Reconceptualizing Patient Safety Beyond Harm: Insights From a Mixed-Methods Qualitative Inquiry

BACKGROUND

Although patients' and care partners' perspectives on patient safety can guide health care learning and improvements, this information remains underutilized. Efforts to leverage this valuable data require challenging the narrow focus of safety as the absence of harm.

PURPOSE

The purpose of this study was to gain a broader insight into how patients and care partners perceive and experience safety.

METHODS

We used a mixed-methods approach that included a literature review and interviews and focus groups with patients, care partners, and health care providers. An emergent coding schema was developed from triangulation of the 2 data sets.

RESULTS

Two core themes-feeling unsafe and feeling safe-emerged that collectively represent a broader view of safety.

CONCLUSION

Knowledge from patients and care partners about feeling unsafe and safe needs to inform efforts to mitigate harm and promote safety, well-being, and positive outcomes and experiences.

Organizational Learning in the Morbidity and Mortality Conference

INTRODUCTION

The focus of morbidity and mortality conferences (M&MCs) has shifted to emphasize quality improvement and systems-level care. However, quality improvement initiatives targeting systems-level errors are challenged by learning in M&MCs, which occurs at the individual attendee level and not at the organizational level. Here, we aimed to describe how organizational learning in M&MCs is optimized by particular organizational and team cultures.

METHODS

A prospective, multiple-case study design was used. Using purposive sampling, three cases covering different medical/surgical specialties in North America were chosen. Data collection included direct observations of the M&MC, semistructured interviews with key M&MC members, and documentary information.

RESULTS

The role of the M&MC in all cases integrated two key concepts: recognition of system-wide trends and learning from error, at an organizational and team level. All cases provided evidence of double-loop learning and used organizational memory strategies to ensure knowledge was retained within the organization. A patient safety culture was linked to the promotion of open communication, fostering learning from adverse events.

CONCLUSION

This study describes three cases of systems-oriented M&MCs that reflected elements of organizational learning theory. The M&MC can therefore provide a context for organizational learning, allowing optimal learning from adverse events.

Integrating Implementation Science in a Quality and Patient Safety Improvement Learning Collaborative: Essential Ingredients and Impact

BACKGROUND

There is a current lack of research exploring the contextual factors of why and how quality improvement collaboratives (QICs) work. To this end, a mixed methods study was undertaken to improve our understanding of what works for whom and in what context among participants in a nationwide Canadian QIC.

METHODS

The authors used a mixed methods approach consisting of a written survey and 30-to-45-minute telephone interviews with collaborative team members, coaches, and senior leaders of participating safety improvement project (SIP) organizations to identify the essential elements of an integrated approach involving implementation science/knowledge translation, quality improvement (QI), patient safety, and collaborative learning/networked approach to enhancing safety and quality and building implementation capabilities. Survey data were analyzed using descriptive statistics. Interview data were analyzed by three team members using thematic analysis and development of an emergent coding schema.

RESULTS

Four themes emerged as the essential elements: (1) integrating implementation science into the QI/patient safety learning collaborative; (2) reinforcing of and opening eyes to implementation science by an expert implementation specialist; (3) valuing the sense making and strategies shared by coaches; and (4) experiencing challenges to implementation amplified by the COVID-19 pandemic. Teams also reported improvements in teamwork and patient outcomes as a result of participating in the QIC.

CONCLUSION

This study's findings provide deeper insight into the "essential ingredients" (expert implementation specialist, coaches) grounded in an integrated approach that drew from QI, patient safety, and implementation science. Organizations can use the key learnings on how best to implement quality and safety projects by leveraging the sense making of the expert implementation specialist and coaches in an integrated networked learning approach.

Measurement and Monitoring of Safety Framework: a qualitative study of implementation through a Canadian learning collaborative

BACKGROUND

The Measurement and Monitoring of Safety Framework (MMSF) aims to move beyond a narrow focus on measurement and past harmful events as the major focus for safety in healthcare organisations. There is limited evidence of MMSF implementation and impact.

OBJECTIVE

We aimed to examine participants' perspectives and experiences to increase understanding of the adaptive work of implementing the MMSF through a learning collaborative programme in diverse healthcare contexts across Canada.

METHODS

The Collaborative consisted of 11 teams from seven provinces. We conducted a qualitative study involving interviews with 36 participants, observations of 5 sites and learning sessions, and collection of documents.

RESULTS

Collaborative sessions and coaching allowed participants to explore reliability, sensitivity to operations, anticipation and preparedness, and integration and learning, in addition to past harm, and move beyond a project and measurement oriented safety approach. Participants noted the importance of time dedicated to engaging stakeholders in talk about MMSF concepts and their significance to their settings, prior to moving to implementing the Framework into practice. While participants generally started with a small number of ways of integrating the MMSF into practice such as rounds or huddles, many teams continued to experiment with incorporating the MMSF into a range of practices. Participants reported changes in thinking about safety, discussions and behaviours, which were perceived to impact healthcare processes. However, participants also reported challenges to sharing the Framework broadly and moving beyond its surface implementation, and difficulties with its sustained and widespread use given misalignments with existing quality and safety processes.

CONCLUSION

The MMSF requires a dramatic departure from traditional safety strategies that focus on discrete problems and emphasise measurement. MMSF implementation requires extensive discussion, coaching and experimentation. Future implementation should consider engaging local leaders and coaches and an organisation or system approach to enable broader reach and systemic change.

Consensus on how to optimise patient/family engagement in hospital planning and improvement: a Delphi survey

OBJECTIVE

Patient and family engagement (PE) in health service planning and improvement is widely advocated, yet little prior research offered guidance on how to optimise PE, particularly in hospitals. This study aimed to engage stakeholders in generating evidence-informed consensus on recommendations to optimise PE.

DESIGN

We transformed PE processes and resources from prior research into recommendations that populated an online Delphi survey.

SETTING AND PARTICIPANTS

Panellists included 58 persons with PE experience including: 22 patient/family advisors and 36 others (PE managers, clinicians, executives and researchers) in round 1 (100%) and 55 in round 2 (95%).

OUTCOME MEASURES

Ratings of importance on a seven-point Likert scale of 48 strategies organised in domains: engagement approaches, strategies to integrate diverse perspectives, facilitators, strategies to champion engagement and hospital capacity for engagement.

RESULTS

Of 50 recommendations, 80% or more of panellists prioritised 32 recommendations (27 in round 1, 5 in round 2) across 5 domains: 5 engagement approaches, 4 strategies to identify and integrate diverse patient/family advisor perspectives, 9 strategies to enable meaningful engagement, 9 strategies by which hospitals can champion PE and 5 elements of hospital capacity considered essential for supporting PE. There was high congruence in rating between patient/family advisors and healthcare professionals for all but six recommendations that were highly rated by patient/family advisors but not by others: capturing diverse perspectives, including a critical volume of advisors on committees/teams, prospectively monitoring PE, advocating for government funding of PE, including PE in healthcare worker job descriptions and sharing PE strategies across hospitals.

