Qualitative methods in a learning healthcare system: Balancing rigour and the need for rapid analysis and dissemination

Qualitative methods are used to capture stakeholder perspectives within learning healthcare systems (LHS), but there is a need to specify methods that balance rigour and pragmatic approaches to inform quality improvement (QI). Utilizing examples from two QI projects within the OTNY LHS, we illustrate methods and strategies that build team capacity and flexibility to respond to an evolving LHS. Method(s): Qualitative methods were tailored to fit each project's timelines and goals, to inform both practice and research. Tools to facilitate rapid cycle feedback included interview/focus group summary templates, aggregate summaries that synthesize findings by stakeholder group, case matrix templates for rapid extraction and systematic categorization of data along topic areas, and dissemination materials adapted for stakeholder audience and project phases. Strategies to maintain rigour included processes for data reduction and interpretation, a multi-disciplinary approach for analysis, frequent consensus-based meetings, data triangulation, and member checks. Result(s): Rapid cycle approaches yielded interim results that reshaped research questions or identified critical gaps. Case summary analysis exploring the impact of COVID-19 revealed limited information on telehealth challenges amongst OTNY participants, necessitating a shift in recruitment and interview focus. For another project, analytic methods were sequenced to rapidly inventory suggestions from interview summaries on how to enhance OTNY practice to better address racism, while subsequent thematic analysis of transcripts captured participants' experiences of racism for context. Challenges included concurrent alignment of data collection and analysis, tailoring summary templates to maximize utility for rapid analysis, and maintaining flexibility to respond to evolving findings and LHS stakeholder input. Conclusion(s): The diverse methods and strategies illustrated by these projects offer guidance for balancing.

Pandemic related mental health

OnTrackNY is a nationally recognized Coordinated Specialty Care model disseminated across New York state for young people experiencing early non-affective psychosis. OnTrackNY is a network of 22 teams located in licensed outpatient clinics, serving over 2500 individuals. OnTrackNY offers medication management, case management, individual and group cognitive behaviourally oriented therapy, family support and psychoeducation, supported employment and education, and peer support services. Teams receive training for implementation through an intermediary organization called OnTrack Central. OnTrackNY was selected as a regional hub of the National Institute of Mental Health Early Psychosis Intervention Network (EPINET), a national learning healthcare system (LHS) for young adults with early psychosis. This symposium will present the different ways in which EPINET OnTrackNY implemented systematic communitybased participatory processes to ensure robust stakeholder involvement to improve the quality of OnTrackNY care. Florence will present results of an assessment of stakeholder feedback experiences used to develop strategies for assertive outreach and engagement of program participants, families and providers. Bello will present on mechanisms for integrating of co-creation principles to design, develop and execute quality improvement projects in EPINET OnTrackNY. Stefancic will present on quality improvement projects that used rapid cycle qualitative methods, tools, and strategies to build team capacity and flexibility to respond to an LHS. Montague will present adaptations to OnTrackNY services during the COVID-19 pandemic using an implementation science framework. Finally, Patel will lead a discussion on the implications of involving individuals with lived experiences in all phases of the process to maximize learning in an LHS.

Measuring Health Systems Resilience: A Comparative Study of Turkey's Health System during COVID-19 Pandemic

The recent outbreak of the COVID-19 pandemic has drawn significant attention to the topic of health-system resilience. Many countries have taken certain measures to deal with the negative outcomes of the pandemic and to improve their health systems. Having a resilient health system during pandemics ensures the continuity and success of healthcare services. Resilience, as a concept, represents a proactive rather than a reactive approach to overcoming the negative outcomes of disasters. Understanding the characteristics of a resilient health system will help to strengthen the health systems for future pandemics or any other disasters. In this research project, characteristics of resilient health systems are investigated using a framework based on three main dimensions of systems resilience: (1) a system's capability to decrease its level of vulnerability to expected and unexpected disruptive events, (2) its ability to change itself and adapt to the changing environment;(3) its ability to recover in the least possible time in case of a disruptive event. Based on this framework, four attributes of resilience are identified, namely agility, adaptability, flexibility, and vulnerability. Further, these attributes of resilience are evaluated using country-specific COVID-19-related qualitative and quantitative data from Turkey and compared with several other countries. Suggestions and further recommendations are provided on how to measure and improve the resiliency of health systems for future pandemics. © 2022 IEEE.

