Ideas from the Frontline: Improvement Opportunities in Federally Qualified Health Centers

BACKGROUND

Engaging frontline clinicians and staff in quality improvement is a promising bottom-up approach to transforming primary care practices. This may be especially true in federally qualified health centers (FQHCs) and similar safety-net settings where large-scale, top-down transformation efforts are often associated with declining worker morale and increasing burnout. Innovation contests, which decentralize problem-solving, can be used to involve frontline workers in idea generation and selection.

OBJECTIVE

We aimed to describe the ideas that frontline clinicians and staff suggested via organizational innovation contests in a national sample of 54 FQHCs.

INTERVENTIONS

Innovation contests solicited ideas for improving care from all frontline workers-regardless of professional expertise, job title, and organizational tenure and excluding those in senior management-and offered opportunities to vote on ideas.

PARTICIPANTS

A total of 1,417 frontline workers across all participating FQHCs generated 2,271 improvement opportunities.

APPROACHES

We performed a content analysis and organized the ideas into codes (e.g., standardization, workplace perks, new service, staff relationships, community development) and categories (e.g., operations, employees, patients).

KEY RESULTS

Ideas from frontline workers in participating FQHCs called attention to standardization (n = 386, 17%), staffing (n = 244, 11%), patient experience (n = 223, 10%), staff training (n = 145, 6%), workplace perks (n = 142, 6%), compensation (n = 101, 5%), new service (n = 92, 4%), management-staff relationships (n = 82, 4%), and others. Voting results suggested that staffing resources, standardization, and patient communication were key issues among workers.

CONCLUSIONS

Innovation contests generated numerous ideas for improvement from the frontline. It is likely that the issues described in this study have become even more salient today, as the COVID-19 pandemic has had devastating impacts on work environments and health/social needs of patients living in low-resourced communities. Continued work is needed to promote learning and information exchange about opportunities to improve and transform practices between policymakers, managers, and providers and staff at the frontlines.

A clinical seminar on Spinoza and Bion: a conversation between Miller AND Koritar

The present transcript follows an online discussion held on April 3, 2022, between Ian Miller, author of Clinical Spinoza: Integrating His Philosophy with Contemporary Therapeutic Practice (2022), and Endre Koritar.

The Importance of Prioritising Politics in Good Governance for Medicines Initiative in Zimbabwe: A Qualitative Policy Analysis Study

In 2004 the World Health Organization (WHO) launched the Good Governance for Medicines (GGM) initiative with the aim of fighting corruption in the pharmaceutical sector. In the case of Zimbabwe, implementation of the initiative slowed down after the development phase. Often, lack of funding and technical considerations are cited as major reasons for issue de-prioritization whilst ignoring the influence of politics in mediating policy diffusion. Between June and August 2021, we conducted an in-depth document review and interviewed individuals involved with GGM in Zimbabwe to understand the political determinants of GGM prioritization in Zimbabwe. To guide and direct our analysis, we used the Shiffman and Smith framework. We found that the inception of GGM was facilitated by capable leaders, effective guiding institutions and resonance of the idea with the political environment. Prioritization from inception to implementation was constrained by limited citizen engagement, restriction of the issue to the pharmaceutical domain and a political transition that re-oriented policy priorities and reconfigured individual actor power. The portrayal of corruption as a priority problem requiring policy action has been hampered by the political sensitivity of the issue, lack of credible indicators on the prevalence and severity of the problem and challenges to measure the effectiveness of interventions such as the GGM. Despite the slowdown, from 2018 GGM actors have taken advantage of momentous policy windows to reconstitute their power by opportunistically framing GGM within the broader framework of access to essential medicines leading to the creation of new policy alliances and establishment of strategic political structures. To sustain the political prioritization, actors need to lobby for the institutionalization of GGM within the Ministry of Health strategy, sensitize citizens on the initiative, involve multiple stakeholders and frame the issue as a strategic intervention that underpins pharmaceutical sector performance within the national developmental framework.

Negotiating Change: Ideas, Institutions, and Political Actors in Tobacco Control Policy Making in Mauritius

CONTEXT

This article explains the policy process that occasioned the development of comprehensive tobacco control policies in Mauritius from 1980 to 2019. It does so by drawing theoretical insights from John Kingdon's streams framework, historical institutionalism, and ideational perspectives to explicate how tobacco control rose to the status of government policy agenda.

