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

A decade of change towards Value-Based Health Care at a Dutch University Hospital: a complexity-informed process study

BACKGROUND

While healthcare organizations in several countries are embracing Value-Based Health Care (VBHC), there are limited insights into how to achieve this paradigm shift. This study examines the decade-long (2012-2023) change towards VBHC in a pioneering Dutch university hospital.

METHOD

Through retrospective, complexity-informed process research, we study how a Dutch university hospital's strategy to implement VBHC evolved, how implementation outcomes unfolded, and the underlying logic behind these developments. Data include the hospital's internal documents (n = 10,536), implementation outcome indicators (n = 4), a survey among clinicians (n = 47), and interviews with individuals contributing to VBHC at the hospital level (n = 20).

RESULTS

The change towards VBHC is characterized by three sequential strategies. Initially, the focus was on deep change through local, tailored implementation of multiple VBHC elements. The strategy then transitioned to a hospital-wide program aimed at evolutionary change on a large scale, emphasizing the integration of VBHC into mainstream IT and policies. Recognizing the advantages and limitations of both strategies, the hospital currently adopts a "hybrid" strategy. This strategy delicately combines deep and broad change efforts. The strategy evolved based on accumulated insights, contextual developments and shifts in decision-makers. The complexity of change was downplayed in plans and stakeholder communication. By the end of 2023, 68 (sub)departments engaged in VBHC, enabled to discuss patients' responses to Patient Reported Outcomes Measures (PROMs) during outpatient care. However, clinicians' use of PROMs data showed limitations. While pioneers delved deeper into VBHC, laggards have yet to initiate it.

CONCLUSIONS

VBHC does not lend itself to linear planning and is not easily scalable. While there appears to be no golden standard for implementation, blending local and larger-scale actions appears advantageous. Local, deep yet harmonized and system-integrated changes culminate in large scale transformation. Embracing complexity and focusing on the ultimate aims of (re)institutionalization and (re)professionalization are crucial.

Creating a framework for change: transitioning to value-based healthcare in Queensland

Value-based healthcare has been described as the sustainable, equitable and transparent use of healthcare resources to achieve improved experiences and outcomes for people and communities. It is supported by all levels of government in Australia, with recent initiatives championing a shift away from traditional, clinician-centric care delivery to a more contemporary, value-based approach. To date, however, efforts in Queensland have focused on smaller scale siloed models of care and have not extended to the transformational change required to create equitable and sustainable healthcare delivery. The Queensland Health Allied Health Framework for Value-Based Health Care (the Framework) builds on contemporary frameworks with reference to the local context in Queensland and provides a structure and starting point for clinicians and managers to work together with consumers to transform services to focus on preventative health and wellbeing, shifting the focus of care to the community and sustainably improving the quality of care delivered. The Framework outlines key considerations for the design and implementation of new services, including understanding the care pathway, supporting an outcome driven workplace culture, measuring what matters and designing for outcomes. Several key lessons were learnt during the development of the Framework, including the importance of early and sustained consumer partnerships, of establishing a shared definition of value-based healthcare that enables integration across the care pathway and the need for leadership at all levels to actively support the change management process. While developed for Queensland public allied health services, the Framework is intended to be a system-wide tool relevant to all health professionals and services.

The Voice of Patients Really Matters: Using Patient-Reported Outcomes and Experiences Measures to Assess Effectiveness of Home-Based Integrated Care-A Scoping Review of Practice

Background: The aim of the study is to analyze the prevalence of using patients’ reported outcomes measures and experiences (PROMs and PREMs) in relation to integrated care (IC). Material and methods: To select eligible studies (<10 years, full-text), PubMed was used. The general subject of the articles referring to the type of disease was indicated on the basis of a review of all full-text publications discussing the effectiveness of IC (N = 6518). The final search included MeSH headings related to outcomes measures and IC. Full-text screening resulted in including 73 articles (23 on COPD, 40 on diabetes/obesity and 10 on depression) with 93.391 participants. Results: Analysis indicated that authors used multiple outcome measures, with 54.8% of studies including at least one patient reported. PROMs were more often used than PREMs. Specific (disease or condition/dimension) outcome measures were reported more often than general, especially those dedicated to self-assessment of health in COPD and depression. PROMs and PREMs were most commonly used in studies from the USA and Netherlands. Conclusion: Using PROMS/PREMS is becoming more popular, although it is varied, both due to the place of research and type of disease.

