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Gray C, Lerner B, Egelfeld J, Robinson J, Urech T, Vashi A. What Should Healthcare Systems Consider When Modernizing Call Centers? Early Considerations From the Veterans Health Administration. J Healthc Manag 2024; 69:205-218. [PMID: 38728546 DOI: 10.1097/jhm-d-23-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
GOAL Growing numbers of hospitals and payers are using call centers to answer patients' clinical and administrative questions, schedule appointments, address billing issues, and offer supplementary care during public health emergencies and national disasters. In 2020, the Veterans Health Administration (VA) implemented VA Health Connect, an enterprise-wide initiative to modernize call centers. VA Health Connect is designed to improve the care experience with the convenience, flexibility, and simplicity of a single toll-free number connected to a range of 24/7 virtual services. The services are organized into four areas: administrative guidance for scheduling and general inquiries; pharmacy support for medication matters; clinical triage for evaluation of symptoms and recommended care; and virtual visits with providers for urgent and episodic care. Through a qualitative evaluation of VA Health Connect, we sought to identify the factors that affected the development of this program and to compile considerations to support the implementation of other enterprise-wide initiatives. METHODS The evaluation team interviewed 29 clinical and administrative leads from across the VA. These leads were responsible for the modernization of their local service networks. PhD-level qualitative methodologists conducted the interviews, asking participants to reflect on barriers and facilitators to modernization and implementation. The team employed a rapid qualitative analytic approach commonly used in healthcare research to distill robust results. PRINCIPAL FINDINGS A review of the early implementation of VA Health Connect found: (1) deadlines proved challenging but provided momentum for the initiative; (2) a balance between standardized processes and local adaptations facilitated implementation; (3) attention to staffing, hiring, and training of call center staff before implementation expedited workflows; (4) establishing national and local leadership commitment to the innovation from the onset increased team cohesion and efficacy; and (5) anticipating information technology infrastructure needs prevented delays to modernization and implementation. PRACTICAL APPLICATIONS Our findings suggest that healthcare systems would benefit from anticipating likely obstacles (e.g., delays in software implementations and negotiations with unions), thus providing ample time to secure leadership buy-in and identify local champions, communicating early and often, and supporting flexible implementation to meet local needs. VA leadership can use this evaluation to refine implementation, and it could also have important implications for regulators, federal health exchanges, insurers, and other healthcare systems when determining resource levels for call centers.
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Affiliation(s)
- Caroline Gray
- Center for Innovation and Implementation (Ci2i), Veterans Health Administration (VA) Palo Alto Health Care System, Palo Alto, California
| | - Barbara Lerner
- Center for Healthcare Organization & Implementation Research, VA Boston Health Care System, Boston, Massachusetts
| | | | | | | | - Anita Vashi
- Ci2i, VA Palo Alto Health Care System and Department of Emergency Medicine, University of California, San Francisco, and Department of Emergency Medicine (affiliated), Stanford University, Stanford, California
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Moses C. Effect of clinical engagement on value, standardisation, decision-making and savings in NHS product procurement. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:326-336. [PMID: 38578934 DOI: 10.12968/bjon.2024.33.7.326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
BACKGROUND UK healthcare expenditure is now £193.8 billion a year. The procurement function is seen as central to driving efficiencies within the NHS. This comes with an increasing onus on clinicians, including nurses and allied health professionals, to accept procurement outcomes to realise efficiency savings, with or without prior engagement. AIMS This empirical study seeks to examine whether clinical engagement in the procurement of healthcare products in the NHS is necessary to achieve value, savings and standardisation; it will thereby address a gap in the research. METHODS A multi-method qualitative case study design was used, which included a survey and eight semi-structured interviews. FINDINGS Results identified three factors that influence the achievement of value, savings and standardisation around clinical engagement: micro-level processes for clinical engagement; clinical stakeholders and clinical procurement professionals as experts at the centre of procurement activity; and clinical value in standardisation. A shift away from standardisation to resilience was identified, resulting from current market supply pressures. CONCLUSION This research brings empirically derived findings to address gaps in research, supports the benefit of clinical engagement through specific forums for collaboration at a trust level and provides a clinical/expert impact/preference matrix as a resource for procurement professionals to facilitate clinical engagement.
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Affiliation(s)
- Claire Moses
- Clinical Procurement Nurse Lead, Worcestershire Acute Hospitals NHS Trust
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3
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Mlaver E, Lynde GC, Sweeney JF, Sharma J. Generalizability of COBRA: A Parsimonious Perioperative Venous Thromboembolism Risk Assessment Model. J Surg Res 2024; 293:8-13. [PMID: 37690384 PMCID: PMC10843055 DOI: 10.1016/j.jss.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 06/30/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Standardized use of venous thromboembolism (VTE) risk assessment models (RAMs) in surgical patients has been limited, in part due to the cumbersome workflow addition required to use available models. The COBRA score-capturing cancer diagnosis, (old) age, body mass index, race, and American Society of Anesthesiologists Physical Status score-has been reported as a potentially automatable VTE RAM that circumvents the cumbersome workflow addition that most RAMs represent. We aimed to test the ability of the COBRA model to effectively risk-stratify patients across various populations. METHODS Patients were included from the 2014-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for two hospitals, representing colorectal, endocrine, breast, transplant, plastic, and general surgery services. COBRA score was calculated for each patient using preoperative characteristics. We calculated negative predictive value (NPV) for VTE outcomes and compared the COBRA score to NSQIP's expected VTE rate for all patients, between the two hospitals, and between subspecialty service lines. RESULTS Of the 10,711 patients included, those with COBRA <4 (31%) had projected median VTE rate of 0.21% (interquartile range, 0.09-0.68%; mean, 0.54%). Patients with higher scores (69%) had median rate of 0.88% (0.26-2.07%; 1.46%); relative rate 2.7. The median projected VTE rates for patients identified as low risk were 0.21% and 0.16% and as high risk were 0.87% and 0.89% at hospitals one and 2, respectively. The median projected VTE rates for patients identified as low risk were 0.17%, 0.61%, and 0.08% and as high risk were 0.52%, 1.43%, and 0.18% among general, colorectal, and endocrine surgery patients, respectively. COBRA had NPV of 0.995 and sensitivity of 0.871 as compared to NPV 0.997 and sensitivity 0.857 of the NSQIP model. CONCLUSIONS The COBRA score is concordant with the traditional gold standard NSQIP VTE RAM and demonstrates interhospital and service-specific generalizability, although performance was limited in especially low-risk patients. The model adequately risk-stratifies surgical patients preoperatively, potentially providing clinical decision support for perioperative workflows.
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Affiliation(s)
- Eli Mlaver
- Department of Surgery, Emory University Hospital, Atlanta, Georgia.
| | - Grant C Lynde
- Department of Anesthesiology, Emory University Hospital, Atlanta, Georgia
| | - John F Sweeney
- Department of Surgery, Emory University Hospital, Atlanta, Georgia
| | - Jyotirmay Sharma
- Department of Surgery, Emory University Hospital, Atlanta, Georgia
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Themelis K, Tang NKY. The Management of Chronic Pain: Re-Centring Person-Centred Care. J Clin Med 2023; 12:6957. [PMID: 38002572 PMCID: PMC10672376 DOI: 10.3390/jcm12226957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 11/26/2023] Open
Abstract
The drive for a more person-centred approach in the broader field of clinical medicine is also gaining traction in chronic pain treatment. Despite current advances, a further departure from 'business as usual' is required to ensure that the care offered or received is not only effective but also considers personal values, goals, abilities, and day-to-day realities. Existing work typically focuses on explaining pain symptoms and the development of standardised interventions, at the risk of overlooking the broader consequences of pain in individuals' lives and individual differences in pain responses. This review underscores the importance of considering additional factors, such as the influence of chronic pain on an individual's sense of self. It explores innovative approaches to chronic pain management that have the potential to optimise effectiveness and offer person-centred care. Furthermore, it delves into research applying hybrid and individual formulations, along with self-monitoring technologies, to enhance pain assessment and the tailoring of management strategies. In conclusion, this review advocates for chronic pain management approaches that align with an individual's priorities and realities while fostering their active involvement in self-monitoring and self-management.