CONCLUSIONS

Decision-makers (eg, health system policy-makers, hospitals executives and managers) can use these recommendations as a framework by which to plan and operationalise PE, or evaluate and improve PE in their own settings. Ongoing research is needed to monitor the uptake and impact of these recommendations on PE policy and practice.

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme

BACKGROUND

Healthcare leaders look to high-reliability organisations (HROs) for strategies to improve safety, despite questions about how to translate these strategies into practice. Weick and Sutcliffe describe five principles exhibited by HROs. Interventions aiming to foster these principles are common in healthcare; however, there have been few examinations of the perceptions of those who have planned or experienced these efforts.

OBJECTIVE

This single-site qualitative study explores how healthcare professionals understand and enact the HRO principles in response to an HRO-inspired hospital-wide safety programme.

METHODS

We interviewed 71 participants representing hospital executives, programme leadership, and staff and physicians from three clinical services. We observed and collected data from unit and hospital-wide quality and safety meetings and activities. We used thematic analysis to code and analyse the data.

RESULTS

Participants reported enactment of the HRO principles 'preoccupation with failure', 'reluctance to simplify interpretations' and 'sensitivity to operations', and described the programme as adding legitimacy, training, and support. However, the programme was more often targeted at, and taken up by, nurses compared with other groups. Participants were less able to identify interventions that supported the HRO principles 'commitment to resilience' and 'deference to expertise' and reported limited examples of changes in practices related to these principles. Moreover, we identified inconsistent, and even conflicting, understanding of concepts related to the HRO principles, often related to social and professional norms and practices. Finally, an individualised rather than systemic approach hindered collective actions underlying high reliability.

CONCLUSION

Our findings demonstrate that the safety programme supported some HRO principles more than others, and was targeted at, and perceived differently across professional groups leading to inconsistent understanding and enactments of the principles across the organisation. Combining HRO-inspired interventions with more targeted attention to each of the HRO principles could produce greater, more consistent high-reliability practices.

Shifting paradigms: Developmental milestones for integrated care

Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care.

Impacts of patient and family engagement in hospital planning and improvement: qualitative interviews with patient/family advisors and hospital staff

Background

Patient engagement (PE) in hospital planning and improvement is widespread, yet we lack evidence of its impact. We aimed to identify benefits and harms that could be used to assess the impact of hospital PE.

Methods

We interviewed hospital-affiliated persons involved in PE activities using a qualitative descriptive approach and inductive content analysis to derive themes. We interpreted themes by mapping to an existing framework of healthcare performance measures and reported themes with exemplar quotes.

Results

Participants included 38 patient/family advisors, PE managers and clinicians from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Benefits of PE activities included 9 impacts on the capacity of hospitals. PE activities involved patient/family advisors and clinicians/staff in developing and spreading new PE processes across hospital units or departments, and those involved became more adept and engaged. PE had beneficial effects on hospital structures/resources, clinician staff functions and processes, patient experience and patient outcomes. A total of 14 beneficial impacts of PE were identified across these domains. Few unintended or harmful impacts were identified: overextended patient/family advisors, patient/family advisor turnover and clinician frustration if PE slowed the pace of planning and improvement.

Conclusions

The 23 self reported impacts were captured in a Framework of Impacts of Patient/Family Engagement on Hospital Planning and Improvement, which can be used by decision-makers to assess and allocate resources to hospital PE, and as the basis for ongoing research on the impacts of hospital PE and how to measure it.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07747-3.

Using Case Costing to Evaluate the Potential Impact of a Reintegration Unit on an Acute-Care Hospital's Capacity and Resources

The Ontario Ministry of Health funded a reintegration unit to transition hospitalized patients who no longer required acute care to alternate level of care (ALC), such as long-term care. In its first year, 102 (3.5%) patients of the hospital's waiting-for-ALC population were transferred, with 37.3% transferred on the day of ALC readiness. The reintegration unit reduced direct hospital costs by $861,000. Using case costing, we modelled optimized scenarios including all transfers on the day of ALC readiness and increased transfers to the reintegration unit; this helped reduce avoided direct costs by $2.3-$5.4 million. Acute-care bed capacity could have increased by 11%. We outline strategies to optimize future performance of the reintegration unit.

Organizational capacity for patient and family engagement in hospital planning and improvement: interviews with patient/family advisors, managers and clinicians

BACKGROUND

Patient and family engagement (PE) in healthcare planning and improvement achieves beneficial outcomes and is widely advocated, but a lack of resources is a critical barrier. Little prior research studied how organizations support engagement specifically in hospitals.

OBJECTIVE

We explored what constitutes hospital capacity for engagement.

METHODS

We conducted descriptive qualitative interviews and complied with criteria for rigour and reporting in qualitative research. We interviewed patient/family advisors, engagement managers, clinicians and executives at hospitals with high engagement activity, asking them to describe essential resources or processes. We used content analysis and constant comparison to identify themes and corresponding quotes and interpreted findings by mapping themes to two existing frameworks of PE capacity not specific to hospitals.

RESULTS

We interviewed 40 patient/family advisors, patient engagement managers, clinicians and corporate executives from nine hospitals (two < 100 beds, four 100 + beds, three teaching). Four over-arching themes about capacity considered essential included resources, training, organizational commitment and staff support. Views were similar across participant and hospital groups. Resources included funding and people dedicated to PE and technology to enable communication and collaboration. Training encompassed initial orientation and project-specific training for patient/family advisors and orientation for new staff and training for existing staff on how to engage with patient/family advisors. Organizational commitment included endorsement from the CEO and Board, commitment from staff and continuous evaluation and improvement. Staff support included words and actions that conveyed value for the role and input of patient/family advisors. The blended, non-hospital-specific framework captured all themes. Hospitals of all types varied in the availability of funding dedicated to PE. In particular, reimbursement of expenses and compensation for time and contributions were not provided to patient/family advisors. In addition to skilled engagement managers, the role of clinician or staff champions was viewed as essential.

CONCLUSION

The findings build on prior research that largely focused on PE in individual clinical care or research or in primary care planning and improvement. The findings closely aligned with existing frameworks of organizational capacity for PE not specific to hospital settings, which suggests that hospitals could use the blended framework to plan, evaluate and improve their PE programs. Further research is needed to yield greater insight into how to promote and enable compensation for patient/family advisors and the role of clinician or staff champions in supporting PE.

The role of hospital characteristics in patient safety: a protocol for a national cohort study

BACKGROUND

Substantial expenditures on health care safety programs have been justified by their goal of reducing health care associated-harm (adverse events), but adverse event rates have not changed over the past 4 decades. The objective of this study is to describe hospital-level factors that are relevant to safety in Canadian hospitals and the impact of these factors on hospital adverse events.

