teledermatology system in Dutch health care. This could increase both the dermatologists' satisfaction and the quality of teledermatology services. Managing trade-offs, such as time investments versus image quality, is crucial for teledermatology implementation and should be assessed from a complexity perspective to understand trade-offs and prevent unintended consequences.

Bracing for the next wave: A critical incident study of frontline decision-making, adaptation and learning in ambulance care during COVID-19

AIM

To explore frontline decision-making, adaptation, and learning in ambulance care during the evolving COVID-19 pandemic.

DESIGN

Descriptive and interpretative qualitative study.

METHODS

Twenty-eight registered nurses from the Swedish ambulance services described 56 critical incidents during the COVID-19 pandemic through free-text questionnaires. The material was analysed using the Critical Incident Technique and Interpretive Description through the lens of potential for resilient performance.

RESULTS

The findings were synthesized into four themes: 'Navigating uncharted waters under never-ending pressure', 'Balancing on the brink of an abyss', 'Sacrificing the few to save the many' and 'Bracing for the next wave'. Frontline decision-making during a pandemic contribute to ethical dilemmas while necessitating difficult prioritizations to adapt and respond to limited resources. Learning was manifested through effective information sharing and the identification of successful adaptations as compared to maladaptations.

CONCLUSIONS

During pandemics or under other extreme conditions, decisions must be made promptly, even amidst emerging chaos, potentially necessitating the use of untested methods and ad-hoc solutions due to initial lack of knowledge and guidelines. Within ambulance care, dynamic leadership becomes imperative, combining autonomous frontline decision-making with support from management. Strengthening ethical competence and fostering ethical discourse may enhance confidence in decision-making, particularly under ethically challenging circumstances.

IMPACT

Performance under extreme conditions can elevate the risk of suboptimal decision-making and adverse outcomes, with older adults being especially vulnerable. Thus, requiring targeted decision support and interventions. Enhancing patient safety in ambulance care during such conditions demands active participation and governance from management, along with decision support and guidelines. Vertical communication and collaboration between management and frontline professionals are essential to ensure that critical information, guidelines, and resources are effectively disseminated and implemented. Further research is needed into management and leadership in ambulance care, alongside the ethical challenges in frontline decision-making under extreme conditions.

REPORTING METHOD

Findings are reported per consolidated criteria for reporting qualitative research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Dynamic adaptive decision support for strategic decision-making in healthcare organizations

PURPOSE

The main objective of this study was to design a dynamic adaptive decision support model for healthcare organizations facing deep uncertainties by considering promising dynamic adaptive approaches. The main argument for this is that healthcare organizations have to make strategic decisions under deep uncertainty, but lack an approach to deal with this.

DESIGN/METHODOLOGY/APPROACH

A Dynamic Adaptive Decision Support model (DADS) is designed using the Design Science Research methodology. The evaluation of an initial model leads, through two case studies on ongoing and strategic decision-making, to the final design of this needed model for healthcare organizations.

FINDINGS

The research reveals the relevance of the designed dynamic and adaptive tool to support strategic decision-making for healthcare organizations. The final design of DADS innovates Decision Making under Deep Uncertainty (DMDU) approaches in an organizational context for ongoing and strategic decision-making.

ORIGINALITY/VALUE

The designed model applies the Dynamic Adaptive Policy Pathways approach in an organizational context and more specifically in health care organizations. It further integrates Corporate Real Estate Management knowledge and experience to develop a most needed tool for decision-makers in healthcare. This is the first DADS designed for an organization facing deep uncertainties in a rapidly changing healthcare environment and dealing with ongoing and strategic decision-making.

Future leaders in a learning health system: Exploring the Health System Impact Fellowship

The Canadian health system is reeling following the COVID-19 pandemic. Strains have become growing cracks, with long emergency department wait times, shortage of human health resources, and growing dissatisfaction from both clinicians and patients. To address long-needed health system reform in Canada, a modernization of training is required for the next generation health leaders. The Canadian Institutes of Health Research Health System Impact Fellowship (HSIF) is an example of a well-funded and connected training program which prioritizes embedded research and embedding technically trained scholars with health system partners. The program has been successful in the scope and impact of its training outcomes as well as providing health system partners with a pool of connected and capable scholars. Looking forward, integrating aspects of evidence synthesis from both domestic and international sources and adapting a general contractor approach to implementation within the HSIF could help catalyze learning health system reform in Canada.

Understanding clinical complexity in organ and organizational systems: Challenges local and global

INTRODUCTION

Complexity in healthcare systems has been arbitrarily defined as tasks or systems ranging from complicated to intractable, with a general view of these not being 'simple'. Complexity in healthcare systems in first-world countries has been well elucidated, however, data from third-world countries is still scant. MATERIALS AND METHODS: We present four cases each from three different organ systems-chronic kidney disease, alcohol use disorder, and heart failure-in the backdrop of our healthcare organization. We present our analysis of the complexities faced clinically and, in our local healthcare system which led to these events.

RESULTS

Analysis of these cases showed that patients with chronic kidney disease had vertebral-spinal pathologies due to poor infection control measures during haemodialysis. All these patients were young with a long history of secondary hypertension. In patients with alcohol use disorder, a common theme of how government regulations and peer pressure promote alcohol use is analysed. In the four patients with unexplained heart failure, vascular health is viewed as a fractal dimension and the various factors affecting vascular health are elaborated.

CONCLUSION

Complexities exist clinically in making a diagnosis, and organizationally, in the variables and nodes dictating patient outcomes. Clinical complexities cannot be simplified but have to be navigated in an optimized way to improve clinical outcomes.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

BACKGROUND

The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements.

METHODS

Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis.

RESULTS

An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care.

CONCLUSIONS

To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

BACKGROUND

Hospital discharge is a complex process encompassing multiple interactions and requiring coordination. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aims of this study were to 1) map coordination and team collaboration across healthcare and social care organisations, 2) describe interdependencies and system variability in the discharge process for older people with complex care needs, and 3) evaluate the alignment between discharge planning and the needs in the home.