METHODS

The main sources of data are government documents, media reports, archival studies, grey literature, and published books and articles. These sources were supplemented by key informant interviews with government officials, civil society groups, and other vested interest groups.

FINDINGS

This article finds that the prevalence of noncommunicable diseases in the late 1980s, the political commitment of Mauritius's Labour government to comprehensive tobacco control, the institutional legacies of Mauritius's Public Health Act of 1925, and the administrative capacity of Mauritius's Ministry of Health and Quality of Life are the primary factors that drove tobacco control policies in Mauritius.

CONCLUSION

The findings from this study will enrich our understanding of policy change and the politics of tobacco control in the global south. Future research should investigate why some countries in Africa have failed to adopt comprehensive tobacco control policies despite ratifying the Framework Convention on Tobacco Control.

Competing interests, clashing ideas and institutionalizing influence: insights into the political economy of malaria control from seven African countries

This article explores how malaria control in sub-Saharan Africa is shaped in important ways by political and economic considerations within the contexts of aid-recipient nations and the global health community. Malaria control is often assumed to be a technically driven exercise: the remit of public health experts and epidemiologists who utilize available data to select the most effective package of activities given available resources. Yet research conducted with national and international stakeholders shows how the realities of malaria control decision-making are often more nuanced. Hegemonic ideas and interests of global actors, as well as the national and global institutional arrangements through which malaria control is funded and implemented, can all influence how national actors respond to malaria. Results from qualitative interviews in seven malaria-endemic countries indicate that malaria decision-making is constrained or directed by multiple competing objectives, including a need to balance overarching global goals with local realities, as well as a need for National Malaria Control Programmes to manage and coordinate a range of non-state stakeholders who may divide up regions and tasks within countries. Finally, beyond the influence that political and economic concerns have over programmatic decisions and action, our analysis further finds that malaria control efforts have institutionalized systems, structures and processes that may have implications for local capacity development.

Effects of Leader Tactics on the Creativity, Implementation, and Evolution of Ideas to Improve Healthcare Delivery

BACKGROUND

Slow progress in quality improvement (QI) has prompted calls to identify new QI ideas. Leaders guiding these efforts are advised to use evidence-based tactics, or specific approaches to address a goal, to promote clinician and staff engagement in the generation and implementation of QI ideas, but little evidence about effective tactics exists.

OBJECTIVE

Examine the association between leader tactics and the creativity, implementation outcome, and evolution of QI ideas from clinicians and staff.

DESIGN

Prospective panel analysis of 220 ideas generated by 12 leaders and teams (N = 72 members) from federally qualified community health practices in one center over 18 months. Measures were extracted from meeting minutes (note-taking by a member during meetings) and expert panel review. Multi-level models were used.

MEASURES

Leader tactics, idea creativity, implementation outcome, evolution pathways, center, and idea-submitter characteristics.

RESULTS

Leaders used one of four approaches: no tactic, meeting ground rules, team brainstorming, or reflection on team process. Implemented ideas evolved in three pathways: Plug and Play, Slow Burn, and Iterate and Generate. Compared with no leader tactic, meeting ground rules resulted in ideas not significantly different in creativity, implementation outcome, or evolution pathway. Brainstorming was associated with greater idea creativity, idea implementation, and ideas following a Plug and Play path (low member engagement and implementation over 2 months or less). Reflection on team process was associated with idea implementation (versus not), and ideas following an Iterate and Generate path (high member engagement and implementation over 3 months or more).

CONCLUSIONS

Two tactics, brainstorming and reflection, are helpful depending on goals. Brainstorming may aide leaders seeking disruptive change via more creative, rapidly implemented ideas. Reflection on team process may aide leaders seeking high-engagement ideas that may be implemented slowly. Both tactics may help leaders cultivate dynamics that increase implementation of ideas that improve healthcare.