METHODS

This is a protocol for a national cohort study to describe the association between hospital-level factors and adverse events. We will survey at least 90 (35%) Canadian hospitals to describe 4 safety-relevant domains, chosen based on the literature and expert consultation, namely patient safety culture, safety strategies, staffing, and volume and capacity. We will retrospectively identify hospital adverse events from a national data source. We will evaluate organization-level factors using established scales and a survey, codesigned by the study team and hospital leaders. Hospital leaders, clinical unit leaders and front-line staff will complete the surveys once a year for 3 years, with an anticipated start date of winter 2022. We will use national health administrative data to estimate the rate and type of hospital adverse events corresponding to each 1-year survey period.

INTERPRETATION

Analysis of data from this project will describe hospital organizational factors that are relevant to safety and help identify organizational initiatives that improve hospital patient safety. In addition to biyearly reports to the leaders of the participating hospitals, we have a multifaceted and tailored dissemination strategy that includes integrating the knowledge users into the study team to increase the likelihood that our study will lead to improved hospital patient safety.

Implementation of a central-line bundle: a qualitative study of three clinical units

Background

Evidence for the central line-associated bloodstream infection (CLABSI) bundle effectiveness remains mixed, possibly reflecting implementation challenges and persistent ambiguities in how CLABSIs are counted and bundle adherence measured. In the context of a tertiary pediatric hospital that had reduced CLABSI by 30% as part of an international safety program, we aimed to examine unit-based socio-cultural factors influencing bundle practices and measurement, and how they come to be recognized and attended to by safety leaders over time in an organization-wide bundle implementation effort.

Methods

We used an interpretivist qualitative research approach, based on 74 interviews, approximately 50 h of observations, and documents. Data collection focused on hospital executives and safety leadership, and three clinical units: a medical specialty unit, an intensive care unit, and a surgical unit. We used thematic analysis and constant comparison methods for data analysis.

Results

Participants had variable beliefs about the central-line bundle as a quality improvement priority based on their professional roles and experiences and unit setting, which influenced their responses. Nursing leaders were particularly concerned about CLABSI being one of an overwhelming number of QI targets for which they were responsible. Bundle implementation strategies were initially reliant on unit-based nurse education. Over time there was recognition of the need for centralized education and reinforcement tactics. However, these interventions achieved limited impact given the influence of competing unit workflow demands and professional roles, interactions, and routines, which were variably targeted in the safety program. The auditing process, initially a responsibility of units, was performed in different ways based on individuals’ approaches to the process. Given concerns about auditing reliability, a centralized approach was implemented, which continued to have its own variability.

Conclusions

Our findings report on a contextualized, dynamic implementation approach that required movement between centralized and unit-based approaches and from a focus on standardization to some recognition of a role for customization. However, some factors related to bundle compliance and measurement remain unaddressed, including harder to change socio-cultural factors likely important to sustainability of the CLABSI reductions and fostering further improvements across a broader safety agenda.

Identification and Adjudication of Adverse Events Following Rectal Cancer Surgery: Observational Case Series in a Region of Ontario, Canada

BACKGROUND

For patients undergoing rectal cancer surgery, we evaluated whether suboptimal preoperative surgeon evaluation of resection margins is a latent condition factor-a factor that is common, unrecognized, and may increase the risk of certain adverse events, including local tumour recurrence, positive surgical margin, nontherapeutic surgery, and in-hospital mortality.

METHODS

In this observational case series of patients who underwent rectal cancer surgery during 2016 in Local Health Integrated Network 4 region of Ontario (population 1.4 million), chart review and a trigger tool were used to identify patients who experienced the adverse events. An expert panel adjudicated whether each event was preventable or nonpreventable and identified potential contributing factors to adverse events.

RESULTS

Among 173 patients, 25 (14.5%) had an adverse event and 13 cases (7.5%) were adjudicated as preventable. Rate of surgeon awareness of preoperative margin status was low at 50% and similar among cases with and without an adverse event (p = 0.29). Suboptimal surgeon preoperative evaluation of surgical margins was adjudicated a contributing factor in all 11 preventable local recurrence, positive margin, and nontherapeutic surgery cases. Failure to rescue was judged a contributing factor in the two cases with preventable in-hospital mortality.

CONCLUSIONS

Suboptimal surgeon preoperative evaluation of surgical margins in rectal cancer is likely a latent condition factor. Optimizing margin evaluation may be an efficient quality improvement target.

Interprofessional and multiprofessional approaches in quality improvement education

The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals' professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.

Approaches to optimize patient and family engagement in hospital planning and improvement: Qualitative interviews

Background

Patient engagement (PE) in health‐care planning and improvement is a growing practice. We lack evidence‐based guidance for PE, particularly in hospital settings. This study explored how to optimize PE in hospitals.

Methods

This study was based on qualitative interviews with individuals in various roles at hospitals with high PE capacity. We asked how patients were engaged, rationale for approaches chosen and solutions for key challenges. We identified themes using content analysis.

Results

Participants included 40 patient/family advisors, PE managers, clinicians and executives from 9 hospitals (2 < 100 beds, 4 100 + beds, 3 teaching). Hospitals most frequently employed collaboration (standing committees, project teams), followed by blended approaches (collaboration + consultation), and then consultation (surveys, interviews). Those using collaboration emphasized integrating perspectives into decisions; those using consultation emphasized capturing diverse perspectives. Strategies to support engagement included engaging diverse patients, prioritizing what benefits many, matching patients to projects, training patients and health‐care workers, involving a critical volume of patients, requiring at least one patient for quorum, asking involved patients to review outputs, linking PE with the Board of Directors and championing PE by managers, staff and committee/team chairs.

Conclusion

This research generated insight on concrete approaches and strategies that hospitals can use to optimize PE for planning and improvement. On‐going research is needed to understand how to recruit diverse patients and best balance blended consultation/collaboration approaches.

Patient or public contribution

Three patient research partners with hospital PE experience informed study objectives and interview questions.

Hospital capacity for patient engagement in planning and improving health services: a cross-sectional survey

Background

Patient engagement (PE) in planning or improving hospital facilities or services is one approach for improving healthcare delivery and outcomes. To provide evidence on hospital capacity needed to support PE, we described the attributes of hospital PE capacity associated with clinical quality measures.

Methods

We conducted a cross-sectional survey of general and specialty hospitals based on the Measuring Organizational Readiness for Patient Engagement framework. We derived a PE capacity index measure, and with Multiple Correspondence Analysis, assessed the association of PE capacity with hospital type, and rates of hand-washing, C. difficile infection rates and 30-day readmission.

Results

Respondents (91, 66.4%) included general: < 100 beds (48.4%), 100+ beds (27.5%), teaching hospitals (11.0%) and specialty (13.2%) hospitals. Most featured PE in multiple clinical and corporate departments. Most employed PE in a range of Planning (design/improve facilities 94.5%, develop strategic plans 87.9%), Evaluation/Quality Improvement (accreditation 91.2%, develop QI plans 90.1%) and Service Delivery activities (develop information/communication aids 92.3%). Hospitals enabled PE with multiple supports (median 12, range 0 to 25), most often: 76.9% strategic plan recognizes PE, 74.7% patient/family advisory council, and 69.2% pool of patient volunteers; and least often: 30.0% PE staff, 26.4% PE funding and 16.5% patient reimbursement or 3.3% compensation. Hospitals employed a range of less (inform, consult) and more (involve, partner) active modes of engagement. Two variables accounted for 29.6% of variance in hospital PE capacity index measure data: number of departments featuring PE and greater use of active engagement modes. PE capacity was not associated with general hospital type or clinical quality measures.