Preparedness and coping with the COVID-19 pandemic

Health disasters have affected humanity since its dawn. In other epidemics, the casualties caused number in the hundreds of thousands. The preparation for confronting the COVID-19 epidemic at the Military Hospital of Matanzas, "Dr. Mario Muñoz Monroy”, began early. In order to analyze this experience, we reflect on the results of the confrontation in 2020, based on the main aspects, the coordination with other organizations, the decisions made, structural changes and modifications of institutional processes. Consolidating scientific improvement has been a permanent pillar, along with discipline, personal and social responsibility of the members of the collective. © 2023, Editorial Ciencias Medicas. All rights reserved.

The integration of principles of co-creation for promoting quality improvement within a learning healthcare system providing coordinated specialty care for people with FEP

Co-creation places key stakeholders at the centre of development processes for quality improvement projects to reduce gaps between research and practice. We describe an Amplify OnTrackNY project that used principles of community-based participatory research to meaningfully partner with individuals with lived experience and describe lessons learned. Method(s): Two individuals with lived experience were hired and coled decision-making about project selection and design. The project examined OnTrackNY provider, participant, and family perspectives on the impact of COVID-19 on service delivery. To enhance the lived experience perspective, we hired two OnTrackNY graduates and a family member, and created mechanisms for team building and integration, and co-planning sessions. All team members contributed to the development of research questions, co-facilitated interviews/ focus groups, and participated in data analysis and dissemination. Result(s): Team members conducted focus groups and semi-structured interviews with 13 participants and five family members, presented results to various stakeholder groups, and are contributing to scientific publications. To ensure participation, our flexible working structure focused on promoting equity and building trust. Dedicated time ensured opportunities for meetings focused on mutual support, sharing, capacity building, and training in qualitative methods. Individuals with lived experience were in decision-making roles, created content, and led project activities embodying principles of power-sharing, reciprocity, and mutual learning. Orienting new team members to the office culture required extra effort. Conclusion(s): Provided sufficient time and infrastructure, it is feasible to meaningfully involve individuals with lived experience in quality improvement projects. Co-creation ensures that important perspectives are incorporated from the outset and procedures improve the relevance and uptake of research findings in the real world.

Impacts of the COVID-19 pandemic on the mother owl program of the VII health region of Pernambuco / Impactos da pandemia da COVID-19 no programa mãe coruja da VII região de saúde de Pernambuco

Resumo Objectives: to analyze the impacts caused by the COVID-19 pandemic on the Mother Owl Program of the VII Health Region of Pernambuco. Methods: descriptive, cross-sectional and quantitative study, carried out at the VII Regional Health Management, in Salgueiro-PE. Data were collected from the Mother Owl Information System, from August to November 2021, being related to women and children registered from 2019 to March 2021. Adopting a time frame for before and during the pandemic, the Student's t and chi-square tests in the analysis of continuous and categorical variables, respectively. Results: data from 581 women and 412 children were analyzed. Before the pandemic, there was a higher average number of prenatal consultations (p<0.001) and greater completeness in the children's race data (p<0.001). During the pandemic, there was a lower frequency of breastfeeding in the first hour of life (p<0.001) and of filling in the data regarding maternal education (p<0.001). In addition, no more than 7 childcare consultations were performed (p<0.001). Conclusions: the assistance of women and children was impacted, mainly with the drop in prenatal and childcare consultations, showing that COVID-19 had a negative impact on the health of people monitored by the Program and on the quality of information inserted in the system.