METHODS

Data were collected through participant observations, interviews, and document review in a region of southern Sweden. The Functional Resonance Analysis Method (FRAM) was used to model the discharge process and visualise and analyse coordination of care across healthcare and social care organisations.

RESULTS

Hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals' performance is constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in health and social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. Flexibility and appropriate resources enable for handling variability and responding to uncertainties in care after discharge.

CONCLUSIONS

Mapping hospital discharge using the FRAM reveals couplings and interdependencies between various individuals, teams, and organisations and the most vulnerable point, when the patient arrives at home. Resilient performance in responding to unexpected events and variations during the first days after the return home requires a system allowing flexibility and facilitating successful adaptation of discharge planning.

Exploring everyday work as a dynamic non-event and adaptations to manage safety in intraoperative anaesthesia care: an interview study

BACKGROUND

Safety has been described as a dynamic non-event and as constantly present in professionals' work processes. Investigating management of complex everyday situations may create an opportunity to elucidate safety management. Anaesthesia has been at the frontline of enhancing patient safety - testing and implementing knowledge from other high-reliability industries, such as aviation, in the complex, adaptive system of an operating room. The aim of this study was to explore factors supporting anaesthesia nurses and anaesthesiologists in managing complex everyday situations during intraoperative anaesthesia care processes.

METHODS

Individual interviews with anaesthesia nurses (n = 9) and anaesthesiologists (n = 6) using cognitive task analysis (CTA) on case scenarios from previous prospective, structured observations. The interviews were analysed using the framework method.

RESULTS

During intraoperative anaesthesia care, management of everyday complex situations is sustained through preparedness, support for mindful practices, and monitoring and noticing complex situations and managing them. The prerequisites are created at the organization level. Managers should ensure adequate resources in the form of trained personnel, equipment and time, team and personnel sustainability and early planning of work. Management of complex situations benefits from high-quality teamwork and non-technical skills (NTS), such as communication, leadership and shared situational awareness.

CONCLUSION

Adequate resources, stability in team compositions and safe boundaries for practice with shared baselines for reoccurring tasks where all viewed as important prerequisites for managing complex everyday work. When and how NTS are used in a specific clinical context depends on having the right organizational prerequisites and a deep expertise of the relevant clinical processes. Methods like CTA can reveal the tacit competence of experienced staff, guide contextualized training in specific contexts and inform the design of safe perioperative work practices, ensuring adequate capacity for adaptation.

Coping with uncertainties: challenges for decision makers in healthcare

Purpose

Health care organizations’ decision-making for the future relies on anticipating changes. Reliable predictions are becoming increasingly difficult, creating anxiety and requires long-term adaptive planning to cope with unforeseen circumstances. The purpose of this study is to gain insights into the awareness of uncertainties that decision makers in healthcare have, particularly when making long-term investments.

Design/methodology/approach

This is a qualitative study with an explorative purpose. The data were collected through semi-structured and open interviews with board members of long-term care organizations.

Findings

The study revealed that respondents are most uncertain about the future financing of their real estate system. Another concern revealed is about the shortage of care professionals combined with an increasing demand for future care. Despite most decision makers do recognize uncertainties during the decision-making process, decision makers hardly address the level of these uncertainties. Although this study did find that some decision makers are aware of deep uncertainties, in terms of “unknown unknowns,” they have no actual approaches for dealing with such situations.

Originality/value

Decision makers at healthcare organizations are uncertain as to their ability to anticipate technological, economic, social and political developments, as well as predict future healthcare system transformations. Some decision makers are aware of deep uncertainties, in terms of “unknown unknowns” and “unidentified unknowns,” but they lack an actual approach to deal with such situations. This study examines how strategies adapt to unforeseen developments or how to deal with deep uncertainties in healthcare as complex adaptive system.

Living Donor Kidney Transplantation in Quebec: A Qualitative Case Study of Health System Barriers and Facilitators

Background

Patients with kidney failure represent a major public health burden, and living donor kidney transplantation (LDKT) is the best treatment option for these patients. Current work to optimize LDKT delivery to patients has focused on microlevel interventions and has not addressed interdependencies with meso and macro levels of practice.

Objective

We aimed to learn from a health system with historically low LDKT performance to identify facilitators and barriers to LDKT. Our specific aims were to understand how LDKT delivery is organized through interacting macro, meso, and micro levels of practice and identify what attributes and processes of this health system facilitate the delivery of LDKT to patients with kidney failure and what creates barriers.

Design

We conducted a qualitative case study, applying a complex adaptive systems approach to LDKT delivery, that recognizes health systems as being made up of dynamic, nested, and interconnected levels, with the patient at its core.

Setting

The setting for this case study was the province of Quebec, Canada.

Participants

Thirty-two key stakeholders from all levels of the health system. This included health care professionals, leaders in LDKT governance, living kidney donors, and kidney recipients.

Methods

Semi-structured interviews with 32 key stakeholders and a document review were undertaken between February 2021 and December 2021. Inductive thematic analysis was used to generate themes.

Results

Overall, we identified strong links between system attributes and processes and LDKT delivery, and more barriers than facilitators were discerned. Barriers that undermined access to LDKT included fragmented LDKT governance and expertise, disconnected care practices, limited resources, and regional inequities. Some were mitigated to an extent by the intervention of a program launched in 2018 to increase LDKT. Facilitators driven by the program included advocacy for LDKT from individual member(s) of the care team, dedicated resources, increased collaboration, and training opportunities that targeted LDKT delivery at multiple levels of practice.

Limitations

Delineating the borders of a "case" is a challenge in case study research, and it is possible that some perspectives may have been missed. Participants may have produced socially desirable answers.

Conclusions

Our study systematically investigated real-world practices as they operate throughout a health system. This novel approach has cross-disciplinary methodological relevance, and our findings have policy implications that can help inform multilevel interventions to improve LDKT.