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Affiliation(s)
- Kristy Themelis
- Department of Psychology, University of Warwick, Coventry CV4 7AL, UK
| | - Nicole K. Y. Tang
- Department of Psychology, University of Warwick, Coventry CV4 7AL, UK
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Chhabra HS, Tamai K, Alsebayel H, AlEissa S, Alqahtani Y, Arand M, Basu S, Blattert TR, Bussières A, Campello M, Costanzo G, Côté P, Darwano B, Franke J, Garg B, Hasan R, Ito M, Kamra K, Kandziora F, Kassim N, Kato S, Lahey D, Mehta K, Menezes CM, Muehlbauer EJ, Mullerpatan R, Pereira P, Roberts L, Ruosi C, Sullivan W, Shetty AP, Tucci C, Wadhwa S, Alturkistany A, Busari JO, Wang JC, Teli MG, Rajasekaran S, Mulukutla RD, Piccirillo M, Hsieh PC, Dohring EJ, Srivastava SK, Larouche J, Vlok A, Nordin M. SPINE20 recommendations 2023: One Earth, one family, one future WITHOUT spine DISABILITY. BRAIN & SPINE 2023; 3:102688. [PMID: 38020998 PMCID: PMC10668083 DOI: 10.1016/j.bas.2023.102688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of "One Earth, One Family, One Future WITHOUT Spine DISABILITY". Research question Not applicable. Material and methods Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results Seven recommendations were delivered to the G20 countries calling them to:-establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes.-eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty.-implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes.-monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity.-develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs.-ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan.-promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.
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Affiliation(s)
| | - Koji Tamai
- Osaka Metropolitan University, Osaka, Japan
| | | | - Sami AlEissa
- National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | | | | | | | | | - Marco Campello
- New York University Grossman School of Medicine, NY, USA
| | | | - Pierre Côté
- Ontario Tech University, Oshawa, Ontario, Canada
| | | | - Jörg Franke
- Klinikum Magdeburg gGmbH, Magdeburg, Germany
| | - Bhavuk Garg
- All India Institute of Medical Sciences, New Delhi, India
| | - Rumaisah Hasan
- Dr Tajuddin Chalid Hospital - Hasanuddin University, Makassar, Indonesia
| | - Manabu Ito
- National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | | | - Frank Kandziora
- Center for Spinal Surgery and Neurotraumatology, Frankfurt, Germany
| | - Nishad Kassim
- The Association of People with Disability, Bangalore, India
| | - So Kato
- The University of Tokyo, Tokyo, Japan
| | | | | | | | | | | | | | - Lisa Roberts
- University of Southampton, Southampton, United Kingdom
| | | | | | | | - Carlos Tucci
- Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Sanjay Wadhwa
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Jeffrey C. Wang
- University of Southern California Keck School of Medicine, CA, USA
| | | | | | | | | | - Patrick C. Hsieh
- University of Southern California Keck School of Medicine, CA, USA
| | | | | | | | - Adriaan Vlok
- Stellenbosch University, Cape Town, South Africa
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Cordasco KM, Gable AR, Ganz DA, Brunner JW, Smith AJ, Hertz B, Post EP, Fix GM. Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements. J Gen Intern Med 2023; 38:1007-1014. [PMID: 37798582 PMCID: PMC10593700 DOI: 10.1007/s11606-023-08285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/13/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.
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Affiliation(s)
- Kristina M Cordasco
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Alicia R Gable
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - David A Ganz
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Julian W Brunner
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | | | - Brian Hertz
- Edward Hines Jr. VA Hospital, Hines, IL, USA
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
- VA Central Office, Washington, DC, USA
| | - Edward P Post
- VA Central Office, Washington, DC, USA
- Ann Arbor VA Healthcare System, Ann Arbor, MI, USA
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gemmae M Fix
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law Policy & Management, Boston University School of Public Health, Boston, MA, USA
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Aubert I, Kletz F, Sardas JC. The Patient as an Actor in His Care Pathway: Insights From the French Case. Health Serv Insights 2023; 16:11786329231196029. [PMID: 37781645 PMCID: PMC10540579 DOI: 10.1177/11786329231196029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 08/03/2023] [Indexed: 10/03/2023] Open
Abstract
In France, patients' right to take part in decisions regarding their health has been recognized by law since 2002. This legal recognition was the outcome of a long-standing call to allow all individuals to be "actors in their own health" and to co-develop their care pathway with the professionals involved. In practice, care pathways simultaneously intertwine both standardization and personalization dynamics, which involve different forms of professional-patient interaction. This article analyses the links between the organizational variables of care pathways, and the ways in which patients are involved in the management of their own pathway. To date, these links have received little attention in the management science and health literatures. We draw on material from a case study carried out in 2 French territories, combining the analysis of patient pathways with interviews conducted with professionals and carers. Building on this analysis, we propose a typology of patient profiles which distinguishes between their different forms of involvement in the development of their care pathway, based on its organizational characteristics.
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Affiliation(s)
| | - Frédéric Kletz
- Mines Paris - Université PSL, Centre de Gestion Scientifique (CGS), Paris, France
| | - Jean-Claude Sardas
- Mines Paris - Université PSL, Centre de Gestion Scientifique (CGS), Paris, France
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Wang W, Fang S, Zhang S, He M, Zhu X, Dong Y, Ma D, Zhao Y, Meng X, Zhang M, Sun J. Gaps in awareness and practice of healthy lifestyles among individuals at high risk of colorectal cancer: A qualitative evidence synthesis. J Clin Nurs 2023; 32:5737-5751. [PMID: 36967562 DOI: 10.1111/jocn.16696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/14/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023]
Abstract
AIMS To systematically examine and review relevant qualitative studies exploring the current lifestyle among individuals at high risk of colorectal cancer (CRC), and their awareness of the role of a healthy lifestyle in CRC prevention. BACKGROUND The increasing incidence and mortality of CRC have presented a serious threat against the health and life of people. As the major population affected by CRC, the lifestyle of individuals at a high risk of CRC is attracting increasing attention. DESIGN A qualitative evidence synthesis using the Thomas and Harden method and the PRISMA 2020 checklist provided by the EQUATOR network were used. DATA SOURCES Literature was retrieved from PubMed, Web of Science, the Cochrane Library, Embase, CINAHL and PsycINFO from the inception to December 2021. REVIEW METHODS Two reviewers independently screened the titles and abstracts and identified the eligible studies. Critical appraisals of each included study were performed. Thematic analysis was used to guide the data synthesis. RESULTS The data from nine articles were analysed. Three interpretive themes were extracted that formed an overarching synthesis of the experience with healthy lifestyles among high-risk individuals of CRC. The findings suggested that these individuals with limited awareness of CRC and personal risks lacked sufficient knowledge about the relationship between lifestyle and CRC, and their attitudes and practices towards the role of a healthy lifestyle in CRC prevention were also diversified. CONCLUSION Professionals can potentially provide personalised guidance for healthy lifestyles based on knowledge of prevention, the actual background and social support of individuals at high risk of CRC. IMPACT Considering that knowledge gaps and health beliefs among these individuals are the premise blocking their adoption of a healthy lifestyle, the findings of this review may make contributions to the design and content of public health policy and prevention programs. No patient or public contribution.
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Affiliation(s)
- Wenxia Wang
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Shuyan Fang
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Shuang Zhang
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Meng He
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Xiangning Zhu
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Yueyang Dong
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Dongfei Ma
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Yanjie Zhao
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Xiangfei Meng
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Mengting Zhang
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
| | - Jiao Sun
- Basic Nursing Department, School of Nursing, Jilin University, Jilin, People's Republic of China
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Moradzadeh M, Karamouzian M, Najafizadeh S, Yazdi-Feyzabadi V, Haghdoost AA. International Journal of Health Policy and Management (IJHPM): A Decade of Advancing Knowledge and Influencing Global Health Policy (2013-2023). Int J Health Policy Manag 2023; 12:8124. [PMID: 37579384 PMCID: PMC10425691 DOI: 10.34172/ijhpm.2023.8124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Mina Moradzadeh
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Karamouzian
- Centre On Drug Policy Evaluation, St. Michael’s Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV, Kerman University of Medical Sciences, Kerman, Iran
| | - Sahar Najafizadeh
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Vahid Yazdi-Feyzabadi
- Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Ali-Akbar Haghdoost
- Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Forsgärde ES, Rööst M, Elmqvist C, Fridlund B, Svensson A. Physicians' experiences and actions in making complex level-of-care decisions during acute situations within older patients' homes: a critical incident study. BMC Geriatr 2023; 23:323. [PMID: 37226161 DOI: 10.1186/s12877-023-04037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/11/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians' decision-making during acute situations in older patients' homes is limited. Therefore, this study aimed to describe physicians' experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes. METHODS Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included. RESULTS In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients' and their significant others' needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians' actions involved searching for an understanding of older patients' and their significant others' wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved. CONCLUSION Physicians strive to individualize complex level-of-care decisions based on older patients' and their significant others' wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 - 7 collaboration between organizations and health care professionals.