Resumo Objetivos: analisar os impactos causados pela pandemia da COVID-19 no Programa Mãe Coruja da VII Região de Saúde de Pernambuco. Métodos: estudo descritivo, transversal e quantitativo, realizado na VII Gerência Regional de Saúde, em Salgueiro-PE. Os dados foram coletados do Sistema de Informação Mãe Coruja, no período de agosto a novembro de 2021, sendo relacionados às mulheres e crianças cadastradas de 2019 a março de 2021. Adotando-se um marco temporal para antes e durante a pandemia, foram utilizados os testes t de Student e qui-quadrado nas análises das variáveis contínuas e categóricas, respectivamente. Resultados: foram analisados os dados de 581 mulheres e 412 crianças. Antes da pandemia constatou-se maior média de consultas de pré-natal (p<0,001) e maior completude nos dados de raça das crianças (p<0,001). Durante a pandemia ocorreu menor frequência da amamentação na primeira hora de vida (p<0,001) e do preenchimento dos dados referentes à escolaridade materna (p<0,001). Assim como, não foram realizadas mais que sete consultas de puericultura (p<0,001). Conclusões: a assistência das mulheres e crianças foi impactada, principalmente com a queda de consultas do pré-natal e da puericultura, evidenciando que a COVID-19 repercutiu negativamente na saúde das pessoas acompanhadas pelo Programa e na qualidade das informações inseridas no sistema.

How Central Ugandan HIV Clinics Adapted During COVID-19 Lockdown Restrictions to Promote Continuous Access to Care: A Qualitative Analysis.

We used qualitative data from the Partners PrEP Program (PPP) to address the question: How did Central Ugandan HIV clinics adapt to COVID-19 lockdown restrictions to promote continuous access to HIV care? PPP was a stepped-wedge cluster randomized trial of integrated PrEP and ART delivery for HIV serodifferent couples at Central Ugandan HIV clinics (NCT03586128). Individual interviews with purposefully selected PPP couples (N = 42) and clinicians, coordinators, and counselors providing HIV care (N = 36) were carried out. Sixty-four interviews were completed after lockdown and included questions about accessing and providing ART/PrEP refills during lockdown restrictions. We used an inductive, content-focused approach to analyze these interview data. Barriers to continuous access identified by interviewees included loss of income with increased cost of transport, reduced staff at clinics, and physical distancing at clinics. Interviewees pointed to multi-month refills, visits to clinics "close to home," transport to clinics for providers, and delivery of refills in neighborhoods as factors promoting continuous access to antiretroviral medications. Access barriers appeared somewhat different for ART and PrEP. Fewer resources for community delivery and pre-refill HIV testing requirements were identified as PrEP-specific access challenges. Participants emphasized their success in continuing ART/PrEP adherence during the lockdown, while providers emphasized missed refill visits. These results highlight the contributions of providers and ART/PrEP users to adaptation of HIV services during COVID-19 lockdown restrictions in Uganda. The roles of direct care providers and service users as drivers of adaptation should be recognized in future efforts to conceptualize and investigate health system resiliency.

COVID-19 Pandemic Response: A Primary Care Experience in Northwest Nigeria.

The effectiveness of healthcare systems during this COVID-19 pandemic will largely depend on their resilience in the face of untold challenges. Hence, we share the ongoing experience of the response of a primary care facility to challenges of the increasing number of undifferentiated patient load in the context of rising COVID-19 cases, infrastructural gap, limited personal protective equipment, and the health workforce in a densely populated town.

L'efficacité des systèmes de soins de santé au cours de la pandémie de COVID-19 dépendra en grande partie de leur résistance face à des défis incalculables. Nous partageons donc l'expérience en cours de la réponse d'un établissement de soins primaires aux défis posés par le nombre croissant de patients indifférenciés dans le contexte de l'augmentation des cas de COVID-19, des lacunes infrastructurelles, de l'équipement de protection individuelle limité et du personnel de santé dans une ville densément peuplée. Mots-clés : COVID-19, Résilience du système de santé, Patients ambulatoires, Pandémie, Soins primaires.

Corrigendum: A novel approach to utilizing the essential public health functions in Ireland's health system recovery and reform.

[This corrects the article DOI: 10.3389/fpubh.2023.1074356.].