Yoga and pain: A mind-body complex system

Introduction

The human body's response to pain is indicative of a complex adaptive system. Therapeutic yoga potentially represents a similar complex adaptive system that could interact with the pain response system with unique benefits.

Objectives

To determine the viability of yoga as a therapy for pain and whether pain responses and/or yoga practice should be considered complex adaptive systems.

Methods

Examination through 3 different approaches, including a narrative overview of the evidence on pain responses, yoga, and complex system, followed by a network analysis of associated keywords, followed by a mapping of the functional components of complex systems, pain response, and yoga.

Results

The narrative overview provided extensive evidence of the unique efficacy of yoga as a pain therapy, as well as articulating the relevance of applying complex systems perspectives to pain and yoga interventions. The network analysis demonstrated patterns connecting pain and yoga, while complex systems topics were the most extensively connected to the studies as a whole.

Conclusion

All three approaches support considering yoga a complex adaptive system that exhibits unique benefits as a pain management system. These findings have implications for treating chronic, pervasive pain with behavioral medicine as a systemic intervention. Approaching yoga as complex system suggests the need for research of mind-body topics that focuses on long-term systemic changes rather than short-term isolated effects.

Guiding Efficient, Effective, and Patient-Oriented Electrolyte Replacement in Critical Care: An Artificial Intelligence Reinforcement Learning Approach

Both provider- and protocol-driven electrolyte replacement have been linked to the over-prescription of ubiquitous electrolytes. Here, we describe the development and retrospective validation of a data-driven clinical decision support tool that uses reinforcement learning (RL) algorithms to recommend patient-tailored electrolyte replacement policies for ICU patients. We used electronic health records (EHR) data that originated from two institutions (UPHS; MIMIC-IV). The tool uses a set of patient characteristics, such as their physiological and pharmacological state, a pre-defined set of possible repletion actions, and a set of clinical goals to present clinicians with a recommendation for the route and dose of an electrolyte. RL-driven electrolyte repletion substantially reduces the frequency of magnesium and potassium replacements (up to 60%), adjusts the timing of interventions in all three electrolytes considered (potassium, magnesium, and phosphate), and shifts them towards orally administered repletion over intravenous replacement. This shift in recommended treatment limits risk of the potentially harmful effects of over-repletion and implies monetary savings. Overall, the RL-driven electrolyte repletion recommendations reduce excess electrolyte replacements and improve the safety, precision, efficacy, and cost of each electrolyte repletion event, while showing robust performance across patient cohorts and hospital systems.

International, national and local trends in the spread of COVID-19: a geographic view of COVID-19 spread and the role to be played by coproduction

BACKGROUND

COVID-19, a respiratory disease caused by the SARS-CoV-2 virus, emerged in 2019 and led to a worldwide pandemic in 2020. The COVID-19 pandemic has been a massive natural experiment in the formation of mitigation strategies to prevent cases and to provide effective healthcare for those afflicted. Regional differences in the impact of the pandemic on morbidity and mortality have been driven by political and regional differences in the coproduction of public health and social policy. We explored the United States (US) experience of COVID-19 for trends and correlations with other nations and also at the national, regional, state and local levels.

OBJECTIVE

To identify geographic and temporal trends in the spread of COVID-19 in the United States.

METHODS

Population data on COVID-19 cases and mortality were acquired on a daily basis from multiple publicly available databases, including the New York Times and Johns Hopkins University. At each geographic level (national, state and county), geographic entities' reported cases were evaluated for correlations using linear least-squares methods to identify patterns of correlation in the cases independent of scale. We evaluated for two specific characteristics: (i) the nature of the curvature of the line linking across percentile scores, ranging from concave to convex and (ii) the area under this curve, indicating how effectively a selected region (nation, state and county) is linked to its entire containing unit (world, country and state). We used this approach to identify three distinct COVID behavior phenotypes, each of which consisted of a number of states in the USA.

RESULTS

We found that COVID activity in the USA follows a unique trend compared to other countries and that within the USA during the first year of the pandemic, three initial COVID phenotypes emerged: (i) the metropolitan outbreak (early outbreak phenotype); (ii) the regional outbreak (summer peak phenotype) and (iii) trans-regional outbreak (fall/winter peak phenotype), which, taken in sum, represent the overall USA national trend. Each phenotype has specific behavioral characteristics and is composed of a cluster of different states experiencing different conditions.

CONCLUSION

Our findings suggest a new opportunity for public health strategy in the pandemic, namely to apply targeted public health approaches to address the specific needs of each phenotype. In the future, we should create databases that capture key health and hardship data elements at the smallest geographic level possible and use these to track trends, predict the future and apply targeted coproduction approaches to more effectively and efficiently safeguard population health, economic vitality and social well-being.

Large scale healthcare facility redevelopment: A scoping review

Internationally, organisations are undertaking large scale facility redevelopment as a strategy for the transformation of care systems. Redeveloping facilities provides a once in a generation opportunity to transform health service delivery, typically, however, system level changes are poorly understood. To address this gap, our aim was to investigate the empirical knowledge base regarding large scale redevelopment of healthcare facilities. A scoping review was undertaken, guided by the redeveloped health service management (HSM) scoping review framework (HSM-SRF). Across 17 articles, five key concepts were identified, and they form the principles for successful redevelopment. First, establish a strong governance framework integrating diverse expertise and evidence base. Second, engage with internal and external stakeholders to build effectual relationships. Third, consult with end users, including clinicians and patients, to encourage the acceptance of the redevelopment and actively manage stakeholder dynamics, including politics and power undercurrents. Fourth, commit appropriate resources, including time, workforce, technology and finance to ensure redevelopment success. Finally, reimagine workflows through consultation with end users, including staff and consumers, allowing them to conceptualise how the space will be utilised. This scoping review is the first to synthesise the empirical knowledge base of the redevelopment of healthcare facilities.

