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Gurung G, Jaye C, Gauld R, Stokes T. Lessons learnt from the implementation of new models of care delivery through alliance governance in the Southern health region of New Zealand: a qualitative study. BMJ Open 2022; 12:e065635. [PMID: 36316079 PMCID: PMC9628683 DOI: 10.1136/bmjopen-2022-065635] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To explore the process of implementation of the primary and community care strategy (new models of care delivery) through alliance governance in the Southern health region of New Zealand (NZ). DESIGN Qualitative semistructured interviews were undertaken. A framework-guided rapid analysis was conducted, informed by implementation science theory-the Consolidated Framework for Implementation Research. SETTING Southern health region of NZ (Otago and Southland). PARTICIPANTS Eleven key informants (Alliance Leadership Team members and senior health professionals) who were involved in the development and/or implementation of the strategy. RESULTS The large number of strategy action plans and interdependencies of activities made implementation of the strategy complex. In the inner setting, communication and relationships between individuals and organisations were identified as an important factor for joint and integrated working. Key elements of a positive implementation climate were not adequately addressed to better align the interests of health providers, and there were multiple competing priorities for the project leaders. A perceived low level of commitment from the leadership of both organisations to joint working and resourcing indicated poor organisational readiness. Gaps in the implementation process included no detailed implementation plan (reflected in poor execution), ambitious targets, the lack of a clear performance measurement framework and an inadequate feedback mechanism. CONCLUSIONS This study identified factors for the successful implementation of the PCSS using an alliancing approach in Southern NZ. A key enabler is the presence of a stable and committed senior leadership team working through high trust relationships and open communication across all partner organisations. With alliances, partnerships and networks increasingly held up as models for integration, this evaluation identifies important lessons for policy makers, managers and services providers both in NZ and internationally.
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Affiliation(s)
- Gagan Gurung
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Centre for Health Systems and Technology (CHeST), University of Otago, Dunedin, New Zealand
| | - Chrystal Jaye
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- CARE Research Theme, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Centre for Health Systems and Technology (CHeST), University of Otago, Dunedin, New Zealand
- Otago Business School, University of Otago, Dunedin, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Centre for Health Systems and Technology (CHeST), University of Otago, Dunedin, New Zealand
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Cumming J, Middleton L, Silwal P, Tenbensel T. Integrated Care in Aotearoa New Zealand 2008-2020. Int J Integr Care 2021; 21:17. [PMID: 34824566 PMCID: PMC8588901 DOI: 10.5334/ijic.5679] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 09/20/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Ten years ago, progress towards integrated care in Aotearoa New Zealand was characterised as slow. Since then, there has been a patchwork of practices occurring under the broad umbrella of integrated care. These include: collective planning approaches (i.e., alliancing), agreed pathways of care, chronic care management initiatives, shared patient information systems, co-located centres and indigenous models of holistic care (e.g., Whānau Ora). DESCRIPTION Although integrated care is often mentioned in national policy documents, implementation has been left to regional and local decision making, and very few initiatives have spread beyond their initial locations. DISCUSSION System incentives that preserve organisational "sovereignty" and path-dependent funding have slowed progress towards more integrated care in some areas. There is some evidence about specific initiatives and their impact, but it is difficult to discern significant trends and commonalities around the country. CONCLUSION In the last ten years, the broad range of initiatives designed to achieve integrated care has absorbed regional and local attention and produced some evidence of progress, but the national picture of change is mixed.
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Affiliation(s)
- Jacqueline Cumming
- Consultant Advisor, Te Hikuwai Rangahau Hauora – Health Services Research Centre, Faculty of Health, Te Herenga Waka – Victoria University of Wellington, Wellington, New Zealand
| | - Lesley Middleton
- Senior Lecturer, School of Health, Faculty of Health, Te Herenga Waka – Victoria University of Wellington, New Zealand
| | - Pushkar Silwal
- Doctoral candidate, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Tim Tenbensel
- Associate Professor, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
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Akmal A, Gauld R. What components are important for effective healthcare alliance governance? Findings from a modified Delphi study in New Zealand. Health Policy 2020; 125:239-245. [PMID: 33390279 DOI: 10.1016/j.healthpol.2020.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/15/2020] [Accepted: 12/22/2020] [Indexed: 11/17/2022]
Abstract
Alliance governance is a form of governance developed in industry settings and more recently applied to healthcare. The core idea behind alliance governance is to involve the many stakeholders in the system to collaboratively develop a joint programme that promotes an integrated and whole of systems approach to care. Little is known about the model in healthcare, nor what those involved in an alliance should be focused upon. Using a modified Delphi method, this research presents a set of components that research participants agreed should underpin development of an effective alliance governance arrangement. These characteristics include a systems perspective-a truly shared governance protocol based on a shared vision and a common purpose; performance measurement-collecting and using real-time data that depicts the realities of an end-to-end system to establish better and more achievable goals based on alliance performance; a relational perspective to promote trust, respect and collaboration amongst alliance members, who historically have been competing for contracts and resources; structural changes that enable and promote a shared governance system; and, finally, equity and inclusion to ensure a diverse alliance which promotes diversity of ideas, and involvement of all stakeholders in the decision making process. This research is relevant to policymakers seeking to develop effective alliance-type arrangements as well as to those involved in the practice of alliance governance.