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

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

The relationship between the living lab approach and successful implementation of healthcare innovations: an integrative review

OBJECTIVES

The concept of living labs as a research method to enhance participation of end-users in the development and implementation process of an innovation, gained increasing attention over the past decade. A living lab can be characterised by five key components: user-centric, cocreation, real-life context, test innovation and open innovation. The purpose of this integrative literature review was to summarise the literature on the relationship between the living lab approach and successful implementation of healthcare innovations.

METHODS

An integrative literature review searching PubMed, EMBASE, PsycINFO and Cinahl databases between January 2000 and December 2019. Studies were included when a living lab approach was used to implement innovations in healthcare and implementation outcomes were reported. Included studies evaluated at least one of the following implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration or sustainability. Quality was assessed based on a tool developed by Hawker et al.

RESULTS

Of the 1173 retrieved articles, 30 studies were included of which 11 of high quality. Most studies involved a combination of patients/public (N=23) and providers (N=17) as key stakeholders in the living lab approach. Living lab components were mostly applied in the development phase of innovations (N=21). The majority of studies reported on achievement of acceptability (N=22) and feasibility (N=17) in terms of implementation outcomes. A broader spectrum of implementation outcomes was only evaluated in one study. We found that in particular six success factors were mentioned for the added-value of using living lab components for healthcare innovations: leadership, involvement, timing, openness, organisational support and ownership.

CONCLUSIONS

The living lab approach showed to contribute to successful implementation outcomes. This integrative review suggests that using a living lab approach fosters collaboration and participation in the development and implementation of new healthcare innovations.

PROSPERO REGISTRATION NUMBER

CRD42020166895.

The implementation of value-based healthcare: a scoping review

Background

The aim of this study was to identify and summarize how value-based healthcare (VBHC) is conceptualized in the literature and implemented in hospitals. Furthermore, an overview was created of the effects of both the implementation of VBHC and the implementation strategies used.

Methods

A scoping review was conducted by searching online databases for articles published between January 2006 and February 2021. Empirical as well as non-empirical articles were included.

Results

1729 publications were screened and 62 were used for data extraction. The majority of the articles did not specify a conceptualization of VBHC, but only conceptualized the goals of VBHC or the concept of value. Most hospitals implemented only one or two components of VBHC, mainly the measurement of outcomes and costs or Integrated Practice Units (IPUs). Few studies examined effects. Implementation strategies were described rarely, and were evaluated even less.

Conclusions

VBHC has a high level of interpretative variability and a common conceptualization of VBHC is therefore urgently needed. VBHC was proposed as a shift in healthcare management entailing six reinforcing steps, but hospitals have not implemented VBHC as an integrative strategy. VBHC implementation and effectiveness could benefit from the interdisciplinary collaboration between healthcare and management science.

Trial registration

This scoping review was registered on Open Science Framework https://osf.io/jt4u7/ (OSF | The implementation of Value-Based Healthcare: a Scoping Review). 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07489-2.

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

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

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

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

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

Optimising Integrated Stroke Care in Regional Networks: A Nationwide Self-Assessment Study in 2012, 2015 and 2019

Background:

To help enhance the quality of integrated stroke care delivery, regional stroke services networks in the Netherlands participated in a self-assessment study in 2012, 2015 and 2019.

Methods:

Coordinators of the regional stroke services networks filled out an online self-assessment questionnaire in 2012, 2015 and 2019. The questionnaire, which was based on the Development Model for Integrated Care, consisted of 97 questions in nine clusters (themes). Cluster scores were calculated as proportions of the activities implemented. Associations between clusters and features of stroke services were assessed by regression analysis.