Missed nursing care and complexity theory: a conceptual paper

Background

Missed nursing care is a complex healthcare problem. Extant literature in this area identifies several interventions that can be used in acute hospital settings to minimise the impact of missed nursing care. However, controversy still exists as to the effectiveness of these interventions on reducing the occurrence of missed nursing care.

Aim

This theoretical paper aimed to provide a conceptual understanding of missed nursing care using complexity theory.

Methods

The method utilised for this paper is based on a literature review on missed care and complexity theory in healthcare.

Results

We found that the key virtues of complexity theory relevant to the missed nursing care phenomenon were adaptation and self-organisation, non-linear interactions and history. It is suggested that the complex adaptive systems approach may be more useful for nurse managers to inform and prepare nurses to meet uncertain encounters in their everyday clinical practice and therefore reduce instances of missed care.

Conclusions

This paper envisions that it is time that methods used to explore missed care changed. Strategies proposed in this paper may have an important impact on the ability of nursing staff to provide quality and innovative healthcare in the modern healthcare system.

Participatory co-design and normalisation process theory with staff and patients to implement digital ways of working into routine care: the example of electronic patient-reported outcomes in UK renal services

BACKGROUND

Successful implementation of digital health systems requires contextually sensitive solutions. Working directly with system users and drawing on implementation science frameworks are both recommended. We sought to combine Normalisation Process Theory (NPT) with participatory co-design methods, to work with healthcare stakeholders to generate implementation support recommendations for a new electronic patient reported outcome measure (ePRO) in renal services. ePROs collect data on patient-reported symptom burden and illness experience overtime, requiring sustained engagement and integration into existing systems.

METHODS

We identified co-design methods that could be mapped to NPT constructs to generate relevant qualitative data. Patients and staff from three renal units in England participated in empathy and process mapping activities to understand 'coherence' (why the ePRO should be completed) and 'cognitive participation' (who would be involved in collecting the ePRO). Observation of routine unit activity was completed to understand 'collective action' (how the collection of ePRO could integrate with service routines).

RESULTS

The mapping activities and observation enabled the research team to become more aware of the key needs of both staff and patients. Working within sites enabled us to consider local resources and barriers. This produced 'core and custom' recommendations specifying core needs that could be met with customised local solutions. We identified two over-arching themes which need to be considered when introducing new digital systems (1) That data collection is physical (electronic systems need to fit into physical spaces and routines), and (2) That data collection is intentional (system users must be convinced of the value of collecting the data).

CONCLUSIONS

We demonstrate that NPT constructs can be operationalised through participatory co-design to work with stakeholders and within settings to collaboratively produce implementation support recommendations. This enables production of contextually sensitive implementation recommendations, informed by qualitative evidence, theory, and stakeholder input. Further longitudinal evaluation is necessary to determine how successful the recommendations are in practice.

Irrational use of antibiotics in Iran from the perspective of complex adaptive systems: redefining the challenge

Background

Irrational use of antibiotics is proving to be a major concern to the health systems globally. This results in antibiotics resistance and increases health care costs. In Iran, despite many years of research, appreciable efforts, and policymaking to avoid irrational use of antibiotics, yet indicators show suboptimal use of antibiotics, pointing to an urgent need for adopting alternative approaches to further understand the problem and to offer new solutions. Applying the Complex Adaptive Systems (CAS) theory, to explore and research health systems and their challenges has become popular. Therefore, this study aimed to better understand the complexity of the irrational use of antibiotics in Iran and to propose potential solutions.

Method

This research utilized a CAS observatory tool to qualitatively collect and analyse data. Twenty interviews and two Focus Group discussions were conducted. The data was enriched with policy document reviews to fully understand the system. MAXQDA software was used to organize and analyze the data.

Result

We could identify several diverse and heterogeneous, yet highly interdependent agents operating at different levels in the antibiotics use system in Iran. The network structure and its adaptive emergent behavior, information flow, governing rules, feedback and values of the system, and the way they interact were identified. The findings described antibiotics use as emergent behavior that is formed by an interplay of many factors and agents over time. According to this study, insufficient and ineffective interaction and information flow regarding antibiotics between agents are among key causes of irrational antibiotics use in Iran. Results showed that effective rules to minimize irrational use of antibiotics are missing or can be easily disobeyed. The gaps and weaknesses of the system which need redesigning or modification were recognized as well.

Conclusion

The study suggests re-engineering the system by implementing several system-level changes including establishing strong, timely, and effective interactions between identified stakeholders, which facilitate information flow and provision of on-time feedback, and create win-win rules in a participatory manner with stakeholders and the distributed control system.

Participatory simulation modeling to inform colorectal cancer screening in a complex remote northern health system: Canada's Northwest Territories

BACKGROUND & AIMS

Colorectal cancer (CRC) mortality in the Northwest Territories (NWT), a northern region of Canada, could be reduced by implementing a CRC screening program. However, this may require additional colonoscopy resources. We used participatory simulation modeling to predict colonoscopy demand and to develop strategies for implementing a feasible and effective CRC screening program in this complex remote northern health system.

METHODS

Using a participatory simulation modeling approach, we first developed a conceptual model of CRC screening with local collaborators. This approach informed our parameter adjustments of an existing microsimulation model, OncoSim-CRC, using data from a retrospective cohort review of CRC screening between 2014-2019 and secondary data. Model scenarios reflecting program implementation were run for 500 million cases. Validity was assessed, and outputs analyzed with collaborators. Alternative scenarios were developed to reduce colonoscopy demand and results were presented to end-users.

RESULTS

We estimated that colonoscopy demand with a CRC screening program phased-in over 5 years would surpass capacity within 2 years. If demand is met, screen-detected cancers would increase by 110 %, and clinically-detected cases would reduce by 26 % over the next 30 years. We also found that prolonging the phase-in period, or revising adenoma follow-up guidelines would reduce colonoscopy demand while still improving cancer detection. Both strategies were considered feasible by collaborators. The adjusted model was valid, and the projections informed local end-users plans for CRC screening delivery.