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Affiliation(s)
- Adeel Akmal
- Centre for Health Systems and Technology, Otago Business School, University of Otago, 60 Clyde Street, Dunedin 9016, New Zealand.
| | - Robin Gauld
- Centre for Health Systems and Technology, Otago Business School, University of Otago, 60 Clyde Street, Dunedin 9016, New Zealand.
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Dummer J, Tumilty E, Hannah D, McAuley K, Baxter J, Doolan-Noble F, Donlevy S, Stokes T. Health Care Utilisation and Health Needs of People with Severe COPD in the Southern Region of New Zealand: A Retrospective Case Note Review. COPD 2020; 17:136-142. [PMID: 32037897 DOI: 10.1080/15412555.2020.1724275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We examined health care utilisation and needs of people with severe COPD in the low-population-density setting of the Southern Region of New Zealand (NZ). We undertook a retrospective case note review of patients with COPD coded as having an emergency department attendance and/or admission with at least one acute exacerbation during 2015 to hospitals in the Southern Region of NZ. Data were collected and analysed from 340 case notes pertaining to: demographics, hospital admissions, outpatient contacts, pulmonary rehabilitation, advance care planning and comorbidities. Geometric mean (95%CI) length of stay for hospital admissions in urban and rural hospitals was 3.0 (2.7-3.4) and 4.0 (2.9-5.4) days respectively. More patients were from areas of higher deprivation but median hospital length of stay for patients from the least deprived areas was 2.0 days longer than others (p = 0.04). There was a median of 4 (range 0-16) comorbidities and 10 medications (range 0-25) per person. Of 169 cases where data was available, 26 (15%) were offered, 17 (10%) declined, and 5 (3%) completed, pulmonary rehabilitation at or in the year prior to the index admission. Patients were less likely to be offered pulmonary rehabilitation if they lived >20km away from the hospital where it took place (odds ratio of 0.12 for those living further away [95%CI 0.02-0.93, p = 0.04]). There were deficits in care: provision and uptake of non-pharmacological interventions was suboptimal and unevenly distributed across the region. Further research is needed to develop and evaluate strategies for delivering non-pharmacological interventions in this setting.
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Affiliation(s)
- Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.,Southern District Health Board, Respiratory Services, Dunedin Hospital, Dunedin, New Zealand
| | - Emma Tumilty
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Debbie Hannah
- Southern District Health Board, Respiratory Services, Dunedin Hospital, Dunedin, New Zealand
| | - Kathryn McAuley
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jo Baxter
- Kōhatu Centre for Hauora Māori, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Fiona Doolan-Noble
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Simon Donlevy
- Southern District Health Board, Respiratory Services, Dunedin Hospital, Dunedin, New Zealand
| | - Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Stokes T, Tumilty E, Latu ATF, Doolan-Noble F, Baxter J, McAuley K, Hannah D, Donlevy S, Dummer J. Improving access to health care for people with severe chronic obstructive pulmonary disease (COPD) in Southern New Zealand: qualitative study of the views of health professional stakeholders and patients. BMJ Open 2019; 9:e033524. [PMID: 31767598 PMCID: PMC6886961 DOI: 10.1136/bmjopen-2019-033524] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Chronic obstructive pulmonary disease (COPD) is a common chronic disease with significant morbidity and mortality, particularly for Māori, which places a large burden on the New Zealand (NZ) health system. We undertook a qualitative study as part of a mixed-methods implementation research project which aimed to determine the barriers and enablers to the provision of accessible high-quality COPD care. SETTING Southern Health Region of NZ (Otago and Southland). PARTICIPANTS Thirteen health professional stakeholders and 23 patients with severe COPD (including one Māori and one Pasifika participant). METHODS Semistructured interviews were undertaken. A thematic analysis using the Levesque conceptual framework for access to healthcare was conducted. RESULTS Health professional stakeholders identified barriers to providing access to health services, in particular: availability (inadequate staffing and resourcing of specialist services and limited geographical availability of pulmonary rehabilitation), affordability (both of regular medication, medication needed for an exacerbation of COPD and the copayment charge for seeing a general practitioner) and appropriateness (a shared model of care across primary and secondary care was needed to facilitate better delivery of key interventions such as pulmonary rehabilitation and advance care planning (ACP). Māori stakeholders highlighted the importance of communication and relationships and the role of whānau (extended family) for support. Patients' accounts showed variable ability to access services through having a limited understanding of what COPD is, a limited knowledge of services they could access, being unable to attend pulmonary rehabilitation (due to comorbidities) and direct (medication and copayment charges) and indirect (transport) costs. CONCLUSIONS People with severe COPD experience multilevel barriers to accessing healthcare in the NZ health system along the pathway of care from diagnosis to ACP. These need to be addressed by local health services if this group of patients are to receive high-quality care.