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Affiliation(s)
- Elin-Sofie Forsgärde
- Department of Health and Caring Sciences, Linnaeus University, PO Box 451, Växjö, 351 95, Sweden.
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Region Kronoberg, PO Box 1207, 351 95, 352 54, Växjö, Växjö, Sweden.
| | - Mattias Rööst
- Department for Research and Development, Region Kronoberg, PO Box 1223, 351 12, Växjö, Sweden
- Department of Clinical Sciences in Malmö, Family Medicine, Lund University, PO Box 50332, 202 13, Malmö, Sweden
| | - Carina Elmqvist
- Department of Health and Caring Sciences, Linnaeus University, PO Box 451, Växjö, 351 95, Sweden
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Region Kronoberg, PO Box 1207, 351 95, 352 54, Växjö, Växjö, Sweden
- Department for Research and Development, Region Kronoberg, PO Box 1223, 351 12, Växjö, Sweden
| | - Bengt Fridlund
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Region Kronoberg, PO Box 1207, 351 95, 352 54, Växjö, Växjö, Sweden
| | - Anders Svensson
- Department of Health and Caring Sciences, Linnaeus University, PO Box 451, Växjö, 351 95, Sweden
- Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, Region Kronoberg, PO Box 1207, 351 95, 352 54, Växjö, Växjö, Sweden
- Ambulance Service, Region Kronoberg, PO Box 1207, 351 95, 352 54, Växjö, Växjö, Sweden
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11
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Chaukos D, Genus S, Maunder R, Mylopoulos M. Preparing future physicians for complexity: a post-graduate elective in HIV psychiatry. BMC MEDICAL EDUCATION 2023; 23:269. [PMID: 37081455 PMCID: PMC10116745 DOI: 10.1186/s12909-023-04233-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/05/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Patients with complex care needs have multiple concurrent conditions (medical, psychiatric, social vulnerability or functional impairment), interfering with achieving desired health outcomes. Their care often requires coordination and integration of services across hospital and community settings. Physicians feel ill-equipped and unsupported to navigate uncertainty and ambiguity caused by multiple problems. A HIV Psychiatry resident elective was designed to support acquisition of integrated competencies to navigate uncertainty and disjointed systems of care - necessary for complex patient care. METHODS Through qualitative thematic analysis of pre- and post-interviews with 12 participants - residents and clinic staff - from December 2019 to September 2022, we explored experiences of this elective. RESULTS This educational experience helped trainees expand their understanding of what makes patients complex. Teachers and trainees emphasize the importance of an approach to "not knowing" and utilizing integrative competencies for navigating uncertainty. Through perspective exchange and collaboration, trainees showed evidence of adaptive expertise: the ability to improvise while drawing on past knowledge. CONCLUSIONS Postgraduate training experiences should be designed to facilitate skills for caring for complex patients. These skills help residents fill in practice gaps, improvise when standardization fails, and develop adaptive expertise. Going forward, findings will be used to inform this ongoing elective.
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Affiliation(s)
- Deanna Chaukos
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
- Department of Psychiatry, Sinai Health System, 600 University Avenue, Toronto, M5G1X5, Canada.
| | - Sandalia Genus
- Department of Psychiatry, Sinai Health System, 600 University Avenue, Toronto, M5G1X5, Canada
- Department of Anthropology, University of Toronto, Toronto, Canada
| | - Robert Maunder
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Psychiatry, Sinai Health System, 600 University Avenue, Toronto, M5G1X5, Canada
| | - Maria Mylopoulos
- Department of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- The Wilson Centre, University of Toronto, Toronto, Canada
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Manoharan R, Kemper J, Young J. Exploring the medical cannabis prescribing behaviours of New Zealand physicians. Drug Alcohol Rev 2022; 41:1355-1366. [PMID: 35604868 PMCID: PMC9544511 DOI: 10.1111/dar.13476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 03/31/2022] [Accepted: 04/03/2022] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Many countries are changing their regulations for prescribing medical cannabis. As gatekeepers, physicians significantly impact patient access to cannabis treatments. It is important to explore how physicians view prescribing cannabis in terms of their existing beliefs, knowledge, possible concerns and personal perceptions. METHODS Individual, semi-structured telephone interviews were undertaken with 14 New Zealand physicians from various specialties. The interviews were thematically analysed using a phenomenological approach. RESULTS The physician-patient relationship was of extreme importance in making prescription decisions, driven largely by trust in the patient. Barriers to prescribing included concern over possible side effects, the quality and standardisation of medication, uncertainty about indications and equity concerns from the high cost for lower socio-economic patients. Some physicians held concerns over their liability and risks to their reputation if issues arose for patients. DISCUSSION AND CONCLUSION The way physicians regard prescribing medical cannabis is based on their personal beliefs and knowledge built up over their medical career. It is important that these are taken into consideration in the design of future guidelines to help alleviate uncertainties and reduce barriers for informed prescribing. While our research and previous research find that physicians generally will follow clinical guidelines based on institutional logics (i.e. the standardised approach to medicine), we find that physicians often allow their personal construals to determine their perceptions and prescribing behaviour to a considerable extent when they practice medicine. Our findings have implications for Continuing Medical Education, marketing and regulation for medical cannabis, especially about the wording of guideline adherence.
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Affiliation(s)
- Rachel Manoharan
- School of Biological SciencesUniversity of AucklandAucklandNew Zealand
| | - Joya Kemper
- Department of Management, Marketing and EntrepreneurshipUniversity of Canterbury, UC Business SchoolChristchurchNew Zealand
| | - Jenny Young
- Plant and Food Research LtdAucklandNew Zealand
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Grove A, Pope C, Currie G, Clarke A. Paragons, Mavericks and Innovators-A typology of orthopaedic surgeons' professional identities. A comparative case study of evidence-based practice. SOCIOLOGY OF HEALTH & ILLNESS 2022; 44:59-80. [PMID: 34706109 PMCID: PMC9298426 DOI: 10.1111/1467-9566.13392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 06/13/2023]
Abstract
Clinical guidelines, as vehicles for evidence-based practice (EBP) attempt to standardize health-care practice, reduce variation and increase quality. However, their use for surgery has been contested, and often resisted. This article examines professional responses to EBP in hip replacement surgery using data from case study observations and interviews in three English orthopaedic departments. A professional identity perspective is adopted to explain how standardization through EBP, represents an empirical phenomenon around which surgeons enact their identities as Paragons, Mavericks or Innovators, to enhance legitimacy and stratify themselves in their response to EBP. Attention is drawn to variation between Paragon surgeons working in university (teaching) hospitals and Maverick and Innovator types located in general hospitals, and the ways this interacts with adoption of EBP. The typology shows how practice variation is related to surgeons' tendencies to align to characteristic types, with distinct social processes, power and prestige, and which are in turn influenced by organizational context. The dynamics of EBP and professional identity continues to limit attempts to standardize surgical practice. The typology contributes to the understanding of failures to follow EBP, as associated with the identities individuals create and negotiate, and with identity narratives used to legitimize differing responses to EBP.
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Affiliation(s)
- Amy Grove
- Warwick Medical SchoolUniversity of WarwickCoventryUK
| | - Catherine Pope
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Graeme Currie
- Warwick Business SchoolUniversity of WarwickCoventryUK
| | - Aileen Clarke
- Warwick Medical SchoolUniversity of WarwickCoventryUK
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Lowane MP, Lebese RT. Missing appointments by patients on antiretroviral therapy: Professional nurses’ perspective. Curationis 2022; 45:e1-e7. [PMID: 35144432 PMCID: PMC8831935 DOI: 10.4102/curationis.v45i1.2213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 10/26/2021] [Accepted: 11/21/2021] [Indexed: 11/01/2022] Open
Abstract
Background: Missed appointments for medicine pick-ups are regarded as a predictor of poor adherence, and should trigger immediate questions about issues that may affect follow-up visits to healthcare settings.Objectives: The study explored and described professional nurses’ perspectives about the factors that contribute to missing appointments by people living with Human Immunodeficiency Virus (PLWHIV) on antiretroviral therapy (ART) at Mopani and Vhembe district in Limpopo Province.Method: A qualitative explorative contextual approach was used for the study. Non-probability, purposive sampling was used to select 14 professional nurses who met the inclusion criteria. Data were collected through face-to-face unstructured interviews. One central question was asked and probing questions were based on the participants’ responses to the central question. Thematic analysis of the findings was carried out. Trustworthiness was ensured through intercoder agreement, audio recording, triangulation, bracketing, and member checking. Required permission, approval, and ethical clearance were also ensured.Results: Organisational health system and management of the healthcare facility were found to be the barriers that negatively impacted on the ability of the PLWHIV on ART to maintain clinic visits appointments. Lack of patient involvement, stereotyped appointment dates selection, poor patient-provider relationships, errors of recording appointment dates and long waiting times came up as sub-themes derived from the main theme.Conclusion: The results suggest that there is a need to increase and improve mutual trust in patient-provider relationships, improve nurses working conditions, develop proper booking systems and reduce clinic waiting hours.