CONCLUSIONS

Using participatory simulation modeling, we projected that a screening program would improve CRC detection but surpass current colonoscopy capacity. Phasing-in the screening program and reducing endoscopic adenoma follow-up would enhance feasibility of a CRC screening program in the NWT and help maintain its effectiveness.

Developing Tools to Enhance the Adaptive Capacity (Safety II) of Health Care Providers at a Children's Hospital

Current safety efforts in health care use Safety I (find and fix), which has benefits and shortcomings. Safety leaders in multiple industries realize that complex adaptive systems require a new approach-Safety II (proactive safety). Our goal was to develop practical, usable tools to spread Safety II and resilience engineering competencies to clinical frontline staff. Using our prior research and Plan-Do-Study-Act cycles, we developed tools to enhance Safety II competencies that individuals with various backgrounds could understand. Tools address recognizing (Pause to Predict), responding (IDEA), and learning (Feed Forward). These are being taught organizationally in a unit-by-unit sequence. Use of these tools is expected to prompt a shift toward a more proactive mental model of safety that we want our frontline providers to adopt. Coordinating the expertise of bedside clinicians during unprecedented events can safely expand the boundaries of conditions under which we can provide high-quality care by increasing individuals' and subsequently our systems' adaptive capacity. We believe this is the first work describing attempts to operationalize Safety II concepts broadly in a health care organization.

Perspectives of Australian hospital leaders on the provision of safe care: implications for safety I and safety II

Purpose

There is evidence that patient safety has not improved commensurate with the global attention and resources dedicated to achieving it. The authors explored the perspectives of hospital leaders on the challenges of leading safe care.

Design/methodology/approach

This paper reports the findings of a three-year longitudinal study of eight Australian hospitals. A representative sample of hospital leaders, comprising board members, senior and middle managers and clinical leaders, participated in focus groups twice a year from 2015 to 2017.

Findings

Although the participating hospitals had safety I systems, the leaders consistently reported that they relied predominantly on their competent well-meaning staff to ensure patient safety, more of a safety II perspective. This trust was based on perceptions of the patient safety actions of staff, rather than actual knowledge about staff abilities or behaviours. The findings of this study suggest this hegemonic relational trust was a defence mechanism for leaders in complex adaptive systems (CASs) unable to influence care delivery at the front line and explores potential contributing factors to these perceptions.

Practical implications

In CASs, leaders have limited control over the bedside care processes and so have little alternative but to trust in “good staff providing good care” as a strategy for safe care. However, trust, coupled with a predominantly safety 1 approach is not achieving harm reduction. The findings of the study suggest that the beliefs the leaders held about the role their staff play in assuring safe care contribute to the lack of progress in patient safety. The authors recommend three evidence-based leadership activities to transition to the proactive safety II approach to pursuing safe care.

Originality/value

This is the first longitudinal study to provide the perspectives of leaders on the provision of quality and safety in their hospitals. A large sample of board members, managers and clinical leaders provides extensive data on their perspectives on quality and safety.

External validation of the detection of indicators and vulnerabilities for emergency room trips (DIVERT) scale: a retrospective cohort study

Background

The Detection of Indicators and Vulnerabilities of Emergency Room Trips (DIVERT) scale was developed to classify and estimate the risk of emergency department (ED) use among home care clients. The objective of this study was to externally validate the DIVERT scale in a secondary population of home care clients.

Methods

We conducted a retrospective cohort study, linking data from the Home Care Reporting System and the National Ambulatory Care Reporting System. Data were collected on older long-stay home care clients who received a RAI Home Care (RAI-HC) assessment. Data were collected for home care clients in the Canadian provinces of Ontario and Alberta, as well as in the cities of Winnipeg, Manitoba and Whitehorse, Yukon Territories between April 1, 2011 and September 30, 2014. The DIVERT scale was originally derived from the items of the RAI-HC through the use of recursive partitioning informed by a multinational clinical panel. This scale is currently implemented alongside the RAI-HC in provinces across Canada. The primary outcome of this study was ED visitation within 6 months of a RAI-HC assessment.

Results

The cohort contained 1,001,133 home care clients. The vast majority of cases received services in Ontario (88%), followed by Alberta (8%), Winnipeg (4%), and Whitehorse (< 1%). Across the four cohorts, the DIVERT scale demonstrated similar discriminative ability to the original validation work for all outcomes during the six-month follow-up: ED visitation (AUC = 0.617–0.647), two or more ED visits (AUC = 0.628–0.634) and hospital admission (AUC = 0.617–0.664).

Conclusions

The findings of this study support the external validity of the DIVERT scale. More specifically, the predictive accuracy of the DIVERT scale from the original work was similar to the accuracy demonstrated within a new cohort, created from different geographical regions and time periods.

Resilient Health Care: a systematic review of conceptualisations, study methods and factors that develop resilience

BACKGROUND

Traditional approaches to safety management in health care have focused primarily on counting errors and understanding how things go wrong. Resilient Health Care (RHC) provides an alternative complementary perspective of learning from incidents and understanding how, most of the time, work is safe. The aim of this review was to identify how RHC is conceptualised, described and interpreted in the published literature, to describe the methods used to study RHC, and to identify factors that develop RHC.

METHODS

Electronic searches of PubMed, Scopus and Cochrane databases were performed to identify relevant peer-reviewed studies, and a hand search undertaken for studies published in books that explained how RHC as a concept has been interpreted, what methods have been used to study it, and what factors have been important to its development. Studies were evaluated independently by two researchers. Data was synthesised using a thematic approach.

RESULTS

Thirty-six studies were included; they shared similar descriptions of RHC which was the ability to adjust its functioning prior to, during, or following events and thereby sustain required operations under both expected and unexpected conditions. Qualitative methods were mainly used to study RHC. Two types of data sources have been used: direct (e.g. focus groups and surveys) and indirect (e.g. observations and simulations) data sources. Most of the tools for studying RHC were developed based on predefined resilient constructs and have been categorised into three categories: performance variability and Work As Done, cornerstone capabilities for resilience, and integration with other safety management paradigms. Tools for studying RHC currently exist but have yet to be fully implemented. Effective team relationships, trade-offs and health care 'resilience' training of health care professionals were factors used to develop RHC.