NIH funding and the pursuit of edge science

The National Institutes of Health (NIH) plays a critical role in funding scientific endeavors in biomedicine. Funding innovative science is an essential element of the NIH's mission, but many have questioned the NIH's ability to fulfill this aim. Based on an analysis of a comprehensive corpus of published biomedical research articles, we measure whether the NIH succeeds in funding work with novel ideas, which we term edge science. We find that edge science is more often NIH funded than less novel science, but with a delay. Papers that build on very recent ideas are NIH funded less often than are papers that build on ideas that have had a chance to mature for at least 7 y. We have three further findings. First, the tendency to fund edge science is mostly limited to basic science. Papers that build on novel clinical ideas are not more often NIH funded than are papers that build on well-established clinical knowledge. Second, novel papers tend to be NIH funded more often because there are more NIH-funded papers in innovative areas of investigation, rather than because the NIH funds innovative papers within research areas. Third, the NIH's tendency to have funded papers that build on the most recent advances has declined over time. In this regard, NIH funding has become more conservative despite initiatives to increase funding for innovative projects. Given our focus on published papers, the results reflect both the funding preferences of the NIH and the composition of the applications it receives.

Short-term effect of the demonstration of human dissection and excursion on students´ ideas about the human organ systems: a Slovak experience

BACKGROUND

Excursions in natural sciences education are justified in the current school system and within the scope of subject focus. The research aimed to observe the immediate impact of demonstration of the human dissection and excursion on the formation of ideas of students about the human body systems.

METHODS

The experiment involved the first Slovak demonstration of a real human autopsy for students of the Biology Teaching Department (PdF TU in Trnava). Concepts of the structure of the human body were analyzed before and after experimental impact by a projective technique. The evaluation included the representation, description, and abundance of organs in the view of various systems. The subject of the research were also the questions focused on the use of illustrative procedures and tools in the educational process.

RESULTS

Significant statistical differences were found in the group affected by human autopsy in understanding of the digestive, urinary, and locomotor systems. Conversely, the skin, endocrine glands, and lymphatic system were the least represented by the experimental groups.

CONCLUSION

Considering the presented results, using different organizational forms and aids (real and virtual) is essential for bringing a positive educational effect on the studied problem (Tab. 1, Fig. 5, Ref. 20).

The Predictive Creative Mind: A First Look at Spontaneous Predictions and Evaluations During Idea Generation

Idea generation, the process of creating and developing candidate solutions that when implemented can solve ill-defined and complex problems, plays a pivotal role in creativity and innovation. The algorithms that underlie classical evolutionary, cognitive, and process models of idea generation, however, appear too inefficient to effectively help solve the ill-defined and complex problems for which one would engage in idea generation. To address this, these classical models have recently been redesigned as forward models, drawing heavily on the "predictive mind" literature. These pose that more efficiency can be achieved by making predictions based on heuristics, previous experiences, and domain knowledge about what material to use to generate ideas with, and evaluate these subsequently generated ideas based on whether they indeed match the initial prediction. When a discrepancy occurs between prediction and evaluation, new predictions are made, and thus shaping what actions, and how these actions, are undertaken. Although promising, forward models of idea generation remain theoretical and thus no empirical evidence exists about whether such predictions and evaluations indeed form part of the idea generation process. To take a first empirical look at this, a mixed-methods study was conducted by analyzing people's self-reports for the reasons of the actions that they take during an idea generation task. The results showed that predictions and evaluations are pervasive in the idea generation process. Specifically, switching between concept selection and conceptual combination and idea generation, as well as repeating idea generation based on earlier selected conceptual combination, and possibly (but to a lesser extent) concept selection and the repetition thereof, are likely to be driven by predictions and evaluations. Moreover, the frequencies of the predictions and evaluations that drive these actions influenced the amount of ideas generated, amount of concepts used, and within-concept fluency (the ratio of the amount of ideas generated per concept used). Therefore, the contribution of this paper is the first empirical evidence that indicates that the idea generation process is driven by both predictions and evaluations.

Age and the Trying Out of New Ideas

The aging of the scientific workforce and graying of grant recipients are central policy concerns in biomedicine. These trends are potentially important because older scientists are often seen as less open to new ideas than younger scientists. In this paper, we put this hypothesis to an empirical test. Using a measure of new ideas derived from the text of nearly all biomedical scientific articles published since 1946, we compare the tendency of younger and older researchers to try out new ideas in their work. We find that papers published in biomedicine by younger researchers are more likely to build on new ideas. Collaboration with an experienced researcher matters as well. Papers with a young first author and a more experienced last author are more likely to try out newer ideas than papers published by other team configurations. Given the crucial role that the trying out of new ideas plays in the advancement of science, our results buttress the case for funding scientific work by young researchers but also provide a caution against unconditional idolatry of youth over experience.