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Affiliation(s)
- Mygirl P Lowane
- Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria.
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15
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Halberg N, Larsen TS, Holen M. Ethnic minority patients in healthcare from a Scandinavian welfare perspective: The case of Denmark. Nurs Inq 2021; 29:e12457. [PMID: 34463004 DOI: 10.1111/nin.12457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 08/11/2021] [Accepted: 08/16/2021] [Indexed: 11/28/2022]
Abstract
The Scandinavian welfare states are known for their universal access to healthcare; however, health inequalities affecting ethnic minority patients are prevalent. Ethnic minority patients' encounters with healthcare systems are often portrayed as part of a system that represents objectivity and neutrality. However, the Danish healthcare sector is a political apparatus that is affected by policies and conceptualisations. Health policies towards ethnic minorities are analysed using Bacchi's policy analysis, to show how implicit problem representations are translated from political and societal discourses into the Danish healthcare system. Our analysis shows that health policies are based on different ideas of who ethnic minority patients are and what kinds of challenges they entail. Two main issues are raised: First, ethnic minorities are positioned as bearers of 'culture' and 'ethnicity'. These concepts of 'othering' become both explanations for and the cause of inappropriate healthcare behaviour. Second, the Scandinavian welfare states are known for their solidarity, collectivism, equality and tolerance, also grounded in a postracial, colour-blind and noncolonial past ideology that forms the societal self-image. Combined with the ethical and legal responsibility of healthcare professionals to treat all patients equally, our findings indicate little leeway for addressing the discrimination experienced by ethnic minority patients.
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Affiliation(s)
- Nina Halberg
- Department of People and Technology, Roskilde University, Roskilde, Denmark.,The Research Unit of Orthopaedic Nursing, Copenhagen University Hospital, Hvidovre, Denmark
| | - Trine S Larsen
- Department of People and Technology, Roskilde University, Roskilde, Denmark.,The Research Unit of Orthopaedic Nursing, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Research, Copenhagen University Hospital, Hvidovre, Denmark
| | - Mari Holen
- Department of People and Technology, Roskilde University, Roskilde, Denmark
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Colldén C, Hellström A, Gremyr I. Value configurations for balancing standardization and customization in chronic care: a qualitative study. BMC Health Serv Res 2021; 21:845. [PMID: 34416902 PMCID: PMC8379884 DOI: 10.1186/s12913-021-06844-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/29/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations - shop, chain, and network - has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions. METHODS A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach. RESULTS Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process. CONCLUSIONS The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.
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Affiliation(s)
- Christian Colldén
- Department of Technology Management and Economics, Division of Service Management and Logistics, Chalmers University of Technology, Gothenburg, Sweden.
- Department of Psychotic Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Andreas Hellström
- Department of Technology Management and Economics, Division of Service Management and Logistics, Chalmers University of Technology, Gothenburg, Sweden
| | - Ida Gremyr
- Department of Technology Management and Economics, Division of Service Management and Logistics, Chalmers University of Technology, Gothenburg, Sweden
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Minvielle E, Fourcade A, Ricketts T, Waelli M. Current developments in delivering customized care: a scoping review. BMC Health Serv Res 2021; 21:575. [PMID: 34120603 PMCID: PMC8201906 DOI: 10.1186/s12913-021-06576-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In recent years, there has been a growing interest in health care personalization and customization (i.e. personalized medicine and patient-centered care). While some positive impacts of these approaches have been reported, there has been a dearth of research on how these approaches are implemented and combined for health care delivery systems. The present study undertakes a scoping review of articles on customized care to describe which patient characteristics are used for segmenting care, and to identify the challenges face to implement customized intervention in routine care. METHODS Article searches were initially conducted in November 2018, and updated in January 2019 and March 2019, according to Prisma guidelines. Two investigators independently searched MEDLINE, PubMed, PsycINFO, Web of Science, Science Direct and JSTOR, The search was focused on articles that included "care customization", "personalized service and health care", individualized care" and "targeting population" in the title or abstract. Inclusion and exclusion criteria were defined. Disagreements on study selection and data extraction were resolved by consensus and discussion between two reviewers. RESULTS We identified 70 articles published between 2008 and 2019. Most of the articles (n = 43) were published from 2016 to 2019. Four categories of patient characteristics used for segmentation analysis emerged: clinical, psychosocial, service and costs. We observed these characteristics often coexisted with the most commonly described combinations, namely clinical, psychosocial and service. A small number of articles (n = 18) reported assessments on quality of care, experiences and costs. Finally, few articles (n = 6) formally defined a conceptual basis related to mass customization, whereas only half of articles used existing theories to guide their analysis or interpretation. CONCLUSIONS There is no common theory based strategy for providing customized care. In response, we have highlighted three areas for researchers and managers to advance the customization in health care delivery systems: better define the content of the segmentation analysis and the intervention steps, demonstrate its added value, in particular its economic viability, and align the logics of action that underpin current efforts of customization. These steps would allow them to use customization to reduce costs and improve quality of care.
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Affiliation(s)
- Etienne Minvielle
- i3-Centre de Recherche en Gestion, Institut Interdisciplinaire de l’Innovation (UMR 9217), École polytechnique, Batiment Ensta, 828, Boulevard des Maréchaux, 91762 Palaiseau Cedex, France
- Institut Gustave Roussy, 114, rue Edouard Vaillant, 94800 Villejuif, France
| | - Aude Fourcade
- Institut Gustave Roussy, 114, rue Edouard Vaillant, 94800 Villejuif, France
| | - Thomas Ricketts
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina USA
| | - Mathias Waelli
- MOS (EA 7418), French School of Public Health, Rennes, France
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Oksavik JD, Aarseth T, Solbjør M, Kirchhoff R. 'What matters to you?' Normative integration of an intervention to promote participation of older patients with multi-morbidity - a qualitative case study. BMC Health Serv Res 2021; 21:117. [PMID: 33541351 PMCID: PMC7863321 DOI: 10.1186/s12913-021-06106-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/20/2021] [Indexed: 02/05/2023] Open
Abstract
Background Interventions in which individual older patients with multi-morbidity participate in formulating goals for their own care are being implemented in several countries. Successful service delivery requires normative integration by which values and goals for the intervention are shared between actors at macro-, meso- and micro-levels of health services. However, health services are influenced by multiple and different institutional logics, which are belief systems guiding actors’ cognitions and practices. This paper examines how distinct institutional logics materialize in justifications for patient participation within an intervention for patients with multi-morbidity, focusing on how variations in the institutional logics that prevail at different levels of health services affect vertical normative integration. Methods This qualitative case study of normative integration spans three levels of Norwegian health services. The macro-level includes a white paper and a guideline which initiated the intervention. The meso-level includes strategy plans and intervention tools developed locally in four municipalities. Finally, the micro-level includes four focus group discussions among 24 health professionals and direct observations of ten care-planning meetings between health professionals and patients. The content analysis draws on seven institutional logics: professional, market, family, community, religious, state and corporate. Results The particular institutional logics that justified patient participation varied between healthcare levels. Within the macro-level documents, seven logics justified patients’ freedom of choice and individualization of service delivery. At meso-level, the operationalization of the intervention into tools for clinical practice was dominated by a state logic valuing equal services for all patients and a medical professional logic in which patient participation meant deciding how to maintain patients’ physical abilities. At micro-level, these two logics were mixed with a corporate logic prioritizing cost-efficient service delivery. Conclusion Normative integration is challenging to achieve. The number of institutional logics in play was reduced downwards through the three levels, and the goals behind the intervention shifted from individualization to standardization. The study broadens our understanding of the dynamic between institutional logics and of how multiple sets of norms co-exist and guide action. Knowledge of mechanisms by which normative justifications are put into practice is important to achieve normative integration of patient participation interventions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06106-y.