CONCLUSIONS

Although there was consistency in the conceptualisation of RHC, methods used to study and the factors used to develop it, several questions remain to be answered before a gold standard strategy for studying RHC can confidently be identified. These include operationalising RHC assessment methods in multi-level and diverse settings and developing, testing and evaluating interventions to address the wider safety implications of RHC amidst organisational and institutional change.

Failure to Rescue Event Mitigation System Assessment: A Mixed-methods Approach to Analysis of Complex Adaptive Systems

Although it is widely acknowledged that health care delivery systems are complex adaptive systems, there are gaps in understanding the application of systems engineering approaches to systems analysis and redesign in the health care domain. Commonly employed methods, such as statistical analysis of risk factors and outcomes, are simply not adequate to robustly characterize all system requirements and facilitate reliable design of complex care delivery systems. This is especially apparent in institutional-level systems, such as patient safety programs that must mitigate the risk of infections and other complications that can occur in virtually any setting providing direct and indirect patient care. The case example presented here illustrates the application of various system engineering methods to identify requirements and intervention candidates for a critical patient safety problem known as failure to rescue. Detailed descriptions of the analysis methods and their application are presented along with specific analysis artifacts related to the failure to rescue case study. Given the prevalence of complex systems in health care, this practical and effective approach provides an important example of how systems engineering methods can effectively address the shortcomings in current health care analysis and design, where complex systems are increasingly prevalent.

An ontology-driven framework to support the dynamic formation of an interdisciplinary healthcare team

BACKGROUND AND PURPOSE

Teamwork has become a modus operandi in healthcare and delivery of patient care by an interdisciplinary healthcare team (IHT) is now a prevailing modality of care. We argue that a formal and automated support framework is needed for an IHT to properly leverage information technology resources. Such a framework should allow for patient preferences and expand a representation of a clinical workflow with a formal model of dynamic formation of a team, especially with regards to team leader- and membership, and the assignment of tasks to team members. Our goal was to develop such a support framework, present its prototype software implementation and verify the implementation using a proof-of-concept use case. Specifically, we focused on clinical workflows for in-patient tertiary care and on patient preferences with regards to selecting team members and team leaders.

MATERIALS AND METHODS

Drawing on the research on clinical teamwork we defined the conceptual foundations for the proposed framework. Then, we designed its architecture and used ontology-driven design and first-order logic with associated reasoning methods to create and operationalize architectural elements. Finally, we incorporated existing solutions for business workflow modeling and execution as a backend for implementing the proposed framework.

RESULTS

We developed a Team and Workflow Management Framework (TWMF) with semantic components that allow for formalizing and operationalizing team formation in in-patient tertiary care setting and support provider-related patient preferences. We also created a prototype software implementation of TWMF using the IBM Business Process Manager platform. This implementation was evaluated in several simulated patient scenarios.

CONCLUSIONS

TWMF integrates existing workflow technologies and extends them with the capabilities to support dynamic formation of an IHT. Results of this research can be used to support real-time execution of clinical workflows, or to simulate their execution in order to assess the impact of various conditions (e.g., patterns of work shifts, staffing) on IHT operations.

Triaging the Terminally Ill-Development of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool

CONTEXT

Evidence-based resource allocation is receiving increasing attention as we strive for equity, transparency, and cost-effectiveness across health care. In the context of finite resources, which of our patients with terminal illness should be prioritized for urgent palliative care?

OBJECTIVES

To develop the scoring system for the novel Responding to Urgency of Need in Palliative Care triage tool.

METHODS

Online international discrete choice experiment involving palliative care clinicians to establish the relative importance of seven key attributes of palliative care triage identified during an earlier qualitative study.

RESULTS

Participants (n = 772) were mainly female (79.9%) with a decade of clinical experience. All attributes contributed significantly (all P-values < 0.001) and independently to clinician assessment of urgency. This study found physical suffering (coefficient 3.45; 95% confidence interval: 3.24 to 3.66) was the most important determinant of urgency, followed by imminent dying (coefficient 1.56; 1.43 to 1.69), psychological suffering (coefficient 1.49; 1.37 to 1.60), caregiver distress (coefficient 1.47; 1.35 to 1.59), discrepancy between care needs and care arrangements (coefficient 1.14; 1.02 to 1.26), mismatch between current and desired site of care (coefficient 0.94; 0.85 to 1.03), and unmet communication needs (coefficient 0.84; 0.76 to 0.92).

CONCLUSION

Palliative care triage, which is complex and contextual, has been made more transparent through this discrete choice experiment. The Responding to Urgency of Need in Palliative Care triage tool provides an important step toward evidence-based assessment of priority for palliative care. Further research is underway to determine the validity of the tool in clinical practice and its impact on patient and caregiver outcomes.

Designing for Physician Trust: Toward a Machine Learning Decision Aid for Radiation Toxicity Risk

The application of machine learning (ML) technologies in health care is expected to improve care delivery and patient outcomes. However, there are no best practices for designing these technologies for use in clinical settings. To explore user needs and design requirements for a user interface of a ML risk prediction tool in development, we consulted with subject matter experts and physicians. We explored physician expectations of using a ML tool in clinical practice and their preferences on designs. Our process revealed physician perspectives on trusting a ML tool and opportunities to design for these considerations, while navigating ambiguity in the tool’s outputs.

A transformative translational change programme to introduce genomics into healthcare: a complexity and implementation science study protocol

INTRODUCTION

Translating scientific advances in genomic medicine into evidence-based clinical practice is challenging. Studying the natural translation of genomics into 'early-adopting' health system sectors is essential. We will (a) examine 29 health systems (Australian and Melbourne Genomics Health Alliance flagships) integrating genomics into practice and (b) combine this learning to co-design and test an evidence-based generalisable toolkit for translating genomics into healthcare.