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Affiliation(s)
- Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Emma Tumilty
- Institute for Translational Sciences, University of Texas Medical Branch School of Health Professions, Galveston, Texas, USA
| | | | - Fiona Doolan-Noble
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Jo Baxter
- Kōhatu, Centre for Hauora Māori, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Kathryn McAuley
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Debbie Hannah
- Southern District Health Board, Otago and Southland, Dunedin, New Zealand
| | - Simon Donlevy
- Southern District Health Board, Otago and Southland, Dunedin, New Zealand
| | - Jack Dummer
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Abstract
This viewpoint outlines a brief history of primary care health reforms over the last 25 years, and how this history has influenced the business of caring. It also suggests where we should next look to improve the provision of equitable patient-centred care in the current climate of fiscal constraint, while meeting the challenges of an ageing population and increasing multimorbidity.
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Rees GH. The evolution of New Zealand's health workforce policy and planning system: a study of workforce governance and health reform. HUMAN RESOURCES FOR HEALTH 2019; 17:51. [PMID: 31277664 PMCID: PMC6612123 DOI: 10.1186/s12960-019-0390-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 06/25/2019] [Indexed: 05/16/2023]
Abstract
INTRODUCTION While considerable attention has been given to improving health workforce planning practice, few articles focus on the relationship between health workforce governance and health reform. By outlining a sequence of health reforms, we reveal how New Zealand's health workforce governance and practices came under pressure, leading to a rethink and the introduction of innovative approaches and initiatives. CASE DESCRIPTION New Zealand's health system was quite stable up to the late 1980s, after which 30 years of structural and system reform was undertaken. This had the effect of replacing the centralised medically led health workforce policy and planning system with a market-driven and short-run employer-led planning approach. The increasing pressures and inconsistencies this approach produced ultimately led to the re-centralisation of some governance functions and brought with it a new vision of how to better prepare for future health needs. While significant gain has been made implementing this new vision, issues remain for achieving more effective innovation diffusion and improved integrated care orientations. DISCUSSION AND EVALUATION The case reveals that there was a failure to consider the health workforce in almost all of the reforms. Health and workforce policy became increasingly disconnected at the central and regional levels, leading to fragmentation, duplication and widening gaps. New Zealand's more recent workforce policy and planning approach has adopted new tools and techniques to overcome these weaknesses that have implications for the workforce and service delivery, workforce governance and planning methodologies. However, further strengthening of workforce governance is required to embed the changes in policy and planning and to improve organisational capabilities to diffuse innovation and respond to evolving roles and team-based models of care. CONCLUSION The case reveals that disconnecting the workforce from reform policy leads to a range of debilitating effects. By addressing how it approaches workforce planning and policy, New Zealand is now better placed to plan for a future of integrated and team-based health care. The case provides cues for other countries considering reform agendas, the most important being to include and consider the health workforce in health reform processes.
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Affiliation(s)
- Gareth H Rees
- ESAN University, Alonso de Molina 1652, Monterrico Chico, 33, Lima, Peru.