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Affiliation(s)
- Jannike Dyb Oksavik
- Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway.
| | - Turid Aarseth
- Faculty of Business Administration and Social Sciences, Molde University College, Specialized University in Logistics, Molde, Norway
| | - Marit Solbjør
- Department of Public Health and Nursing, Trondheim, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ralf Kirchhoff
- Department of Health Sciences, Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Ålesund, Norway
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Bansler JP. Challenges in user-driven optimization of EHR: A case study of a large Epic implementation in Denmark. Int J Med Inform 2021; 148:104394. [PMID: 33485217 DOI: 10.1016/j.ijmedinf.2021.104394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Research suggests that capturing the benefits of electronic health records (EHR) requires systematic and ongoing optimization of technology configuration and use after implementation. However, little is known about EHR optimization in a hospital context. OBJECTIVE To explore the issues and challenges involved in organizing and managing a systematic user-driven EHR optimization program. METHODS A longitudinal case study of an EHR optimization program launched in two large Danish hospital systems was undertaken. It involved interviewing 28 key managers, clinicians and IT staff, participating in formal and informal meetings, and reviewing policy documents, meeting minutes, teaching materials and other relevant documents. FINDINGS The two hospital systems are struggling to find the best way to organize and manage the optimization program. So far, the program has been a mixed success. Involving clinicians in EHR optimization poses serious dilemmas for hospital managers, who must manage two related tensions: between standardization and adaptation, and between centralized control and local autonomy. CONCLUSION The findings highlight the significant challenges in designing a successful EHR optimization program and underscore the importance of developing more sophisticated strategies for clinical standardization and innovation.
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Affiliation(s)
- Jørgen P Bansler
- University of Copenhagen, Universitetsparken 1, 2100, Copenhagen, Denmark.
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Vogus TJ, McClelland LE, Lee YS, McFadden KL, Hu X. Creating a compassion system to achieve efficiency and quality in health care delivery. JOURNAL OF SERVICE MANAGEMENT 2021. [DOI: 10.1108/josm-05-2019-0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PurposeHealth care delivery is experiencing a multi-faceted epidemic of suffering among patients and care providers. Compassion is defined as noticing, feeling and responding to suffering. However, compassion is typically seen as an individual rather than a more systemic response to suffering and cannot match the scale of the problem as a result. The authors develop a model of a compassion system and details its antecedents (leader behaviors and a compassionate human resource (HR) bundle), its climate or the extent that the organization values, supports and rewards expression of compassion and the behaviors and practices through which it is enacted (standardization and customization) and its effects on efficiently reducing suffering and delivering high quality care.Design/methodology/approachThis paper uses a conceptual approach that synthesizes the literature in health services, HR management, organizational behavior and service operations to develop a new conceptual model.FindingsThe paper makes three key contributions. First, the authors theorize the central importance of compassion and a collective commitment to compassion (compassion system) to reducing pervasive patient and care provider suffering in health care. Second, the authors develop a model of an organizational compassion system that details its antecedents of leader behaviors and values as well as a compassionate HR bundle. Third, the authors theorize how compassion climate enhances collective employee well-being and increases standardization and customization behaviors that reduce suffering through more efficient and higher quality care, respectively.Originality/valueThis paper develops a novel model of how health care organizations can simultaneously achieve efficiency and quality through a compassion system. Specific leader behaviors and practices that enable compassion climate and the processes through which it achieves efficiency and quality are detailed. Future directions for how other service organizations can replicate a compassion system are discussed.
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Bertels L, Lucassen P, van Asselt K, Dekker E, van Weert H, Knottnerus B. Motives for non-adherence to colonoscopy advice after a positive colorectal cancer screening test result: a qualitative study. Scand J Prim Health Care 2020; 38:487-498. [PMID: 33185121 PMCID: PMC7781896 DOI: 10.1080/02813432.2020.1844391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
SETTING Participants with a positive faecal immunochemical test (FIT) in screening programs for colorectal cancer (CRC) have a high risk for colorectal cancer and advanced adenomas. They are therefore recommended follow-up by colonoscopy. However, more than ten percent of positively screened persons do not adhere to this advice. OBJECTIVE To investigate FIT-positive individuals' motives for non-adherence to colonoscopy advice in the Dutch CRC screening program. SUBJECTS Non-adherent FIT-positive participants of the Dutch CRC screening program. DESIGN We conducted semi structured in-depth interviews with 17 persons who did not undergo colonoscopy within 6 months after a positive FIT. Interviews were undertaken face-to-face and data were analysed thematically with open coding and constant comparison. RESULTS All participants had multifactorial motives for non-adherence. A preference for more personalised care was described with the following themes: aversion against the design of the screening program, expectations of personalised care, emotions associated with experiences of impersonal care and a desire for counselling where options other than colonoscopy could be discussed. Furthermore, intrinsic motives were: having a perception of low risk for CRC (described by all participants), aversion and fear of colonoscopy, distrust, reluctant attitude to the treatment of cancer and cancer fatalism. Extrinsic motives were: having other health issues or priorities, practical barriers, advice from a general practitioner (GP) and financial reasons. CONCLUSION Personalised screening counselling might have helped to improve the interviewees' experiences with the screening program as well as their knowledge on CRC and CRC screening. Future studies should explore whether personalised screening counselling also has potential to increase adherence rates. Key points Participants with a positive FIT in two-step colorectal cancer (CRC) screening programs are at high risk for colorectal cancer and advanced adenomas. Non-adherence after an unfavourable screening result happens in all CRC programs worldwide with the consequence that many of the participants do not undergo colonoscopy for the definitive assessment of the presence of colorectal cancer. Little qualitative research has been done to study the reasons why individuals participate in the first step of the screening but not in the second step. We found a preference for more personalised care, which was not reported in previous literature on this subject. Furthermore, intrinsic factors, such as a low risk perception and distrust, and extrinsic factors, such as the presence of other health issues and GP advice, may also play a role in non-adherence. A person-centred approach in the form of a screening counselling session may be beneficial for this group of CRC screening participants.
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Affiliation(s)
- Lucinda Bertels
- Department of General Practice, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Socio-Medical Sciences, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- CONTACT Lucinda Bertels , .Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; Erasmus School of Health Policy & Management, Rotterdam
| | - Peter Lucassen
- Department of Primary and Community Care, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Kristel van Asselt
- Department of General Practice, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk van Weert
- Department of General Practice, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart Knottnerus
- Department of General Practice, Cancer Center Amsterdam, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands
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Ettleson MD, Bianco AC. Individualized Therapy for Hypothyroidism: Is T4 Enough for Everyone? J Clin Endocrinol Metab 2020; 105:dgaa430. [PMID: 32614450 PMCID: PMC7382053 DOI: 10.1210/clinem/dgaa430] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT It is well recognized that some hypothyroid patients on levothyroxine (LT4) remain symptomatic, but why patients are susceptible to this condition, why symptoms persist, and what is the role of combination therapy with LT4 and liothyronine (LT3), are questions that remain unclear. Here we explore evidence of abnormal thyroid hormone (TH) metabolism in LT4-treated patients, and offer a rationale for why some patients perceive LT4 therapy as a failure. EVIDENCE ACQUISITION This review is based on a collection of primary and review literature gathered from a PubMed search of "hypothyroidism," "levothyroxine," "liothyronine," and "desiccated thyroid extract," among other keywords. PubMed searches were supplemented by Google Scholar and the authors' prior knowledge of the subject. EVIDENCE SYNTHESIS In most LT4-treated patients, normalization of serum thyrotropin levels results in decreased serum T3/T4 ratio, with relatively lower serum T3 levels; in at least 15% of the cases, serum T3 levels are below normal. These changes can lead to a reduction in TH action, which would explain the slower rate of metabolism and elevated serum cholesterol levels. A small percentage of patients might also experience persistent symptoms of hypothyroidism, with impaired cognition and tiredness. We propose that such patients carry a key clinical factor, for example, specific genetic and/or immunologic makeup, that is well compensated while the thyroid function is normal but might become apparent when compounded with relatively lower serum T3 levels. CONCLUSIONS After excluding other explanations, physicians should openly discuss and consider therapy with LT4 and LT3 with those hypothyroid patients who have persistent symptoms or metabolic abnormalities despite normalization of serum thyrotropin level. New clinical trials focused on symptomatic patients, genetic makeup, and comorbidities, with the statistical power to identify differences between monotherapy and combination therapy, are needed.