Conclusions

Hospitals with fewer resources can establish favourable PE conditions by deploying PE widely and actively engaging patients. Healthcare policy-makers, hospital executives and PE managers can use these findings to allocate PE resources. Future research should explore how PE modes and methods impact clinical outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06174-0.

Applying the principles of adaptive leadership to person-centred care for people with complex care needs: Considerations for care providers, patients, caregivers and organizations

Background

Health systems in many countries see person‐centred care as a critical component of high‐quality care but many struggle to operationalize it in practice. We argue that models such as adaptive leadership can be a critical lever to support person‐centred care, particularly for people who have multiple complex care needs.

Objective

To reflect on two concepts: person‐centred care and adaptive leadership and share how adaptive leadership can advance person‐centred care at the front‐line care delivery level and the organizational level.

Findings

The defining feature of adaptive leadership is the separation of technical solutions (ie applying existing knowledge and techniques to problems) from adaptive solutions (ie requiring shifts in how people work together, not just what they do). Addressing adaptive challenges requires identifying key assumptions that may limit motivations for change and the behaviours influenced by these assumptions. Thus, effective care for patients, particularly those with multiple complex care needs, often entails helping care providers and patients to examine their relationships and behaviours not just identifying technical solutions. Addressing adaptive challenges also requires a supportive and enabling organizational context. We provide illustrative examples of how adaptive leadership principles can be applied at both the front line of care and the organization level in advancing person‐centred care delivery.

Conclusions

Advancing person‐centred care at both the clinical and organizational levels requires a growth mindset, a willingness to try (and fail) and try again, comfort in being uncomfortable and a commitment to figure things out, in partnership, in iterative ways. Patients, caregivers, care providers and organizational leaders all need to be adaptive leaders in this endeavour.

Experiential Learning in Project-Based Quality Improvement Education: Questioning Assumptions and Identifying Future Directions

PURPOSE

Project-based experiential learning is a defining element of quality improvement (QI) education despite ongoing challenges and uncertainties. The authors examined stakeholders' perceptions and experiences of QI project-based learning to increase understanding of factors that influence learning and project experiences.

METHOD

The authors used a case study approach to examine QI project-based learning in 3 advanced longitudinal QI programs, 2 at the University of Toronto and 1 at an academic tertiary-care hospital. From March 2016 to June 2017, they undertook 135 hours of education program observation and 58 interviews with learners, program directors, project coaches, and institutional leaders and reviewed relevant documents. They analyzed data using a conventional and directed data analysis approach.

RESULTS

The findings provide insight into 5 key factors that influenced participants' project-based learning experiences and outcomes: (1) variable emphasis on learning versus project objectives and resulting benefits, tensions, and consequences; (2) challenges integrating the QI project into the curriculum timeline; (3) project coaching factors (e.g., ability, capacity, role clarity); (4) participants' differing access to resources and ability to direct a QI project given their professional roles; and (5) workplace environment influence on project success.

CONCLUSIONS

The findings contribute to an empirical basis toward more effective experiential learning in QI by identifying factors to target and optimize. Expanding conceptualizations of project-based learning for QI education beyond learner-initiated, time-bound projects, which are at the core of many QI educational initiatives, may be necessary to improve learning and project outcomes.

New Voices, New Power, New Ways of Working: Bringing integrated care to the National Health Service in England

This issue of Healthcare Quarterly features the third and final instalment in a three-part series developed by Ontario's The Change Foundation featuring international perspectives on health service delivery models that improve system integration and ensure seamless services and better coordination. Part one featured Chris Ham, chief executive of the London-based King's Fund think tank, and part two featured Geoff Huggins, director for health and social care integration in Scotland. In this issue, Helen Bevan, chief transformation officer of England's National Health Service, discusses the radical shifts she'd like to see in how we approach integration.

Integrating Care in Scotland

This issue of Healthcare Quarterly includes the second of a three-part series developed by Ontario's The Change Foundation featuring international perspectives on health service delivery models that improve system integration and ensure seamless services and better coordination. Part 1 featured Chris Ham, chief executive of the London-based King's Fund think tank. In this issue, Geoff Huggins, director for Health and Social Care Integration in Scotland, discusses Scotland's experience and lessons learned after legislating integrated health and social care in 2015.

Engaging primary care physicians in care coordination for patients with complex medical conditions

OBJECTIVE

To explore the dynamics of primary care physicians' (PCPs') engagement with the Seamless Care Optimizing the Patient Experience (SCOPE) project.

DESIGN

Qualitative study using semistructured interviews.

SETTING

Solo and small group primary care practices in urban Toronto, Ont.

PARTICIPANTS

A total of 22 of the 29 SCOPE PCPs (75.8%) were interviewed 14 to 19 months after the initiation of SCOPE.

METHODS

Qualitative semistructured interviews were conducted to examine influencing factors associated with PCPs' engagement in SCOPE. Transcripts were analyzed using a grounded theory-informed approach and key themes were identified.

MAIN FINDINGS

The SCOPE project provided practical mechanisms through which PCPs could access information and connect with resources. Contextual and historical factors including strained relationships between hospital specialists and community PCPs and PCPs' feelings of responsibility, isolation, disconnection, and burnout influenced readiness to engage. Provision of clinically useful supports in a trusting, collaborative manner encouraged PCPs' engagement in newer, more collaborative ways of working.

CONCLUSION

The SCOPE project provided an opportunity for PCPs to build meaningful relationships, reconnect to the broader health care system, and redefine their roles. For many PCPs, reestablishing connections reaffirmed their role in the system and enabled a more collaborative care model. Strategies for connecting community-based PCPs to the broader system need to consider contextual factors and the effects of new linkages and coordination on the identities and relationships of PCPs.

Supporting Patient and Family Engagement for Healthcare Improvement: Reflections on "Engagement-Capable Environments" in Pan-Canadian Learning Collaboratives

Although the involvement of patients in their care has been central to the concept of patient-centred care, patient engagement in the realms of health professional education, policy making, governance, research and healthcare improvement has been rapidly evolving in Canada in the past decade. The Canadian Foundation for Healthcare Improvement (CFHI) has supported healthcare organizations across Canada to meaningfully partner with patients in quality improvement and system redesign efforts. This article describes CFHI initiatives to enhance patient engagement efforts across Canada and the lessons learned in the context of "engagement-capable environments" and offers reflections for the future of patient engagement in Canada.