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Stokes T, Atmore C, Penno E, Richard L, Wyeth E, Richards R, Doolan-Noble F, Gray AR, Sullivan T, Gauld R. Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand. BMJ Open 2019; 9:e030076. [PMID: 30928966 PMCID: PMC6477391 DOI: 10.1136/bmjopen-2019-030076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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
INTRODUCTION Achieving effective integration of healthcare across primary, secondary and tertiary care is a key goal of the New Zealand (NZ) Health Strategy. NZ's regional District Health Board (DHB) groupings are fundamental to delivering integration, bringing the country's 20 DHBs together into four groups to collaboratively plan, fund and deliver health services within their defined geographical regions. This research aims to examine how, for whom and in what circumstances the regional DHB groupings work to improve health service integration, healthcare quality, health outcomes and health equity, particularly for Māori and Pacific peoples. METHODS AND ANALYSIS This research uses a mixed methods realist evaluation design. It comprises three linked studies: (1) formulating initial programme theory (IPT) through developing programme logic models to describe regional DHB working; (2) empirically testing IPT through both a qualitative process evaluation of regional DHB working using a case study design; and (3) a quantitative analysis of the impact that DHB regional groupings may have on service integration, health outcomes, health equity and costs. The findings of these three studies will allow refinement of the IPT and should lead to a programme theory which will explain how, for whom and in what circumstances regional DHB groupings improve service integration, health outcomes and health equity in NZ. ETHICS AND DISSEMINATION The University of Otago Human Ethics Committee has approved this study. The embedding of a clinician researcher within a participating regional DHB grouping has facilitated research coproduction, the research has been jointly conceived and designed and will be jointly evaluated and disseminated by researchers and practitioners. Uptake of the research findings by other key groups including policymakers, Māori providers and communities and Pacific providers and communities will be supported through key strategic relationships and dissemination activities. Academic dissemination will occur through publication and conference presentations.
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Affiliation(s)
- Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Carol Atmore
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Erin Penno
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Lauralie Richard
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Emma Wyeth
- Ngāi Tahu Māori Health Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Rosalina Richards
- Va’a o Tautai, Centre for Pacific Health, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Fiona Doolan-Noble
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Andrew R Gray
- Biostatistics Unit, Division of Health Sciences, University of Otago, Dunedin, New Zealand
| | - Trudy Sullivan
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Otago Business School, University of Otago, Dunedin, New Zealand
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Stokes T, Tumilty E, Doolan-Noble F, Gauld R. HealthPathways implementation in a New Zealand health region: a qualitative study using the Consolidated Framework for Implementation Research. BMJ Open 2018; 8:e025094. [PMID: 30598490 PMCID: PMC6318537 DOI: 10.1136/bmjopen-2018-025094] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/03/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES To explore the process of implementation of an online health information web-based portal and referral system (HealthPathways) using implementation science theory: the Consolidated Framework for Implementation Research (CFIR). SETTING Southern Health Region of New Zealand (Otago and Southland). PARTICIPANTS Key Informants (providers and planners of healthcare) (n=10) who were either involved in the process of implementing HealthPathways or who were intended end-users of HealthPathways. METHODS Semistructured interviews were undertaken. A deductive thematic analysis using CFIR was conducted using the framework method. RESULTS CFIR postulates that for an intervention to be implemented successfully, account must be taken of the intervention's core components and the adaptable periphery. The core component of HealthPathways-the web portal and referral system that contains a large number of localised clinical care pathways-had been addressed well by the product developers. Little attention had, however, been paid to addressing the adaptable periphery (adaptable elements, structures and systems related to HealthPathways and the organisation into which it was being implemented); it was seen as sufficient just to deliver the web portal and referral system and the set of clinical care pathways as developed to effect successful implementation. In terms of CFIR's 'inner setting' corporate and professional cultures, the implementation climate and readiness for implementation were not properly addressed during implementation. There were also multiple failures of the implementation process (eg, lack of planning and engagement with clinicians). As a consequence, implementation of HealthPathways was highly problematic. CONCLUSIONS The use of CFIR has furthered our understanding of the factors needed for the successful implementation of a complex health intervention (HealthPathways) in the New Zealand health system. Those charged with implementing complex health interventions should always consider the local context within which they will be implemented and tailor their implementation strategy to address these.