Enabling Anyone to Translate Clinically Relevant Ideas to Therapies

How do we inspire new ideas that could lead to potential treatments for rare or neglected diseases, and allow for serendipity that could help to catalyze them? How many potentially good ideas are lost because they are never tested? What if those ideas could have lead to new therapeutic approaches and major healthcare advances? If a clinician or anyone for that matter, has a new idea they want to test to develop a molecule or therapeutic that they could translate to the clinic, how would they do it without a laboratory or funding? These are not idle theoretical questions but addressing them could have potentially huge economic implications for nations. If we fail to capture the diversity of ideas and test them we may also lose out on the next blockbuster treatments. Many of those involved in the process of ideation may be discouraged and simply not know where to go. We try to address these questions and describe how there are options to raising funding, how even small scale investments can foster preclinical or clinical translation, and how there are several approaches to outsourcing the experiments, whether to collaborators or commercial enterprises. While these are not new or far from complete solutions, they are first steps that can be taken by virtually anyone while we work on other solutions to build a more concrete structure for the "idea-hypothesis testing-proof of concept-translation-breakthrough pathway".

The Exile of Hansen's Disease Patients to Moloka'i: A Diffusion of Innovations Perspective

This article analyzes the exile of patients with Hansen's disease (leprosy) to Moloka'i (Hawaii) by applying the diffusion of innovations (DoI) theory. Developed by Rogers, DoI posits that an innovation (i.e., idea, movement, or trend) is initiated within a culture. Then, it is diffused via particular channels across diverse cultures. Instead of evolving independently, innovations diffuse from one culture to another through various forms of contact and communication. In the context of this analysis, the objective is to examine how the diffusion of certain ideas, namely, abolishing the stigma associated with leprosy, could have improved the lives of Hawaiians. An important premise of this article is that the Hawaiian government barely applied the tenets of DoI, which is the reason why many people lost their lives. So, this article seeks to explore what could have been done to improve their situation and what pitfalls should be avoided in the future.

Scoring Divergent Thinking Tests by Computer With a Semantics-Based Algorithm

Divergent thinking (DT) tests are useful for the assessment of creative potentials. This article reports the semantics-based algorithmic (SBA) method for assessing DT. This algorithm is fully automated: Examinees receive DT questions on a computer or mobile device and their ideas are immediately compared with norms and semantic networks. This investigation compared the scores generated by the SBA method with the traditional methods of scoring DT (i.e., fluency, originality, and flexibility). Data were collected from 250 examinees using the “Many Uses Test” of DT. The most important finding involved the flexibility scores from both scoring methods. This was critical because semantic networks are based on conceptual structures, and thus a high SBA score should be highly correlated with the traditional flexibility score from DT tests. Results confirmed this correlation (r = .74). This supports the use of algorithmic scoring of DT. The nearly-immediate computation time required by SBA method may make it the method of choice, especially when it comes to moderate- and large-scale DT assessment investigations. Correlations between SBA scores and GPA were insignificant, providing evidence of the discriminant and construct validity of SBA scores. Limitations of the present study and directions for future research are offered.

Framing and the health policy process: a scoping review

Framing research seeks to understand the forces that shape human behaviour in the policy process. It assumes that policy is a social construct and can be cast in a variety of ways to imply multiple legitimate value considerations. Frames provide the cognitive means of making sense of the social world, but discordance among them forms the basis of policy contestation. Framing, as both theory and method, has proven to generate considerable insight into the nature of policy debates in a variety of disciplines. Despite its salience for understanding health policy debates; however, little is known about the ways frames influence the health policy process. A scoping review using the Arksey and O’Malley framework was conducted. The literature on framing in the health sector was reviewed using nine health and social science databases. Articles were included that explicitly reported theory and methods used, data source(s), at least one frame, frame sponsor and evidence of a given frame’s effect on the health policy process. A total of 52 articles, from 1996 to 2014, and representing 12 countries, were identified. Much of the research came from the policy studies/political science literature (n = 17) and used a constructivist epistemology. The term ‘frame’ was used as a label to describe a variety of ideas, packaged as values, social problems, metaphors or arguments. Frames were characterized at various levels of abstraction ranging from general ideological orientations to specific policy positions. Most articles presented multiple frames and showed how actors advocated for them in a highly contested political process. Framing is increasingly an important, yet overlooked aspect of the policy process. Further analysis on frames, framing processes and frame conflict can help researchers and policymakers to understand opaque and highly charged policy issues, which may facilitate the resolution of protracted policy controversies.