Collaborating for COVID-19: Hospital Health Information Exchange and Public Health Partnership.

Background: The coronavirus disease (COVID-19) pandemic highlighted the need for effective communication and information sharing among health care organizations and public health systems (PHSs). Health information exchange (HIE) plays a vital role in improving quality control and efficiency in hospital settings, particularly in underserved areas. Objective: This study aimed to investigate the variation of HIE availability among hospitals based on their collaboration with the PHS and affiliation with Accountable Care Organizations (ACOs) in 2020, as well as variation by community social determinants of health. Methods: The primary data set used for this study comprised the linked data set of the 2020 American Hospital Association (AHA) Annual Survey and the AHA Information Technology Supplement. The measures used included the hospital's participation in HIE networks, availability of data exchange, and HIE measures during the COVID-19 pandemic, including whether hospitals effectively received electronically transmitted information from outside providers for COVID-19 treatment. Results: The sample size of hospitals ranged from 1,316 to 1,436, depending on different outcomes related to HIE questions. Of the hospitals surveyed, ∼67% reported public health collaboration and ACO affiliation, while 7% reported neither. Hospitals without public health collaboration or ACO affiliation were more likely to be located in underserved areas. Compared with hospitals without public health collaboration or ACO affiliation, hospitals with both were 9% more likely to report the availability of electronically transmitted clinical information from outside providers and to participate in local and national HIE networks. Furthermore, these hospitals were 30% (marginal effect [ME] = 0.30, p < 0.001) more likely to report effective receipt of information from outside providers for COVID-19 treatment and 12% (ME = 0.12, p = 0.02) more likely to always/often receive clinical information for COVID-19 treatment electronically. Conclusions: Hospital collaboration with the PHS and ACO affiliation are associated with greater availability of electronic health data, particularly during the COVID-19 pandemic.

A critical analysis of health system in Nepal; Perspective's based on COVID-19 response.

Background: Nepal moved from a unitary government to a federal system of government in 2015 under its constitution. Nepal is a federal democratic republic governed by three levels of government: a federal, provincial, and local level. The response to COVID-19 in Nepal has been majorly led and controlled by the federal government. All three levels of government are performing their responsibilities; however, they face various challenges in responding to COVID-19. This study aimed to critically analyze Nepal's health system in the context of the COVID-19 response. Methods: We conducted semi-structured in-depth interviews by telephone among the policymakers, health workers, and stakeholders at the federal, provincial, and local levels (n = 41) between January to July 2021. The interviews were audio recorded, transcribed into English, and coded using inductive-deductive approaches. Results: COVID-19 considerably impacted routine health care, mainly maternity services and immunization. Inadequate financial resources, inadequate human resources, and the lack of ventilators, ICUs, and X-ray services were the significant challenges in tackling and managing COVID-19 effectively. Conclusion: The study found that all three levels of government perform their roles and responsibilities and effectively manage the pandemic. The federal and provincial governments focused more on the plans and policy development, while the local government demonstrated greater accountability in implementing those plans and policies. Therefore, all three tiers of government need to coordinate together for preparing and communicating information in times of emergency. Besides, it is imperative to empower local governments to maintain Nepal's federal health system.

Understanding Impacts of Online Dual Practice on Health System Performance: A Qualitative Study in China.

The outbreak of the COVID-19 pandemic has boosted the global development of online healthcare platforms. An increasing number of public hospital doctors are providing online services on private third-party healthcare platforms, creating a new form of dual practice-online dual practice. To explore the impacts of online dual practice on health system performance as well as potential policy responses, we undertook a qualitative approach that uses in-depth interviews and thematic analysis. Following a purposive sampling, we interviewed 57 Chinese respondents involved in online dual practice. We asked respondents for their opinions on the effects of online dual practice on access, efficiency, quality of care, and advice on regulatory policy. The results suggest that online dual practice can generate mixed impacts on health system performance. The benefits include improved accessibility due to increased labor supply of public hospital doctors, better remote access to high-quality services, and lower privacy concerns. It can improve efficiency and quality by optimizing patient flows, reducing repetitive tasks, and improving the continuity of care. However, the potential distraction from designated work at public hospitals, inappropriate use of virtual care, and opportunistic physician behaviors may undermine overall accessibility, efficiency, and quality. Countries should mitigate these adverse consequences via regulations that are appropriate to their healthcare system context, policy priority, and governance capacity.