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Affiliation(s)
- Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Emma Tumilty
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
- Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas, USA
| | - Fiona Doolan-Noble
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Otago Business School, University of Otago, Dunedin, Otago, New Zealand
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Gauld R, Asgari-Jirhandeh N, Patcharanarumol W, Tangcharoensathien V. Reshaping public hospitals: an agenda for reform in Asia and the Pacific. BMJ Glob Health 2018; 3:e001168. [PMID: 30588348 PMCID: PMC6278916 DOI: 10.1136/bmjgh-2018-001168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/15/2018] [Accepted: 10/23/2018] [Indexed: 01/17/2023] Open
Abstract
Hospitals in the Asia-Pacific today face the 'triple aim' challenge, proposed by the Institute for Healthcare Improvement, of how to improve quality of care and population health, while at the same time controlling healthcare costs. Yet, pursuing these challenges in combination is presently a remote prospect for many hospitals and, indeed, in a majority of countries in the region. The roles and functions of the public hospital sector within local health systems need redefinition and reform in the context of demographic and epidemiological transitions. Policymakers, managers and health professionals have an obligation to reshape the future of public hospitals. This article outlines actions for how public hospitals can be reshaped from a health system perspective. First, hospitals should be integrated into the fabric of the local health system; they can lead in this through working in alliances with other healthcare facilities, including primary care and private hospitals. Policymakers have a role in facilitating this as it contributes to health improvement of the population. Second, investments in system innovation, management improvement and information systems are required and their impact assessed. Such investments can contribute to cost control and efficiency. Public hospital sector investments should be strategic, efficient and should not bias investment in broader determinants of health. Third, reorienting health workforce competencies and appropriate skills should be central to hospital sector reforms, from policy to frontline services delivery. Creative thinking is needed to build and support flexible care delivery arrangements for services designed to respond to patients ' and providers' needs. Pivotal to achievement of each of these three areas of reform is good governance and leadership.
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Affiliation(s)
- Robin Gauld
- Otago Business School, University of Otago, Dunedin, New Zealand
| | - Nima Asgari-Jirhandeh
- Asia-Pacific Observatory on Health Systems and Policies, World Health Organization, Delhi, India
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Nicholson C, Hepworth J, Burridge L, Marley J, Jackson C. Translating the Elements of Health Governance for Integrated Care from Theory to Practice: A Case Study Approach. Int J Integr Care 2018; 18:11. [PMID: 29588645 PMCID: PMC5854213 DOI: 10.5334/ijic.3106] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Against a paucity of evidence, a model describing elements of health governance best suited to achieving integrated care internationally was developed. The aim of this study was to explore how health meso-level organisations used, or planned to use, the governance elements. METHODS A case study design was used to offer two contrasting contexts of health governance. Semi-structured interviews were conducted with participants who held senior governance roles. Data were thematically analysed to identify if the elements of health governance were being used, or intended to be in the future. RESULTS While all participants agreed that the ten elements were essential to developing future integrated care, most were not used. Three major themes were identified: (1) organisational versus system focus, (2) leadership and culture, and, (3) community (dis)engagement. DISCUSSION Several barriers and enablers to the use of the elements were identified and would require addressing in order to make evidence-based changes. CONCLUSION Despite a clear international policy direction in support of integrated care this study identified a number of significant barriers to its implementation. The study reconfirmed that a focus on all ten elements of health governance is essential to achieve integrated care.
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Affiliation(s)
- Caroline Nicholson
- Primary Care Clinical Unit, University of Queensland, AU
- Mater Research Institute, University of Queensland, AU
- Mater Misericordiae Ltd, South Brisbane, AU
| | - Julie Hepworth
- Mater Research Institute, University of Queensland, AU
- School of Public Health and Social Work, Queensland University of Technology, AU
| | - Letitia Burridge
- Primary Care Clinical Unit, University of Queensland, AU
- School of Human Services and Social Work, Griffith University, AU
| | - John Marley
- Faculty of Health Sciences, University of Queensland, AU
| | - Claire Jackson
- Primary Care Clinical Unit, University of Queensland, AU
- Mater Research Institute, University of Queensland, AU
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Stokes T, Tumilty E, Doolan-Noble F, Gauld R. Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study. BMC FAMILY PRACTICE 2017; 18:51. [PMID: 28381260 PMCID: PMC5382371 DOI: 10.1186/s12875-017-0622-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/23/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. METHODS Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method. RESULTS Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. CONCLUSIONS These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.
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Affiliation(s)
- Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
| | - Emma Tumilty
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
| | - Fiona Doolan-Noble
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
| | - Robin Gauld
- Otago Business School, University of Otago, Dunedin, New Zealand
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13
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Jackson CL, Hambleton SJ. Value co-creation driving Australian primary care reform. Med J Aust 2016; 204:S45-6. [PMID: 27078793 DOI: 10.5694/mja16.00128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/18/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Claire L Jackson
- Discipline of General Practice, Centre of Research Excellence – Building Primary Care Quality, Performance and Sustainability via Research Co-Creation, University of Queensland, Brisbane, QLD
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Abstract
Australia, in common with most developed countries, needs to reorientate its health system to meet the needs of the future. There is general acceptance that the current approach geared towards acute episodic care is no longer fit for purpose. This article explores the concept of integration in healthcare in Australia and specifically describes the role of clinicians over the last five years in brokering and supporting change in the way services are delivered.
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Affiliation(s)
- Jenny May
- University of Newcastle Department of Rural Health, Tamworth, NSW, Australia
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