METHODS AND ANALYSIS

Twenty-nine flagships integrating genomics into clinical settings are studied as complex adaptive systems to understand emergent and self-organising behaviours among inter-related actors and processes. The Effectiveness-Implementation Hybrid approach is applied to gather information on the delivery and potential for real-world implementation. Stages '1' and '2a' (representing hybrid model 1) are the focus of this protocol. The Translation Science to Population Impact (TSci Impact) framework is used to study policy decisions and service provision, and the Theoretical Domains Framework (TDF) is used to understand individual level behavioural change; both frameworks are applied across stages 1 and 2a. Stage 1 synthesises interview data from 32 participants involved in developing the genomics clinical practice systems and approaches across five 'demonstration-phase' (early adopter) flagships. In stage 2a, stakeholders are providing quantitative and qualitative data on process mapping, clinical audits, uptake and sustainability (TSci Impact), and psychosocial and environmental determinants of change (TDF). Findings will be synthesised before codesigning an intervention toolkit to facilitate implementation of genomic testing. Study methods to simultaneously test the comparative effectiveness of genomic testing and the implementation toolkit (stage 2b), and the refined implementation toolkit while simply observing the genomics intervention (stage 3) are summarised.

ETHICS AND DISSEMINATION

Ethical approval has been granted. The results will be disseminated in academic forums and used to refine interventions to translate genomics evidence into healthcare. Non-traditional academic dissemination methods (eg, change in guidelines or government policy) will also be employed.

Applications of artificial neural networks in health care organizational decision-making: A scoping review

Health care organizations are leveraging machine-learning techniques, such as artificial neural networks (ANN), to improve delivery of care at a reduced cost. Applications of ANN to diagnosis are well-known; however, ANN are increasingly used to inform health care management decisions. We provide a seminal review of the applications of ANN to health care organizational decision-making. We screened 3,397 articles from six databases with coverage of Health Administration, Computer Science and Business Administration. We extracted study characteristics, aim, methodology and context (including level of analysis) from 80 articles meeting inclusion criteria. Articles were published from 1997–2018 and originated from 24 countries, with a plurality of papers (26 articles) published by authors from the United States. Types of ANN used included ANN (36 articles), feed-forward networks (25 articles), or hybrid models (23 articles); reported accuracy varied from 50% to 100%. The majority of ANN informed decision-making at the micro level (61 articles), between patients and health care providers. Fewer ANN were deployed for intra-organizational (meso- level, 29 articles) and system, policy or inter-organizational (macro- level, 10 articles) decision-making. Our review identifies key characteristics and drivers for market uptake of ANN for health care organizational decision-making to guide further adoption of this technique.

Novel application of discrete choice experiment methodology to understand how clinicians around the world triage palliative care needs: A research protocol

Objective

As referrals to specialist palliative care (PC) grow in volume and diversity, an evidence-based triage method is needed to enable services to manage waiting lists in a transparent, efficient, and equitable manner. Discrete choice experiments (DCEs) have not to date been used among PC clinicians, but may serve as a rigorous and efficient method to explore and inform the complex decision-making involved in PC triage. This article presents the protocol for a novel application of an international DCE as part of a mixed-method research program, ultimately aiming to develop a clinical decision-making tool for PC triage.

Method

Five stages of protocol development were undertaken: (1) identification of attributes of interest; (2) creation and (3) execution of a pilot DCE; and (4) refinement and (5) planned execution of the final DCE.

Result

Six attributes of interest to PC triage were identified and included in a DCE that was piloted with 10 palliative care practitioners. The pilot was found to be feasible, with an acceptable cognitive burden, but refinements were made, including the creation of an additional attribute to allow independent analysis of concepts involved. Strategies for recruitment, data collection, analysis, and modeling were confirmed for the final planned DCE.

Significance of results

This DCE protocol serves as an example of how the sophisticated DCE methodology can be applied to health services research in PC. Discussion of key elements that improved the utility, integrity, and feasibility of the DCE provide valuable insights.

Seven Core Principles of Substance Use Treatment System Design to Aid in Identifying Strengths, Gaps, and Required Enhancements

OBJECTIVE

System planners and funders encounter many challenges in taking action toward evidence-informed enhancement of substance use treatment systems. Researchers are increasingly asked to contribute expertise to these processes through comprehensive system reviews. In this role, all parties can benefit from guiding frameworks to help organize key questions and data collection activities, and thereby set the stage for both high-level and on-the-ground strategic directions and recommendations. This article summarizes seven core principles of substance use treatment system design that are supported by a large international evidence base and that together have proven applicable as a framework for several systems review projects conducted predominantly in Canada.

METHOD

The methodology was based on a narrative review approach.

RESULTS

The principles address a wide range of issues. Specifically, a broad systems approach is needed to address the full spectrum of issues; accessibility and effectiveness are improved through collaboration across stakeholders; a range of system supports are needed; need for services should be grounded in self-determination, holistic cultural practices, choice, and partnership; attention to diversity and social-structural disadvantages are crucial to equitable system design; systematic screening and assessment is needed to match people to appropriate treatment services in a stepped service framework; and, last, individualized treatment planning must include the right mix of evidence-informed interventions.

CONCLUSIONS

By bringing researchers and stakeholders back to the high-level goals of substance use treatment systems, these principles provide a comprehensive, evidence-based, organizing framework that has the potential to improve the quality of system design and review internationally.