Effective Approaches to Integrating Care: A Three-Part Series

This issue of Healthcare Quarterly introduces a three-part series featuring international perspectives on health service delivery models that improve system integration and ensure seamless services and better coordination. The series, developed by Ontario's Change Foundation, will feature Chris Ham, chief executive of the London-based King's Fund think tank; Geoff Huggins, director for health and social care integration in Scotland; and Helen Bevan, chief transformation officer of England's National Health Service.

Mechanisms, contexts and points of contention: operationalizing realist-informed research for complex health interventions

Background

The concept of “mechanism” is central to realist approaches to research, yet research teams struggle to operationalize and apply the concept in empirical research. Our large, interdisciplinary research team has also experienced challenges in making the concept useful in our study of the implementation of models of integrated community-based primary health care (ICBPHC) in three international jurisdictions (Ontario and Quebec in Canada, and in New Zealand).

Methods

In this paper we summarize definitions of mechanism found in realist methodological literature, and report an empirical example of a realist analysis of the implementation ICBPHC.

Results

We use our empirical example to illustrate two points. First, the distinction between contexts and mechanisms might ultimately be arbitrary, with more distally located mechanisms becoming contexts as research teams focus their analytic attention more proximally to the outcome of interest. Second, the relationships between mechanisms, human reasoning, and human agency need to be considered in greater detail to inform realist-informed analysis; understanding these relationships is fundamental to understanding the ways in which mechanisms operate through individuals and groups to effect the outcomes of complex health interventions.

Conclusions

We conclude our paper with reflections on human agency and outline the implications of our analysis for realist research and realist evaluation.

Team dynamics within quality improvement teams: a scoping review

Purpose

This scoping review examines what is known about the processes of quality improvement (QI) teams, particularly related to how teams impact outcomes. The aim is to provide research-informed guidance for QI leaders and to inform future research questions.

Data sources

Databases searched included: MedLINE, EMBASE, CINAHL, Web of Science and SCOPUS.

Study selection

Eligible publications were written in English, published between 1999 and 2016. Articles were included in the review if they examined processes of the QI team, were related to healthcare QI and were primary research studies. Studies were excluded if they had insufficient detail regarding QI team processes.

Data extraction

Descriptive detail extracted included: authors, geographical region and health sector. The Integrated (Health Care) Team Effectiveness Model was used to synthesize findings of studies along domains of team effectiveness: task design, team process, psychosocial traits and organizational context.

Results of data synthesis

Over two stages of searching, 4813 citations were reviewed. Of those, 48 full-text articles are included in the synthesis. This review demonstrates that QI teams are not immune from dysfunction. Further, a dysfunctional QI team is not likely to influence practice. However, a functional QI team alone is unlikely to create change. A positive QI team dynamic may be a necessary but insufficient condition for implementing QI strategies.

Conclusions

Areas for further research include: interactions between QI teams and clinical microsystems, understanding the role of interprofessional representation on QI teams and exploring interactions between QI team task, composition and process.

Expanding patient engagement in quality improvement and health system redesign: Three Canadian case studies

Healthcare organizations face growing pressures to increase patient-centred care and to involve patients more in organizational decisions. Yet many providers worry that such involvement requires additional time and resources and do not see patients as capable of contributing meaningfully to decisions. This article discusses three efforts in four organizations to engage patients in quality improvement efforts. McGill University Health Centre, Saskatoon Health Region, and Vancouver Coastal and Fraser Health Regions all engaged patients in quality improvement and system redesign initiatives that were successful in improving care processes, outcomes, and patient experience measures. Patient involvement in redesigning care may provide a way to demonstrate the value of patients' experiences and inputs into problem-solving, building support for their involvement in other areas. Further study of these cases and a broader survey of organizational experiences with patient involvement may help elucidate the factors that support greater patient engagement.

Contributing causes to adverse events in home care and potential interventions to reduce their incidence

The increasing complexity of home care services, pressures to discharge patients quicker, and the growing vulnerabilities of home care clients all contribute to adverse events in home care. In this article, home care staff in six programs analyzed 27 fall- and medication-related events. Classification of contributing causes indicates that patient and environmental factors were common in fall events, while organization and management factors along with patient, task, team, and individual factors were common in medication-related events. Home care settings create specific challenges in identifying and mitigating risks. Some factors, such as variations in home environments, are difficult to address. However, changing care coordination structures and communication methods could ameliorate other factors, including poor communications among staff and limited team and cross-sector communication and coordination. Ensuring that medication ordering and administration processes are optimized for home environments would also contribute to safer care.

Engaging patients to improve quality of care: a systematic review

BACKGROUND

To identify the strategies and contextual factors that enable optimal engagement of patients in the design, delivery, and evaluation of health services.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Cochrane, Scopus, PsychINFO, Social Science Abstracts, EBSCO, and ISI Web of Science from 1990 to 2016 for empirical studies addressing the active participation of patients, caregivers, or families in the design, delivery and evaluation of health services to improve quality of care. Thematic analysis was used to identify (1) strategies and contextual factors that enable optimal engagement of patients, (2) outcomes of patient engagement, and (3) patients' experiences of being engaged.

RESULTS

Forty-eight studies were included. Strategies and contextual factors that enable patient engagement were thematically grouped and related to techniques to enhance design, recruitment, involvement and leadership action, and those aimed to creating a receptive context. Reported outcomes ranged from educational or tool development and informed policy or planning documents (discrete products) to enhanced care processes or service delivery and governance (care process or structural outcomes). The level of engagement appears to influence the outcomes of service redesign-discrete products largely derived from low-level engagement (consultative unidirectional feedback)-whereas care process or structural outcomes mainly derived from high-level engagement (co-design or partnership strategies). A minority of studies formally evaluated patients' experiences of the engagement process (n = 12; 25%). While most experiences were positive-increased self-esteem, feeling empowered, or independent-some patients sought greater involvement and felt that their involvement was important but tokenistic, especially when their requests were denied or decisions had already been made.

CONCLUSIONS

Patient engagement can inform patient and provider education and policies, as well as enhance service delivery and governance. Additional evidence is needed to understand patients' experiences of the engagement process and whether these outcomes translate into improved quality of care.

REGISTRATION

N/A (data extraction completed prior to registration on PROSPERO).

A Network Analysis Perspective to Implementation: The Example of Health Links to Promote Coordinated Care

Although implementation models broadly recognize the importance of social relationships, our knowledge about applying social network analysis (SNA) to formative, process, and outcome evaluations of health system interventions is limited. We explored applications of adopting an SNA lens to inform implementation planning, engagement and execution, and evaluation. We used Health Links, a province-wide program in Canada aiming to improve care coordination among multiple providers of high-needs patients, as an example of a health system intervention. At the planning phase, an SNA can depict the structure, network influencers, and composition of clusters at various levels. It can inform the engagement and execution by identifying potential targets (e.g., opinion leaders) and by revealing structural gaps and clusters. It can also be used to assess the outcomes of the intervention, such as its success in increasing network connectivity; changing the position of certain actors; and bridging across specialties, organizations, and sectors. We provided an overview of how an SNA lens can shed light on the complexity of implementation along the entire implementation pathway, by revealing the relational barriers and facilitators, the application of network-informed and network-altering interventions, and testing hypotheses on network consequences of the implementation.