Results:

The response rate varied from 93.1% (2012) to 85.5% (2019). Over the years, the regional stroke services networks increased in ‘size’: the median number of organisations involved and the volume of patients per network increased (7 and 499 in 2019, compared to 5 and 364 in 2012). At the same time, fewer coordinators were appointed for more than 1 day a week in 2019 (35.1%) compared to 2012 (45.9%). Between 2012 and 2019, there were statistically significantly more elements implemented in four out of nine clusters: ‘Transparent entrepreneurship’ (MD = 18.0% F(1) = 10.693, p = 0.001), ‘Roles and tasks’ (MD = 14.0% F(1) = 9.255, p = 0.003), ‘Patient-centeredness’ (MD = 12.9% F(1) = 9.255, p = 0.003), and ‘Commitment’ (MD = 11.2%, F(1) = 4.982, p = 0.028). A statistically significant positive correlation was found for all clusters between implementation of activities and age of the network. In addition, the number of involved organisations is associated with better execution of implemented activities for ‘Transparent entrepreneurship’, ‘Result-focused learning’ and ‘Quality of care’. Conversely, there are small but negative associations between the volume of patients and implementation rates for ‘Interprofessional teamwork’ and ‘Patient-centredness’.

Conclusion:

This long-term analyses of stroke service development in the Netherlands, showed that between 2012 and 2019, integrated care activities within the regional stroke networks increased. Experience in collaboration between organisations within a network benefits the uptake of integrated care activities.

Improving the Uptake of Transcatheter Aortic Valve Replacement in Ontario

Background The rising costs of healthcare delivery globally and the increasing research production rate create immense opportunities for implementing novel and more effective medical interventions that significantly benefit patient outcomes. However, the successful uptake of medical innovations is complex and often extremely contextual based on many sociopolitical and economic factors. These barriers to implementation can delay or derail new practices, procedures, products, and pharmaceuticals. Understanding the barriers to the successful implementation of medical innovations and the best practices and strategies to mitigate them is an extremely important area for translational research in health sciences. This study examines the barriers and potential challenges in implementing medical innovations and the possible preemptive measures that can be addressed early to increase the use of life-saving medical innovations. We consider the importance of appropriate, timely, and user-defined implementation techniques as a critical component of the successful uptake of medical innovations and use the uptake of transcatheter valve replacement therapy (TAVR), which is an alternative life-saving intervention for patients at risk for surgical complications, in Ontario, Canada as the practical case study of the challenges and potential instructive opportunities to establish best practices for systematic and effective innovation uptake. Methodology In addition to contextual and informal investigations, a small pilot survey of decision-makers across the University of Toronto-affiliated teaching hospitals helped compare and contrast the barriers to medical innovation uptake (in the literature) with the suggested barriers to the successful implementation of TAVR. This study looks primarily at the role of funding, physician preference, clinical guidelines, and patient comorbidities as decision-making factors contributing to TAVR uptake. The study also explores how the differences and similarities of TAVR uptake related to the decision-making factors above can help develop recommended strategies to address future implementation barriers. Results We observed that the decision-makers across the surveyed institutions refer patients with intermediate to high risk for surgery for TAVR. Funding and physician preference were identified as possible barriers to TAVR uptake, with underlying comorbidities of patients being a primary decision determinant for TAVR referral. Physician preferences were based on multiple factors such as clinical judgment, patient comorbidities, clinical guidelines, knowledge, TAVR, and surgical valve replacement skills. Conclusions To the best of our knowledge, this study is one of the first to use the Toronto Translational Thinking Framework to assess an innovative treatment uptake in the Ontario healthcare system. Although the study sample size was 11 and did not reflect the views of all decision-makers regarding TAVR use in Ontario, the survey reflected participants who directly make decisions regarding TAVR use, strengthening the credibility of the survey results. The insights from this study are intended to inform both the continued implementation of TAVR and to contribute to a broader field of investigation that aims to identify and operationalize the principles and best practices of translational research that may contribute to the efficacy of implementing other medical innovations in Ontario hospitals and beyond.