Impact of a Pharmacist-Led Intervention on 30-Day Readmission and Assessment of Factors Predictive of Readmission in African American Men With Heart Failure

Heart failure (HF) is responsible for more 30-day readmissions than any other condition. Minorities, particularly African American males (AAM), are at much higher risk for readmission than the general population. In this study, demographic, social, and clinical data were collected from the electronic medical records of 132 AAM patients (control and intervention) admitted with a primary or secondary admission diagnosis of HF. Both groups received guideline-directed therapy for HF. Additionally the intervention group received a pharmacist-led intervention. Data collected from these patients were used to develop and validate a predictive model to evaluate the impact of the pharmacist-led intervention, and identify predictors of readmission in this population. After propensity score matching, the intervention was determined to have a significant impact on readmission, as a significantly smaller proportion of patients in the intervention group were readmitted as compared to the control group (11.5% vs. 42.9%; p = .03). A predictive model for 30-day readmission was developed using K-nearest neighbor (KNN) classification algorithm. The model was able to correctly classify about 71% patients with an AUROC of 0.70. Additionally, the model provided a set of key patient attributes predictive of readmission status. Among these predictive attributes was whether or not a patient received the intervention. A relative risk analysis identified that patients who received the intervention are less likely to be readmitted within 30 days. This study demonstrated the benefit of a pharmacist-led intervention for AAM with HF. Such interventions have the potential to improve quality of life for this patient population.

Leadership experiences and practices of South African health managers: what is the influence of gender? -a qualitative, exploratory study

BACKGROUND

The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women's full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being 'left behind' in terms of career development and progression into senior health leadership positions.

METHODS

Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments.

RESULTS

Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the 'first' to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture.

CONCLUSION

This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play.

Balancing Health Information Exchange and Privacy Governance from a Patient-Centred Connected Health and Telehealth Perspective

Objectives:  Connected healthcare is an essential part of patient-centred care delivery. Technology such as telehealth is a critical part of connected healthcare. However, exchanging health information brings the risk of privacy issues. To better manage privacy risks we first need to understand the different patterns of patient-centred care in order to tailor solutions to address privacy risks.

Methods:  Drawing upon published literature, we develop a business model to enable patient-centred care via telehealth. The model identifies three patient-centred connected health patterns. We then use the patterns to analyse potential privacy risks and possible solutions from different types of telehealth delivery.

Results:  Connected healthcare raises the risk of unwarranted access to health data and related invasion of privacy. However, the risk and extent of privacy issues differ according to the pattern of patient-centred care delivery and the type of particular challenge as they enable the highest degree of connectivity and thus the greatest potential for privacy breaches.

Conclusion:  Privacy issues are a major concern in telehealth systems and patients, providers, and administrators need to be aware of these privacy issues and have guidance on how to manage them. This paper integrates patient-centred connected health care, telehealth, and privacy risks to provide an understanding of how risks vary across different patterns of patient-centred connected health and different types of telehealth delivery.

Strategic planning in an academic radiation medicine program

Background

In this paper, we report on the process of strategic planning in the Radiation Medicine Program (rmp) at the Princess Margaret Cancer Centre. The rmp conducted a strategic planning exercise to ensure that program priorities reflect the current health care environment, enable nimble responses to the increasing burden of cancer, and guide program operations until 2020.

Methods

Data collection was guided by a project charter that outlined the project goal and the roles and responsibilities of all participants. The process was managed by a multidisciplinary steering committee under the guidance of an external consultant and consisted of reviewing strategic planning documents from close collaborators and institutional partners, conducting interviews with key stakeholders, deploying a program-wide survey, facilitating an anonymous and confidential e-mail feedback box, and collecting information from group deliberations.

Results

The process of strategic planning took place from December 2014 to December 2015. Mission and vision statements were developed, and core values were defined. A final document, Strategic Roadmap to 2020, was established to guide programmatic pursuits during the ensuing 5 years, and an implementation plan was developed to guide the first year of operations.

Conclusions

The strategic planning process provided an opportunity to mobilize staff talents and identify environmental opportunities, and helped to enable more effective use of resources in a rapidly changing health care environment. The process was valuable in allowing staff to consider and discuss the future, and in identifying strategic issues of the greatest importance to the program. Academic programs with similar mandates might find our report useful in guiding similar processes in their own organizations.

Analysing a Chinese Regional Integrated Healthcare Organisation Reform Failure using a Complex Adaptive System Approach

Introduction:

China’s organised health system has remained outdated for decades. Current health systems in many less market-oriented countries still adhere to traditional administrative-based directives and linear planning. Furthermore, they neglect the responsiveness and feedback of institutions and professionals, which often results in reform failure in integrated care. Complex adaptive system theory (CAS) provides a new perspective and methodology for analysing the health system and policy implementation.

Methods:

We observed the typical case of Qianjiang’s Integrated Health Organization Reform (IHO) for 2 years to analyse integrated care reforms using CAS theory. Via questionnaires and interviews, we observed 32 medical institutions and 344 professionals. We compared their cooperative behaviours from both organisational and inter-professional levels between 2013 and 2015, and further investigated potential reasons for why medical institutions and professionals did not form an effective IHO. We discovered how interested parties in the policy implementation process influenced reform outcome, and by theoretical induction, proposed a new semi-organised system and corresponding policy analysis flowchart that potentially suits the actual realisation of CAS.

Results:

The reform did not achieve its desired effect. The Qianjiang IHO was loosely integrated rather than closely integrated, and the cooperation levels between organisations and professionals were low. This disappointing result was due to low mutual trust among IHO members, with the main contributing factors being insufficient financial incentives and the lack of a common vision.

Discussion and Conclusions:

The traditional organised health system is old-fashioned. Rather than being completely organised or adaptive, the health system is currently more similar to a semi-organised system. Medical institutions and professionals operate in a middle ground between complete adherence to administrative orders from state-run health systems and completely adapting to the market. Thus, decision-making, implementation and analysis of health policies should also be updated according to this current standing. The simplest way to manage this new system is to abandon linear top-down orders and patiently wait for an explicit picture of IHO mechanisms to be revealed after complete and spontaneous negotiation between IHO allies is reached. In the meantime, bottom-up feedback from members should be paid attention to, and common benefits and fluid information flow should be prioritised in building a successful IHO.