Quality improvement and patient safety: Reality and responsibility from Codman to today

Quality improvement and patient safety (QIPS) has become increasingly important in the practice of medicine, particularly since the Institute of Medicine's report, "To Err is Human." Despite surgery having been initially at the forefront in instituting QIPS, there has been a lag in promoting its importance until recently. A short history of QIPS is presented along with an introduction to the SQUIRE guidelines used for standardizing QIPS publications. As surgeons we are becoming even more accountable in promoting value in health care. As such, knowledge of QIPS will become an increasingly important component of our future practices and publications.

Patient engagement in hospital health service planning and improvement: a scoping review

OBJECTIVES

Patient engagement (PE) improves patient, organisation and health system outcomes, but most research is based on primary care. The primary purpose of this study was to describe the characteristics of published empirical research that evaluated PE in hospital health service improvement.

DESIGN

Scoping review.

METHODS

Five databases were searched from 2006 to September 2016. English language studies that evaluated patient or provider beliefs, participation in PE, influencing factors or impact were eligible. Screening and data extraction were done in triplicate. PE characteristics, influencing factors and impact were extracted and summarised.

RESULTS

From a total of 3939 search results, 227 studies emerged as potentially relevant; of these, 217 were not eligible, and 10 studies were included in the review. None evaluated behavioural interventions to promote or support PE. While most studies examined involvement in standing committees or projects, patient input and influence on decisions were minimal. Lack of skill and negative beliefs among providers were PE barriers. PE facilitators included careful selection and joint training of patients and providers, formalising patient roles, informal interaction to build trust, involving patients early in projects, small team size, frequent meetings, active solicitation of patient input in meetings and debriefing after meetings. Asking patients to provide insight into problems rather than solutions and deploying provider champions may enhance patient influence on hospital services.

CONCLUSIONS

Given the important role of PE in improving hospital services and the paucity of research on this topic, future research should develop and evaluate behavioural interventions for PE directed at patients and providers informed by the PE barriers and facilitators identified here. Future studies should also assess the impact on various individual and organisational outcomes.

Indigenous Values and Health Systems Stewardship in Circumpolar Countries

Circumpolar regions, and the nations within which they reside, have recently gained international attention because of shared and pressing public policy issues such as climate change, resource development, endangered wildlife and sovereignty disputes. In a call for national and circumpolar action on shared areas of concern, the Arctic states health ministers recently met and signed a declaration that identified shared priorities for international cooperation. Among the areas for collaboration raised, the declaration highlighted the importance of enhancing intercultural understanding, promoting culturally appropriate health care delivery and strengthening circumpolar collaboration in culturally appropriate health care delivery. This paper responds to the opportunity for further study to fully understand indigenous values and contexts, and presents these as they may apply to a framework that will support international comparisons and systems improvements within circumpolar regions. We explored the value base of indigenous peoples and provide considerations on how these values might interface with national values, health systems values and value bases between indigenous nations particularly in the context of health system policy-making that is inevitably shared between indigenous communities and jurisdictional or federal governments. Through a mixed methods nominal consensus process, nine values were identified and described: humanity, cultural responsiveness, teaching, nourishment, community voice, kinship, respect, holism and empowerment.

What works in implementation of integrated care programs for older adults with complex needs? A realist review

PURPOSE

A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.

DATA SOURCES

International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.

STUDY SELECTION

Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.

DATA EXTRACTION

Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.

RESULTS OF DATA SYNTHESIS

A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.

CONCLUSIONS

This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.

"On the Margins and Not the Mainstream:" Case Selection for the Implementation of Community Based Primary Health Care in Canada and New Zealand

Healthcare system reforms are pushing beyond primary care to more holistic, integrated models of community based primary health care (CBPHC) to better meet the needs of aging populations and their carers. Across the world CBPHC is at varying stages of evolution and no standard model exists. In order to scale up and spread successful models of care it is important to study what works well and why to support broader efforts to implement, scale-up and spread promising innovations. The first step in this endevour is to select appropriate cases to study. In this paper we share our adaptation of case study methodology to iteratively select models of CBPHC in three jurisdictions: Ontario, Quebec (Canada) and New Zealand. A combination of literataure searches (of empirical and gray sources) and stakeholder engagement enabled the selection of cases to study, with the latter providing the most fruitful method. We conclude that it is possible to use personal networks and experts exclusively. It is not clear how much value formal searching adds over and above expert advice. However in a situation where there is no existing definitive list of potential cases, and no acknowledged "gold standard" way to create such a list, it seems appropriate to gather cases using multiple methods and to document those methods systematically.

Organizational knowledge and capabilities in healthcare: Deconstructing and integrating diverse perspectives

Diverse concepts and bodies of work exist in the academic literature to guide research and practice on organizational knowledge and capabilities. However, these concepts have largely developed in parallel with minimal cross-fertilization, particularly in the healthcare domain. This contributes to confusion regarding conceptual boundaries and relationships, and to a lack of application of potentially useful evidence. The aim of this article is to assess three concepts associated with organizational knowledge content—intellectual capital, organizational core competencies, and dynamic capabilities—and to propose an agenda for future research. We conducted a literature review to identify and synthesize papers that apply the concepts of intellectual capital, organizational core competencies, and dynamic capabilities in healthcare settings. We explore the meaning of these concepts, summarize and critique associated healthcare research, and propose a high-level framework for conceptualizing how the concepts are related to each other. To support application of the concepts in practice, we conducted a case study of a healthcare organization. Through document review and interviews with current and former leaders, we identify and describe the organization’s intellectual capital, organizational core competencies, and dynamic capabilities. The review demonstrates that efforts to identify, understand, and improve organizational knowledge have been limited in health services research. In the literature on healthcare, we identified 38 papers on intellectual capital, 4 on core competencies, and 5 on dynamic capabilities. We link these disparate fields of inquiry by conceptualizing the three concepts as distinct, but overlapping concepts influenced by broader organizational learning and knowledge management processes. To aid healthcare researchers in studying and applying a knowledge-based view of organizational performance, we propose an agenda for future research involving longitudinal comparative case studies.

Associations between patient factors and adverse events in the home care setting: a secondary data analysis of two canadian adverse event studies

Background

Early identification of patients at who have a higher risk for the occurrence of harm can provide patient safety improvement opportunities. Patient factors contribute to adverse event occurrence. The study aim was to identify a single, parsimonious model of home care patient factors that, regardless of location and differences in home care program management and design factors, could provide a means of locating patients at higher and lower risk of harm.

Methods

Split modeling using secondary analyses of data from two recent Canadian home care patient safety studies was undertaken. Patient factors from the Minimum Data Set Resident Assessment Instrument (RAI) for Home Care and diagnoses consistent with ICD-10 and RAI-Mental Health assessment were used. Continuous and categorical measures of factors were considered. Adverse events were defined using World Health Organization taxonomy and measured on a dichotomous yes/no scale. Patient factors significantly associated (Pearson’s Chi Square, p ≤ .05) with the occurrence of adverse events in both earlier studies were entered in forward selection regression analyses to locate factors predictive of adverse event occurrence.