Medical students as health workers during the COVID-19 pandemic.

BACKGROUND: We describe efforts at one tertiary university teaching hospital to rapidly recruit, train and deploy medical students into paid clinical support worker roles during the COVID-19 pandemic. METHODS: Recruitment was conducted by means of a single email outlining the emergent clinical situation and specifying role descriptions, terms and conditions, and temporary staff enrolment paperwork. Applicants could begin work provided they were in good standing and received departmental orientation. Student representatives liaised with teaching faculty and participating departments. Roles were modified in response to student and departmental feedback. RESULTS: Between 25 December 2020 and 9 March 2021, 189 students contributed 1335 shifts, providing 10 651 hours of clinical care in total. The median number of shifts worked per student was 6 (mean: 7; range: 1-35). Departmental leaders attested that the student workers eased the burden on hospital nursing teams. CONCLUSION: Medical students contributed usefully and safely to the provision of healthcare within well-defined and supervised clinical support worker roles. We propose a model of working which could be adapted in the event of future pandemics or major incidents. The pedagogical value to medical students of working in clinical support roles warrants closer evaluation.

Institutional Environment and Tourism: Moderating Role of Host Countries' Health System

Tourism has gradually emerged to become a significant factor for sustainable economic growth around the globe. Along with other variables, the institutional environment has a significant influence on the growth of the tourism industry. Consequently, there are two primary goals for this study: firstly, to improve the body of knowledge already available on the institution-tourism nexus;secondly, to investigate how the health systems of the host countries contribute to the said nexus. To analyze these relations, we collected data from 50 countries across 10 years (2009-2018). We apply multiple regression analysis to a balanced panel dataset of 500 observations. Furthermore, we also used an interactive variable in conjunction with the primary independent, dependent, and control variables of the study to determine the moderating effect of the host countries' health systems. The study's findings demonstrated the significance of an efficient institutional structure in boosting tourism. Additionally, the health systems of the host nations play a significant role in strengthening the connection between institutions and tourism, especially in the post-COVID-19 period. Through the creation of institutional frameworks and health infrastructure, the study's findings will assist policymakers in developing efficient tourism policies. All of the above strategies will eventually lead to a trustworthy, safe, and healthy environment for both locals and visitors.

The power of telemedicine to improve CAR-T cell therapy programs: lessons learned from COVID-19 pandemic.

PURPOSE: CAR-T programs will burden increasingly on healthcare systems, since the implementation of these therapies involves: multidisciplinary team collaboration, post-infusion hospitalization with risk of life-threatening toxicities, frequent in hospital visits and prolonged follow-up which heavily influence patients' quality of life. In this review we propose an innovative, telehealth-based, model for monitoring CAR-T patients: this method was used for managing a case of COVID-19 infection occurred two weeks after CAR-T cell infusion. METHODS: Several benefits for management of all these aspects of CAR-T programs could be made using telemedicine: for example, telemedicine real-time clinical monitoring could reduce the COVID-19 contagion risks for CAR-T patients. RESULTS: Our experience confirmed feasibility and utility of this approach in a real-life case. We believe that use of telemedicine for CAR-T patients could improve: the logistics of toxicity monitoring (frequent vital sign checks and neurologic assessments), the multidisciplinary team communication (patient selection, specialists consulting, coordination with pharmacists, etc.), the decrease in hospitalization time and the reduction of ambulatory visits. CONCLUSIONS: This approach will be fundamental for future CAR-T cell program development, enhancing patients' quality of life and cost-effectiveness for healthcare systems.

Calculation, knowledge, and identity: Dimensions of trust when making COVID-19 vaccination choices in China.