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Affiliation(s)
- Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
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Abstract
INTRODUCTION The Fontan procedure is the final stage of surgical palliation for the children with functionally single ventricle anatomy. The post-operative medical management of this patient population can be variable and hospital length of stay prolonged. The purpose of this quality improvement project was to determine if the implementation of an evidence-based clinical pathway for post-operative management of the Fontan patient at a large Midwestern academic paediatric medical centre would standardise care and decrease length of stay. MATERIALS AND METHODS The clinical pathway was developed using key components from three published pathways for the Fontan procedure from other paediatric institutions across the United States. Components of the clinical pathway included (1) supplemental oxygen until pleural drainage tubes are removed, (2) fluid restriction to 80% daily maintenance and a prescribed low-fat diet, (3) aggressive and standardised diuretic therapy while inpatient and (4) central venous access. The pathway was trialed using Plan-Do-Study-Act cycles in 2016, implemented in 2017 and sustained in 2018-2019. A retrospective electronic medical record review was performed to compare key outcomes from pre-pathway (2014-2015, 37 patients) with post-pathway implementation (2017-2018, 30 patients). RESULTS Adherence to the pathway was nearly 100% with a statistically significant decrease in length of stay from 12 to 9 days (p = 0.007) and no increase in readmissions. CONCLUSION Standardising care can improve clinical and financial outcomes for the Fontan patient population without negatively impacting quality of care, thus providing a positive benefit to the healthcare institution, industry and patient.
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Nordling P, Priebe G, Björkelund C, Hensing G. Assessing work capacity - reviewing the what and how of physicians' clinical practice. BMC FAMILY PRACTICE 2020; 21:72. [PMID: 32340611 PMCID: PMC7187489 DOI: 10.1186/s12875-020-01134-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 03/29/2020] [Indexed: 11/10/2022]
Abstract
Background Although a main task in the sickness certification process, physicians’ clinical practice when assessing work capacity has not been thoroughly described. Increased knowledge on the matter is needed to better understand and support the certification process. In this review, we aimed to synthesise existing qualitative evidence to provide a clearer description of the assessment of work capacity as practiced by physicians. Method Seven electronic databases were searched systematically for qualitative studies examining what and how physicians do when they assess work capacity. Data was analysed and integrated using thematic synthesis. Results Twelve articles were included. Results show that physicians seek to form a knowledge base including understanding the condition, the patient and the patient’s workplace. They consider both medical and non-medical aspects to affect work capacity. To acquire and process the information they use various skills, methods and resources. Medical competence is an important basis, but not enough. Time, trust, intuition and reasoning are also used to assess the patient’s claims and to translate the findings into a final assessment. The depth and focus of the information seeking and processing vary depending on several factors. Conclusion The assessment of work capacity is a complex task where physicians rely on their non-medical skills to a higher degree than in ordinary clinical work. These skills are highly relevant but need to be complemented with access to appropriate resources such as understanding of the associations between health, work and social security, enough time in daily work for the assessment and ways to better understand the patient’s work place. Also, the notion of an “objective” evaluation is questioned, calling for a greater appreciation of the complexity of the assessment and the role of professional judgement.
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Affiliation(s)
- P Nordling
- School of Public Health and Community Medicine, The Sahlgrenska Academy at University of Gothenburg, Box 453, SE-405 30, Gothenburg, Sweden. .,Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden.
| | - G Priebe
- School of Public Health and Community Medicine, The Sahlgrenska Academy at University of Gothenburg, Box 453, SE-405 30, Gothenburg, Sweden
| | - C Björkelund
- School of Public Health and Community Medicine, The Sahlgrenska Academy at University of Gothenburg, Box 453, SE-405 30, Gothenburg, Sweden.,Region Västra Götaland, Närhälsan Research and Development Primary Health Care, Gothenburg, Sweden
| | - G Hensing
- School of Public Health and Community Medicine, The Sahlgrenska Academy at University of Gothenburg, Box 453, SE-405 30, Gothenburg, Sweden
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Mathijssen EGE, van den Bemt BJF, Wielsma S, van den Hoogen FHJ, Vriezekolk JE. Exploring healthcare professionals' knowledge, attitudes and experiences of shared decision making in rheumatology. RMD Open 2020; 6:e001121. [PMID: 31958279 PMCID: PMC7046943 DOI: 10.1136/rmdopen-2019-001121] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/14/2019] [Accepted: 11/19/2019] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To explore physicians' and nurses' knowledge, attitudes and experiences of shared decision making (SDM) in rheumatology, to identify barriers and facilitators to SDM, and to examine whether physicians' and nurses' perspectives of SDM differ. METHODS A cross-sectional, exploratory, online survey was used. Besides demographic characteristics, healthcare professionals' knowledge, attitudes and experiences of SDM in rheumatology were assessed. Barriers and facilitators to SDM were identified from healthcare professionals' answers. Descriptive statistics were computed and differences between physicians' and nurses' perspectives of SDM were examined with a t-test or Fisher's exact test, as appropriate. RESULTS Between April and June 2019, 77 physicians and 70 nurses completed the survey. Although most healthcare professionals lacked a full conceptual understanding of SDM, almost all physicians (92%) and all nurses had a (very) positive attitude toward SDM, which was most frequently motivated by the belief that SDM improves patients' treatment adherence. The majority (>50%) of healthcare professionals experienced problems with the application of SDM in clinical practice, mostly related to time constraints. Other important barriers were the incompatibility of SDM with clinical practice guidelines and beliefs that patients do not prefer to be involved in decision making or are not able to take an active role. Modest differences between physicians' and nurses' perspectives of SDM were found. CONCLUSIONS There is a clear need for education and training that equips and empowers healthcare professionals to apply SDM. Furthermore, the commitment of time, resources and financial support for national, regional and organisational initiatives is needed to make SDM in rheumatology a practical reality.
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Affiliation(s)
| | - Bart J F van den Bemt
- Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
- Pharmacy, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Sabien Wielsma
- Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Frank H J van den Hoogen
- Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands
- Rheumatic Diseases, Radboud University Medical Centre, Nijmegen, the Netherlands
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Abbott PA, Weinger MB. Health information technology:Fallacies and Sober realities - Redux A homage to Bentzi Karsh and Robert Wears. APPLIED ERGONOMICS 2020; 82:102973. [PMID: 31677422 DOI: 10.1016/j.apergo.2019.102973] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 08/27/2019] [Accepted: 10/03/2019] [Indexed: 06/10/2023]
Abstract
Since the publication of "Health Information Technology: Fallacies and Sober Realities" in 2010, health information technology (HIT) has become nearly ubiquitous in US healthcare facilities. Yet, HIT has yet to achieve its putative benefits of higher quality, safer, and lower cost care. There has been variable but largely marginal progress at addressing the 12 HIT fallacies delineated in the original paper. Here, we revisit several of the original fallacies and add five new ones. These fallacies must be understood and addressed by all stakeholders for HIT to be a positive force in achieving the high value healthcare system the nation deserves. Foundational cognitive and human factors engineering research and development continue to be essential to HIT development, deployment, and use.
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Affiliation(s)
- Patricia A Abbott
- Department of Systems, Populations and Leadership, USA; Department of Leadership, Analytics, & Innovation, University of Michigan, School of Nursing, USA.
| | - Matthew B Weinger
- Departments of Anesthesiology, Biomedical Informatics, and Medical Education, Vanderbilt University School of Medicine, USA; Geriatric Research Education and clinical Center, VA Tennessee Valley Healthcare System, USA.
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Rosenbaum L, Johnson M, Li M, Raval JS. Total plasma volume determinations for patients with potentially challenging conditions requiring therapeutic plasma exchange: Dealer's choice. J Clin Apher 2019; 35:138-139. [PMID: 31774189 DOI: 10.1002/jca.21764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Lizabeth Rosenbaum
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico.,Vitalant, Albuquerque, New Mexico
| | | | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque, New Mexico
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Abstract
Purpose
The purpose of this paper is to investigate frontline meetings in hospitals and how they are used for coordination of daily operations across organizational and occupational boundaries.
Design/methodology/approach
An in-depth multiple-case study of four purposefully selected departments from four different hospitals is conducted. The selected cases had actively developed and embedded scheduled meetings as structural means to achieve coordination of daily operations.
Findings
Health care professionals and managers, next to their traditional mono-professional meetings (e.g. doctors or nurses), develop additional operational, daily meetings such as work-shift meetings, huddles and hand-off meetings to solve concrete care tasks. These new types of meetings are typically short, task focussed, led by a chair and often inter-disciplinary. The meetings secure a personal proximity which the increased dependency on hospital-wide IT solutions cannot. During meetings, objects and representations (e.g. monitors, whiteboards or paper cards) create a needed gathering point to span across boundaries. As regards embedding meetings, local engagement helps contextualizing meetings and solving concrete care tasks, thereby making health care professionals more likely to value these daily meeting spaces.
Practical implications
Health care professionals and managers can use formal meeting spaces aided by objects and representations to support solving daily and interdependent health care tasks in ways that IT solutions in hospitals do not offer today. Implementation requires local engagement and contextualization.