Results

Instrumental activities of daily living dependency and escalating co-morbidity counts are associated with patient vulnerability to adverse events.

Conclusions

Instrumental activities of daily living dependency and burden of illness, both easily identifiable early in the episode of care, are significantly associated with the risk of adverse event occurrence, however there is regional variability in the relationships.

AbstractsUnderstanding the impact of a QI intervention on newborn mortality in 3 central districts in Malawi: a post-hoc theory-based evaluationAdvancing Implementation Science for Quality and Safety in Primary Health Care: The Integrated Care for Older Adults with Complex Health Needs Study (iCOACH)

Introduction

A recent WHO multi-country study on maternal and newborn health concluded that there was no evidence of an association between high coverage with essential interventions and reduced mortality in health care facilities, or improvement in other outcomes.1 According to Horton the missing ingredient in this relation is quality of care.2 Quality improvement in healthcare has adopted techniques mainly from industries such as manufacturing and has been used widely in Europe and US. However, evidence of success of these techniques in healthcare is not very conclusive, especially in low and middle-income countries. There have been limited efforts to critically analyse the techniques used in quality improvement interventions. One of the main challenges in evaluating quality improvement is the complexity of the interventions themselves and the complex nature of the systems in which they are implemented. Robust evidence regarding quality improvement interventions for resource poor settings is generally lacking.

The MaiKhanda trial looked at the effect of QI interventions and community women's groups on maternal and newborn mortality in 3 central districts in Malawi.3 The impact evaluation measuring effect on newborn mortality for the QI interventions, using a cluster RCT approach, remained inconclusive. We use a Theory-Based Evaluation (TBE) approach to understand why improvement interventions undertaken by MaiKhanda for new-born care did not show an effect. Absence of effect could be attributed to a failure of theory, a failure of implementation, an evaluation failure or a combination of these.

Our primary objective was to understand the mechanisms by which the QI interventions worked (or not) and explore the interaction between the various factors that mediated the lack of effect on neonatal mortality that was observed in the cluster randomized control trial.

Methods

Our research strategy consisted of developing a post-hoc Theory of Change, consolidating and synthesizing all the available evidence using an appropriate framework, and analysing the program and implementation theory using theory based approaches to evaluation.

Data synthesis was conducted using the Consolidate Framework for Implementation Research (CFIR).4 The synthesis takes into consideration the various reports and documents accumulated through the life of the project and complements the process evaluation studies conducted during the same period. In doing so, it draws a picture of the intervention with a multi-dimensional perspective, which provides insights into the evolution of the project. The framework is very comprehensive covering 5 major domains and a range of constructs, not all of which were included in our study. As this was post-hoc analysis, the choice of constructs was based on the availability of data rather than prioritizing the key constructs to consider.

CFIR helps to produce structured and comprehensive data that is then used for analysing the program theory in relation to the intervention outcome. The program theory thus generated for the MaiKhanda intervention is compared with the program theories of the Michigan Keystone Project, which used similar collaborative methods to successfully reduce their central venous line blood stream infections in 106 participating ICUs.5 The rationale for such a comparison is that while the interventions per se are very unique and specific to their context, the program theories underlying the use of collaborative methods in both the interventions is the same and therefore comparable. Theories offer a higher level of abstraction that can be comparable across different settings.6

Results

The key finding from analysis of the program theory is that similar intervention strategies that triggered successful mechanisms for improvement in the Keystone Project failed to generate such mechanisms in MaiKhanda project.

The Model for Improvement used in MaiKhanda was built around Deming's improvement theory7 and Roger's diffusion of innovation theory.8 The former theory considers improvement as a product of subject matter knowledge and profound knowledge. Subject matter knowledge on essential and emergency newborn care was generally lacking among health care providers in Malawi. Similarly, understanding variations within the health systems is an acquired skill. While the implementing partners, provided ample opportunities for the Malawian health system to learn the Institute for Healthcare Improvement (IHI) model for improvement, in general, QI teams lacked capacity to collate data and analyse the variations between the health facilities. QI was a fairly new concept in Malawi and MaiKhanda's attempts to embed it within existing health system was limited by challenges of the health systems context, MaiKhanda's own organizational transition and QI and clinical capacity of health care providers.

The main challenge for MaiKhanda was to simultaneously implement and sustain the various change packages it had introduced in the different facilities. While there were isolated instances of successful intervention activities within MaiKhanda, it did not build enough momentum to generate mechanisms across a critical mass of the facilities that would eventually result in improved newborn outcomes. This can be attributed to the implementation strength, context and complexity of MaiKhanda's interventions. This is explored further using the implementation theory.

Implementation was based on diffusion theories where better performing facilities were to act as role models for other facilities to emulate. The cRCT design for measuring impact evaluation required a random allocation of the improvement facilities and this conflicted with innovation diffusion theories, which prescribed a gradual organic spread of the interventions by strategically engaging the innovators and early adapters.

Limitations of the evaluation design notwithstanding, the implementation strength characterized by the dose, duration, intensity and specificity of the intervention was sub-optimal.

Implementation strength is not the only factor triggering an intervention mechanism and cannot be measured independent of the intervention complexity or the intervention context. For example, MaiKhanda struggled to show an effect of its interventions, despite having a long pre-intervention period to refine its interventions, while the Michigan study produced results within 18 month period. This could be because of other factors related to intervention complexity such as the long implementation chain for intervention delivery, the subjective perception of the agency (QI teams) regarding QI and contextual factors such as organizational readiness, the health systems context, QI team capacity to deliver QI interventions and MaiKhanda's own internal capacity.

Human agency is at the heart of implementation and the intervention required a continuous and prolonged time and effort, than was anticipated, to engage and train the health facility QI teams on the improvement model.

One of the key factors affecting the uptake of strategies was MaiKhanda's positioning within the health system and the degree of influence it could exert on other actors. This factor has a significant role to play in country where projects are donor supported and perhaps also donor driven. The period of the intervention also saw MaiKhanda going through a period of rapid organizational transition, which affected intervention implementation on the ground. Furthermore, MaiKhanda's own understanding of QI concepts was evolving gradually and this coupled with its long implementation chain, influenced the subjective understanding of the QI teams regarding QI concepts. Health facility staff also lacked the necessary skills and knowledge related to management of newborn health.