Vaccine hesitancy threatens the response to the COVID-19 pandemic and to other infectious disease outbreaks globally. Fostering trust has been highlighted as a critical factor in addressing vaccine hesitancy and expanding vaccine coverage, but qualitative exploration of trust in the context of vaccination remains limited. We contribute to filling this gap by providing a comprehensive qualitative analysis of trust in the context of COVID-19 vaccination in China. We conducted 40 in-depth interviews with Chinese adults in December 2020. During data collection, trust emerged as a highly salient topic. Interviews were audio-recorded, transcribed verbatim, translated into English, and analyzed with a combination of inductive and deductive coding. Following established trust literature, we differentiate between three types of trust - calculation-based trust, knowledge-based trust, and identity-based trust - which we grouped across components of the health system, as informed by the WHO's building blocks. Our results highlight how participants attributed their level of trust in COVID-19 vaccines to their trust in the medical technology itself (based on assessing risks and benefits or previous vaccination experiences), the service delivery and health workforce (informed by past experiences with health providers and their role throughout the pandemic), and leadership and governance (drawing on notions of government performance and patriotism). Reducing negative impact from past vaccine controversies, increasing the credibility of pharmaceutical companies, and fostering clear communication are identified as important channels for facilitating trust. Our findings emphasize a strong need for comprehensive information on COVID-19 vaccines and increased promotion of vaccination by credible figures.

Shared longitudinal health records for clinical and population health

The ability of a health information exchange (HIE) to consolidate information, collected from multiple, disparate information systems, into a single, person-centric health record can provide a comprehensive and longitudinal representation of an individual's medical history. Shared, longitudinal health records can be leveraged to enhance the delivery of individual clinical care and provide opportunities to improve health outcomes at the population level. This chapter describes the clinical benefits imparted by the shared health record (SHR) component an HIE infrastructure. It also characterizes the potential public health benefits of the aggregate level, population health indicators calculated, stored, and distributed by a health management information system (HMIS) component. Tools for visualizing health indicators from the HMIS, including disease surveillance systems developed during the COVID-19 pandemic, are also described. Postpandemic components such as the SHR and HMIS will likely play critical roles in strengthening health information infrastructures in states and nations. © 2023 Elsevier Inc. All rights reserved.

Healthcare in the Himalayan Kingdom of Bhutan: Lessons for the United States and other western healthcare systems

Bhutan has demonstrated a trajectory of advances in healthcare, while still remaining true to its culture and traditional forms of medicine. Most recently, Bhutan gained international attention when it implemented a strategic Covid-19 vaccination programme that protected a greater percentage of its population than observed in Western industrialised nations. This accomplishment supports the idea that there are lessons from Bhutan to be shared with the rest of the world. In this work, we delineate our observations of the Bhutanese healthcare system, based on field observations in several Bhutanese cities, and results from surveys of Bhutanese physicians. We identify a number of unique practices that influence patient compliance, health education, and access to care in the Bhutanese system, that may be of particular interest and applicability to other healthcare systems. These include housing multiple health services at one location, fully funded medical visits, using non-physician teachers for health education and use of Gross National Happiness (GNH) measures in care.

Is it time for a paradigmatic shift in relation to healthcare in the UK? A reflection.

CONTEXT: Conflict is a driver of change and unions representing professional groups across the National Health Service (NHS) are currently engaged in direct conflict with the government. For the first time in the history of the NHS, healthcare professionals have taken industrial strike action. Junior doctors and consultant physicians are currently engaged in their respective union ballots and indicative poll surveys regarding potential strike action in the future. In the wake of such widespread industrial action, we have taken time to think deeply about the confronting challenges and issues and offer this reflection as an opportunity to redefine and re-frame an unsustainable healthcare system into one that is the best it can be in terms of fit for purpose. INSIGHTS AND RESOURCE SIGNPOSTING: We present the current context with a reflective framework table focused on 'What do we do well? What is not done so well? What could some possible ideas and solutions be? and How could this change be supported?'We outline how a culture of well-being could be strategically and operationally introduced into the NHS workplace using research-based evidence and practical tools supported by expert guidance.