Originality/value
This research paper shows the importance of daily, operational hospital meetings for frontline coordination. Organizational meetings are a prevalent collaborative activity, yet scarcely researched organizational phenomenon.
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Esquivel Garzón N, Díaz Heredia LP, Cañon Montañez W. Intervenciones adaptadas en personas con enfermedad cardiovascular: hacia un abordaje de enfermería para el cuidado individualizado. REVISTA CUIDARTE 2019. [DOI: 10.15649/cuidarte.v10i3.947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A nivel mundial, las enfermedades cardiovasculares (ECV) constituyen la primera causa de morbimortalidad, lo que genera pérdida de años de vida productivos, discapacidad y muerte prematura, además de los costos sociales y para los sistemas de salud derivados de su atención1. Para el adecuado control de los factores de riesgo y el manejo de las ECV, se requiere que la persona modifique su estilo de vida, asuma hábitos saludables y se adhiera al tratamiento farmacológico. En este contexto, resulta indispensable no solamente lograr la participación activa del paciente en el mantenimiento de su propia salud2, sino también que los profesionales de la salud reconozcan al individuo como un ser activo, con habilidades para gestionar su salud, capaz de discernir y tomar decisiones dirigidas al logro de los objetivos terapéuticos.
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Abstract
This study advances theory on professionals by introducing a novel ‘coalface perspective’ to study frontline professionals’ standardizing work. Our multimethod quantitative and qualitative approach explores when, why and how medical professionals in German university hospitals actively maintain care pathway enactment – a technique to standardize day-to-day medical work – in their everyday patient treatment. Professionals’ actively standardizing their work is an understudied yet highly relevant phenomenon that the established ‘autonomy perspective’ – which covers how professionals resist standardization – falls short of explaining. Introducing a coalface perspective overcomes this shortcoming by uncovering novel links between professionals’ day-to-day problem-driven motivations for standardizing work, the characteristics of everyday situations of frontline professional work and practices of standardizing work at the frontline. This study has implications for research on frontline professionals and coalface-perspective research in general.
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31
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Church DL, Naugler C. Benefits and risks of standardization, harmonization and conformity to opinion in clinical laboratories. Crit Rev Clin Lab Sci 2019; 56:287-306. [PMID: 31060412 DOI: 10.1080/10408363.2019.1615408] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Large laboratory systems that include facilities with a range of capabilities and capacity are being created within consolidated healthcare systems. This paradigm shift is being driven by administrators and payers seeking to achieve resource efficiencies and to conform practice to the requirements of computerization as well as the adoption of electronic medical records. Although standardization and harmonization of practice improves patient care outcomes and operational efficiencies, administratively driven practice conformity (conformity to opinion) also has serious drawbacks and may lead to significant system failure. Juxtaposition of the distinct philosophical approaches of physicians and scientists (i.e. "professionalism") versus administrators and managers (i.e. "managerialism") towards bringing about conformity of the laboratory system inherently creates conflict. Despite an administrative edict to "perform all tests using the same methods" regardless of available "best practice" evidence to do so, medical/scientific input on these decisions is critical to ensure quality and safety of patient care. Innovation within the laboratory system, including the adoption of advanced technologies, practices, and personalized medicine initiatives, will be enabled by balancing the relentless drive by non-medical administration to meet "business" requirements, the medical responsibility to provide the best care possible, and customizing practice to meet individual patient care needs.
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Affiliation(s)
- Deirdre L Church
- a Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada.,b Department of Medicine , University of Calgary , Calgary , Canada
| | - Christopher Naugler
- a Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada.,c Department of Community Health Sciences , University of Calgary , Calgary , Canada.,d Department of Family Medicine , University of Calgary , Calgary , Canada
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Chadborn NH, Goodman C, Zubair M, Sousa L, Gladman JRF, Dening T, Gordon AL. Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review. BMJ Open 2019; 9:e026921. [PMID: 30962238 PMCID: PMC6500328 DOI: 10.1136/bmjopen-2018-026921] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes. DESIGN Realist review. SETTING Care homes. METHODS The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute. RESULTS 130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care. CONCLUSION The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings. TRIAL REGISTRATION NUMBER CRD42017062601.
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Affiliation(s)
- Neil H Chadborn
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands, Nottingham, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East of England, Cambridge, UK
| | - Maria Zubair
- Faculty of Health, Psychology and Social Care, Manchester Metropolitan University, Manchester, UK
| | - Lídia Sousa
- Santa Maria University Hospital, Lisbon, Portugal
| | - John R F Gladman
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands, Nottingham, UK
- Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Tom Dening
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East Midlands, Nottingham, UK
- Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
- School of Health Sciences, City, University of London, London, UK
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Hower KI, Vennedey V, Hillen HA, Kuntz L, Stock S, Pfaff H, Ansmann L. Implementation of patient-centred care: which organisational determinants matter from decision maker's perspective? Results from a qualitative interview study across various health and social care organisations. BMJ Open 2019; 9:e027591. [PMID: 30940764 PMCID: PMC6500213 DOI: 10.1136/bmjopen-2018-027591] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES Health and social care systems, organisations and providers are under pressure to organise care around patients' needs with constrained resources. To implement patient-centred care (PCC) successfully, barriers must be addressed. Up to now, there has been a lack of comprehensive investigations on possible determinants of PCC across various health and social care organisations (HSCOs). Our qualitative study examines determinants of PCC implementation from decision makers' perspectives across diverse HSCOs. DESIGN Qualitative study of n=24 participants in n=20 semistructured face-to-face interviews conducted from August 2017 to May 2018. SETTING AND PARTICIPANTS Decision makers were recruited from multiple HSCOs in the region of the city of Cologne, Germany, based on a maximum variation sampling strategy varying by HSCOs types. OUTCOMES The qualitative interviews were analysed using an inductive and deductive approach according to qualitative content analysis. The Consolidated Framework for Implementation Research was used to conceptualise determinants of PCC. RESULTS Decision makers identified similar determinants facilitating or obstructing the implementation of PCC in their organisational contexts. Several determinants at the HSCO's inner setting and the individual level (eg, communication among staff and well-being of employees) were identified as crucial to overcome constrained financial, human and material resources in order to deliver PCC. CONCLUSIONS The results can help to foster the implementation of PCC in various HSCOs contexts. We identified possible starting points for initiating the tailoring of interventions and implementation strategies and the redesign of HSCOs towards more patient-centredness.
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Affiliation(s)
- Kira Isabel Hower
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Vera Vennedey
- Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne (AöR), Cologne, Germany
| | - Hendrik Ansgar Hillen
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Ludwig Kuntz
- Department of Business Administration and Health Care Management, University of Cologne, Cologne, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, University Hospital Cologne (AöR), Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Lena Ansmann
- Department of Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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Martin G, Ozieranski P, Leslie M, Dixon-Woods M. How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals. J Health Serv Res Policy 2019; 24:145-154. [PMID: 30823848 PMCID: PMC7307407 DOI: 10.1177/1355819619828403] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives The prominence given to issues of patient safety in health care organizations varies, but little is known about how or why this variation occurs. We sought to compare and contrast how three English hospitals came to identify, prioritize and address patient safety issues, drawing on insights from the sociological and political science literature on the process of problem definition. Methods In-depth qualitative fieldwork, involving 99 interviews, 246 hours of ethnographic observation, and document collection, was carried out in three case-study hospitals as part of a wider mixed-methods study. Data analysis was based on the constant comparative method. Results How problems of patient safety came to be recognized, conceptualized, prioritized and matched to solutions varied across the three hospitals. In each organization, it took certain ‘triggers’ to problematize safety, with crises having a particularly important role. How problems were constructed – and whose definitions were prioritized in the process – was highly consequential for organizational response, influencing which solutions were seen as most appropriate, and allocation of responsibility for implementing them. Conclusions A process of problem definition is crucial to raising the profile of patient safety and to rendering problems amenable to intervention. How problems of patient safety are defined and constructed is highly consequential, influencing selection of solutions and their likely sustainability.