Limited resources within the health facilities meant that gains achieved in some aspects of the intervention could not be sustained in the long run. External contextual factors such as fuel shortages contributed to poor implementation. Changes in policy such as government ban on TBAs, affected intervention uptake and resulted in an increase in health facility deliveries, overwhelming the already under-resourced staff capacity in the health facilities. It is conceivable that quality improvement was not on top of their priority list. But, ‘motivation’ to be involved in QI Collaboratives remained high. In resource constrained settings, ‘motivation’ can be influenced by the lure of personal incentives (such as per diems for attending workshops and meetings) as much as individual's commitment to broader social gains (ie reduction in newborn case fatality rates in their facility). The improvement model was competing against other existing models and it was difficult to get enough stakeholder commitment to the prescribed model as there were huge expectations fuelled by the poverty and poor governance structures and a culture of “perdiemitis” was prevalent in Malawian health care system.9

Discussion

As is evident from the study, a single research method will not be able to provide justice to evaluation of a complex set of factors that influence newborn outcomes. We propose a research strategy that includes developing a Theory of Change, followed by evaluation of the program theory, measuring implementation strength, analysing implementation theory and comparing this in relation to the outcomes of the intervention observed through the impact evaluation. The results arising from such a comprehensive evaluation will contribute to the growth of improvement science with the accumulation of knowledge and explanation rather than being just a bedrock of observational facts.

More generally, we propose that design, implementation and evaluation of QI activities, particularly in resource-poor settings, should consider five key principles i.e it should include whole systems thinking, accountability, participatory approach, should be evidence-based and adapt innovative methods.10

Evaluating investment in quality improvement capacity building: a systematic review

PURPOSE

Leading health systems have invested in substantial quality improvement (QI) capacity building, but little is known about the aggregate effect of these investments at the health system level. We conducted a systematic review to identify key steps and elements that should be considered for system-level evaluations of investment in QI capacity building.

METHODS

We searched for evaluations of QI capacity building and evaluations of QI training programmes. We included the most relevant indexed databases in the field and a strategic search of the grey literature. The latter included direct electronic scanning of 85 relevant government and institutional websites internationally. Data were extracted regarding evaluation design and common assessment themes and components.

RESULTS

48 articles met the inclusion criteria. 46 articles described initiative-level non-economic evaluations of QI capacity building/training, while 2 studies included economic evaluations of QI capacity building/training, also at the initiative level. No system-level QI capacity building/training evaluations were found. We identified 17 evaluation components that fit within 5 overarching dimensions (characteristics of QI training; characteristics of QI activity; individual capacity; organisational capacity and impact) that should be considered in evaluations of QI capacity building. 8 key steps in return-on-investment (ROI) assessments in QI capacity building were identified: (1) planning-stakeholder perspective; (2) planning-temporal perspective; (3) identifying costs; (4) identifying benefits; (5) identifying intangible benefits that will not be included in the ROI estimation; (6) discerning attribution; (7) ROI calculations; (8) sensitivity analysis.

CONCLUSIONS

The literature on QI capacity building evaluation is limited in the number and scope of studies. Our findings, summarised in a Framework to Guide Evaluations of QI Capacity Building, can be used to start closing this knowledge gap.

Culture and cognition in health systems change

PURPOSE

Large-scale change involves modifying not only the structures and functions of multiple organizations, but also the mindsets and behaviours of diverse stakeholders. This paper focuses on the latter: the informal, less visible, and often neglected psychological and social factors implicated in change efforts. The purpose of this paper is to differentiate between the concepts of organizational culture and mental models, to argue for the value of applying a shared mental models (SMM) framework to large-scale change, and to suggest directions for future research.

DESIGN/METHODOLOGY/APPROACH

The authors provide an overview of SMM theory and use it to explore the dynamic relationship between culture and cognition. The contributions and limitations of the theory to change efforts are also discussed.

FINDINGS

Culture and cognition are complementary perspectives, providing insight into two different levels of the change process. SMM theory draws attention to important questions that add value to existing perspectives on large-scale change. The authors outline these questions for future research and argue that research and practice in this domain may be best served by focusing less on the potentially narrow goal of "achieving consensus" and more on identifying, understanding, and managing cognitive convergences and divergences as part of broader research and change management programmes.

ORIGINALITY/VALUE

Drawing from both cultural and cognitive paradigms can provide researchers with a more complete picture of the processes by which coordinated action are achieved in complex change initiatives in the healthcare domain.

Organizational Capabilities for Integrating Care: A Review of Measurement Tools

The success of integrated care interventions is highly dependent on the internal and collective capabilities of the organizations in which they are implemented. Yet, organizational capabilities are rarely described, understood, or measured with sufficient depth and breadth in empirical studies or in practice. Assessing these capabilities can contribute to understanding why some integrated care interventions are more effective than others. We identified, organized, and assessed survey instruments that measure the internal and collective organizational capabilities required for integrated care delivery. We conducted an expert consultation and searched Medline and Google Scholar databases for survey instruments measuring factors outlined in the Context and Capabilities for Integrating Care Framework. A total of 58 instruments were included in the review and assessed based on their psychometric properties, practical considerations, and applicability to integrated care efforts. This study provides a bank of psychometrically sound instruments for describing and comparing organizational capabilities. Greater use of these instruments across integrated care interventions and studies can enhance standardized comparative analyses and inform change management. Further research is needed to build an evidence base for these instruments and to explore the associations between organizational capabilities and integrated care processes and outcomes.

Improving healthcare using Lean processes

For more than a decade, healthcare organizations across Canada have been using Lean management tools to improve care processes, reduce preventable adverse events, increase patient satisfaction and create better work environments. The largest system-wide effort in Canada, and perhaps anywhere, is currently under way in Saskatchewan. The jury is still out on whether Lean efforts in that province, or elsewhere in Canada, are robust enough to transform current delivery systems and sustain new levels of performance. This issue of Healthcare Quarterly features several articles that provide a perspective on Lean methods in healthcare.

Leading the implementation of health links in Ontario

Ontario's Health Links initiative aims to coordinate and improve care for complex patients. In this paper, we draw from interviews with leaders and providers from Health Links and Local Health Integration Networks to discuss key leadership and governance issues influencing the implementation and success of the Health Links. We close with a short discussion of how leaders manage ambiguity by creating a context that supports change and the delivery of integrated care.

Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature

Since its publication in 2008, SQUIRE (Standards for Quality Improvement Reporting Excellence) has contributed to the completeness and transparency of reporting of quality improvement work, providing guidance to authors and reviewers of reports on healthcare improvement work. In the interim, enormous growth has occurred in understanding factors that influence the success, and failure, of healthcare improvement efforts. Progress has been particularly strong in three areas: the understanding of the theoretical basis for improvement work; the impact of contextual factors on outcomes; and the development of methodologies for studying improvement work. Consequently, there is now a need to revise the original publication guidelines. To reflect the breadth of knowledge and experience in the field, we solicited input from a wide variety of authors, editors and improvement professionals during the guideline revision process. This Explanation and Elaboration document (E&E) is a companion to the revised SQUIRE guidelines, SQUIRE 2.0. The product of collaboration by an international and interprofessional group of authors, this document provides examples from the published literature, and an explanation of how each reflects the intent of a specific item in SQUIRE. The purpose of the guidelines is to assist authors in writing clearly, precisely and completely about systematic efforts to improve the quality, safety and value of healthcare services. Authors can explore the SQUIRE statement, this E&E and related documents in detail at http://www.squire-statement.org.