Internal consistency & validity of Indian disability evaluation and assessment scale (IDEAS) in patients with schizophrenia

BACKGROUND & OBJECTIVES

The Indian Disability Evaluation and Assessment Scale (IDEAS) has been recommended for assessment and certification of disability by the Government of India (GOI). However, the psychometric properties of IDEAS as adopted by GOI remain understudied. Our aim, thus, was to study the internal consistency and validity of IDEAS in patients with schizophrenia.

METHODS

A total of 103 consenting patients with residual schizophrenia were assessed for disability, quality of life (QOL) and psychopathology using the IDEAS, WHO QOL-100 and Positive and Negative symptom scale (PANSS) respectively. Internal consistency was calculated using Cronbach's alpha. For construct validity, relations between IDEAS, and psychopathology and QOL were studied.

RESULTS

The inter-item correlations for IDEAS were significant with a Cronbach's alpha of 0.721. All item scores other than score on communication and understanding; total and global IDEAS scores correlated significantly with the positive, negative and general sub-scales, and total PANSS scores. Communication and understanding was significantly related to negative sub-scale score only. Total and global disability scores correlated negatively with all the domains of WHOQOL-100 (ρ<0.01). The individual IDEAS item scores correlated negatively with various WHOQOL-100 domains (ρ0< 0.01).

INTERPRETATION & CONCLUSIONS

This study findings showed that the GOI-modified IDEAS had good internal consistency and construct validity as tested in patients with residual schizophrenia. Similar studies need to be done with other groups of patients.

Ideas and enhancements related to mobile applications to support type 1 diabetes

Background

Mobile devices have become increasingly important to young people who now use them to access a wide variety of health-related information. Research and policy related to the integration of health information and support with this technology do not effectively consider the viewpoint of a younger patient. Views of young people with type 1 diabetes are vital in developing quality services and improving their own health-related quality of life (HRQOL), yet research on their lifestyle and use of Web and mobile technology to support their condition and in non–health-related areas is sparse.

Objective

To develop insight into young people with type 1 diabetes and their current use of Web and mobile technology and its potential impact on HRQOL. This can be achieved by constructing an in-depth picture of their day-to-day experiences from qualitative interviewing and exploring how they make use of technology in their lives and in relation to their condition and treatment. The goal was then to build something to help them, using the researcher’s technical expertise and seeking users’ opinions during the design and build, utilizing sociotechnical design principles.

Methods

Data were collected by semistructured, in-depth qualitative interviews (N=9) of young people with type 1 diabetes aged 18-21. Interviews were transcribed and loaded onto NVivo for theme identification. Data analysis was undertaken during initial interviews (n=4) to locate potential ideas and enhancements for technical development. Latter interviews (n=5) assisted in the iterative sociotechnical design process of the development and provided additional developmental ideas.

Results

Six themes were identified providing an understanding of how participants lived with and experienced their condition and how they used technology. Four technological suggestions for improvement were taken forward for prototyping. One prototype was developed as a clinically approved app. A number of ideas for new mobile apps and enhancements to currently existing apps that did not satisfactorily cater to this age group’s requirements for use in terms of design and functionality were suggested by interviewees but were not prototyped.

Conclusions

This paper outlines the nonprototyped suggestions from interviewees and argues that young people with type 1 diabetes have a key role to play in the design and implementation of new technology to support them and improve HRQOL. It is vital to include and reflect on their suggestions as they have a radically different view of technology than either their parents or practitioners. We need to consider the relationship to technology that young people with type 1 diabetes have, and then reflect on how this might make a difference to them and when it might not be a suitable mechanism to use.

Brokering the boundary between science and advocacy: the case of intermittent preventive treatment among infants

The process of translating research into policy has gained considerable attention in recent years and a number of studies have investigated the nexus between the two ‘worlds’ of research and policy. One issue that has been little addressed is about the boundaries between research and advocacy: how far scientists do, or should, promote particular findings to policy makers and others. This article analyses a particular intervention in malaria control and the Consortium set up to accelerate its potential implementation. Using a framework that emphasizes the interplay of interests, institutions and ideas, it provides an example of how a network of committed researchers and funders attempted to follow a rational policy process, but faced conflicts and fundamental questions about their roles in generating scientific evidence and influencing global health policy. In an era of ever more and larger researcher groups and consortia, the findings offer insights and lessons to those engaged in the process of knowledge translation.