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Affiliation(s)
- Graham Martin
- 1 Director of Research, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, UK
| | - Piotr Ozieranski
- 2 Lecturer, Department of Social and Policy Sciences, University of Bath, UK
| | - Myles Leslie
- 3 Assistant Professor, Department of Community Health Sciences, University of Calgary, Canada
| | - Mary Dixon-Woods
- 4 Health Foundation Professor of Healthcare Improvement Studies, THIS Institute (The Healthcare Improvement Studies Institute), University of Cambridge, UK
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35
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Lucas JM, Kozlowski KF. The Underutilization of Lifestyle Modifications in Primary Care Medicine. EXERCISE MEDICINE 2019. [DOI: 10.26644/em.2019.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mannion R, Exworthy M. Researching the Co-Existence and Continuity of Standardization and Customization in Healthcare: A Response to Recent Commentaries. Int J Health Policy Manag 2018; 7:572-573. [PMID: 29935138 PMCID: PMC6015515 DOI: 10.15171/ijhpm.2018.07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/20/2018] [Indexed: 01/27/2023] Open
Affiliation(s)
- Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Mark Exworthy
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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Ansmann L, Pfaff H. Providers and Patients Caught Between Standardization and Individualization: Individualized Standardization as a Solution Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare". Int J Health Policy Manag 2018; 7:349-352. [PMID: 29626403 PMCID: PMC5949226 DOI: 10.15171/ijhpm.2017.95] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/01/2017] [Indexed: 01/12/2023] Open
Abstract
In their 2017 article, Mannion and Exworthy provide a thoughtful and theory-based analysis of two parallel
trends in modern healthcare systems and their competing and conflicting logics: standardization and
customization. This commentary further discusses the challenge of treatment decision-making in times of
evidence-based medicine (EBM), shared decision-making and personalized medicine. From the perspective of
systems theory, we propose the concept of individualized standardization as a solution to the problem. According
to this concept, standardization is conceptualized as a guiding framework leaving room for individualization in
the patient physician interaction. The theoretical background is the concept of context management according
to systems theory. Moreover, the comment suggests multidisciplinary teams as a possible solution for the
integration of standardization and individualization, using the example of multidisciplinary tumor conferences
and highlighting its limitations. The comment also supports the authors’ statement of the patient as co-producer
and introduces the idea that the competing logics of standardization and individualization are a matter of
perspective on macro, meso and micro levels.
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Affiliation(s)
- Lena Ansmann
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, Faculty of Human Sciences and Faculty of Medicine, University of Cologne, Cologne, Germany
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Saks M. Competing Logics and Healthcare Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare". Int J Health Policy Manag 2018; 7:359-361. [PMID: 29626406 PMCID: PMC5949229 DOI: 10.15171/ijhpm.2017.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/09/2017] [Indexed: 11/09/2022] Open
Abstract
This paper offers a short commentary on the editorial by Mannion and Exworthy. The paper highlights the
positive insights offered by their analysis into the tensions between the competing institutional logics of
standardization and customization in healthcare, in part manifested in the conflict between managers and
professionals, and endorses the plea of the authors for further research in this field. However, the editorial is
criticized for its lack of a strong societal reference point, the comparative absence of focus on hybridization,
and its failure to highlight structural factors impinging on the opposing logics in a broader neo-institutional
framework. With reference to the Procrustean metaphor, it is argued that greater stress should be placed on the
healthcare user in future health policy. Finally, the case of complementary and alternative medicine is set out
which – while not explicitly mentioned in the editorial – most effectively concretizes the tensions at the heart
of this analysis of healthcare.
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Affiliation(s)
- Mike Saks
- University of Suffolk, Ipswich, UK.,University of Lincoln, Lincoln, UK.,Royal Veterinary College, University of London, London, UK.,University of St Mark and St John, Plymouth, UK.,University of Toronto, Toronto, ON, Canada
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Needham C. Best of Both Worlds Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare". Int J Health Policy Manag 2018; 7:356-358. [PMID: 29626405 PMCID: PMC5949228 DOI: 10.15171/ijhpm.2017.99] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/09/2017] [Indexed: 11/09/2022] Open
Abstract
This article builds on Mannion and Exworthy’s account of the tensions between standardization and customization
within health services to explore why these tensions exist. It highlights the limitations of explanations which root them in an expression of managerialism versus professionalism and suggests that each logic is embedded in a
set of ontological, epistemological and moral commitments which are held in tension. At the front line of care
delivery, people cannot resolve these tensions but must navigate and negotiate them. The legitimacy of a health
system depends on its ability to deliver the ‘best of both worlds’ to citizens, offering the reassurance of sameness and the dignity of difference.
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Affiliation(s)
- Catherine Needham
- Health Services Management Centre, University of Birmingham, Birmingham, UK
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40
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Minvielle E. Toward Customized Care Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare". Int J Health Policy Manag 2018. [PMID: 29524957 PMCID: PMC5890073 DOI: 10.15171/ijhpm.2017.84] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Patients want their personal needs to be taken into account. Accordingly, the management of care has long
involved some degree of personalization. In recent times, patients’ wishes have become more pressing in a
moving context. As the population ages, the number of patients requiring sophisticated combinations of longterm
care is rising. Moreover, we are witnessing previously unvoiced demands, preferences and expectations
(eg, demand for information about treatment, for care complying with religious practices, or for choice of
appointment dates). In view of the escalating costs and the concerns about quality of care, the time has now
come to rethink healthcare delivery. Part of this reorganization can be related to customization: what is needed
is a customized business model that is effective and sustainable. Such business model exists in different service
sectors, the customization being defined as the development of tailored services to meet consumers’ diverse and
changing needs at near mass production prices. Therefore, its application to the healthcare sector needs to be
seriously considered.
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Affiliation(s)
- Etienne Minvielle
- Ecole des hautes études en santé publique (EHESP), Institut Gustave Roussy, Villejuif, France
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Greenfield D, Eljiz K, Butler-Henderson K. It Takes Two to Tango: Customization and Standardization as Colluding Logics in Healthcare Comment on "(Re) Making the Procrustean Bed Standardization and Customization as Competing Logics in Healthcare". Int J Health Policy Manag 2018. [PMID: 29524942 PMCID: PMC5819378 DOI: 10.15171/ijhpm.2017.77] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The healthcare context is characterized with new developments, technologies, ideas and expectations that are continually reshaping the frontline of care delivery. Mannion and Exworthy identify two key factors driving this complexity, 'standardization' and 'customization,' and their apparent resulting paradox to be negotiated by healthcare professionals, managers and policy makers. However, while they present a compelling argument an alternative viewpoint exists. An analysis is presented that shows instead of being 'competing' logics in healthcare, standardization and customization are long standing 'colluding' logics. Mannion and Exworthy's call for further sustained work to understand this complex, contested space is endorsed, noting that it is critical to inform future debates and service decisions.
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Affiliation(s)
- David Greenfield
- Australian Institute of Health Service Management, University of Tasmania, Sydney, Australia
| | - Kathy Eljiz
- Australian Institute of Health Service Management, University of Tasmania, Sydney, Australia
| | - Kerryn Butler-Henderson
- Australian Institute of Health Service Management, University of Tasmania, Sydney, Australia
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Ferlie E. Personalisation - An Emergent Institutional Logic in Healthcare? Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare". Int J Health Policy Manag 2018; 7:92-95. [PMID: 29325410 PMCID: PMC5745875 DOI: 10.15171/ijhpm.2017.71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/14/2017] [Indexed: 01/16/2023] Open
Abstract
This commentary on the recent think piece by Mannion and Exworthy reviews their core arguments, highlighting their suggestion that recent forces for personalization have emerged which may counterbalance the strong standardization wave which has been evident in many healthcare settings and systems over the last two decades. These forces for personalization can take very different forms. The commentary explores the authors' suggestion that these themes can be fruitfully examined theoretically through an institutional logics (ILs) literature, which has recently been applied by some scholars to healthcare settings. This commentary outlines key premises of that theoretical tradition. Finally, the commentary makes suggestions for taking this IL influenced research agenda further, along with some issues to be addressed.
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Affiliation(s)
- Ewan Ferlie
- School of Management and Business, King's College London, London, UK
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Mannion R, Braithwaite J. False Dawns and New Horizons in Patient Safety Research and Practice. Int J Health Policy Manag 2017; 6:685-689. [PMID: 29172374 PMCID: PMC5726317 DOI: 10.15171/ijhpm.2017.115] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/16/2017] [Indexed: 11/09/2022] Open
Abstract
In response to a weight of evidence that patients are frequently harmed as a result of their care, there have been concerted efforts to make healthcare safer, with health systems across the globe investing significant resources in policies and programmes designed to reduce adverse events. Yet, despite extensive efforts, improvements in safety have proved difficult to sustain and spread, with studies confirming there has been no measurable, systems-level improvement in the overall rates of preventable harm. Here, we highlight the limitations of the thinking which underpins current efforts to make healthcare systems safer and point to new and emerging approaches to understanding and addressing patient safety in complex, dynamic health systems.
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Affiliation(s)
- Russell Mannion
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Jeffrey Braithwaite
- Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
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