Temporary healthcare services for crisis response: organization and management of a mass vaccination center.

PURPOSE: Scientific description of the organization and management of a temporary large scale healthcare (T-LSHc) vaccination clinic and evidence-based guidance for future temporary healthcare (T-Hc) services. DESIGN/METHODOLOGY/APPROACH: Mixed-methods rapid feedback case study, using interviews, document analysis and quantitative data, with both data collection and analysis guided by a research-informed systems program theory of the clinic. FINDINGS: Private contractors were not willing to bid for contracts to set up and close a T-LSHc vaccination clinic in 2022, although they had done so earlier in the year. The public health system was able successfully to set up and run the clinic itself for 2 months, serving 3,000 people a day at its peak. Part of the success was because a dedicated unit to set up and run T-Hc services had been created in 2020. The Stockholm organization model differed from the Milan model by using information technology to reduce the need for a large number of on-site doctors. RESEARCH LIMITATIONS/IMPLICATIONS: There may be recall bias in interview data as interviews were carried out four months after the closing of the clinic. The conclusions apply to clinically simple but managerially complex T-Hc services but are limited to public healthcare systems operating in a similar context to that of the case study service. The study contributes to the new science of healthcare crisis organization and management and fills gaps in knowledge in disaster medicine for enduring and fluctuating health crises. The findings show the importance of a capacity to establish and manage T-Hc, and of the specialist management and HIT competence that health systems will need to build to meet the crises that threaten our health, both now and in the future. PRACTICAL IMPLICATIONS: Public healthcare systems can provide clinically simple and managerially complex T-Hc services quickly and successfully if they have experience and capacity to plan and set up such services, skilled operational managers respected by staff, staff who can be redeployed, and suitable health information technology. SOCIAL IMPLICATIONS: The need for healthcare services to respond to crises is likely to increase in the future. Information for creating the service may be limited at first and changing. The exact nature of the health threat may be uncertain, as may the demand and needs of subpopulations and individuals. The study findings can help to respond quickly to reduce morbidity illness and death through creating and organizing temporary large-scale public healthcare services when existing services cannot be reorganized to meet the scale of the need. ORIGINALITY/VALUE: This article is the first detailed empirical description and analysis of a large-scale temporary healthcare service operated by the primary care division of an integrated public healthcare system, with research informed guidance for future services of this type in similar contexts. This article compares two organization models of T-LSHc services, and contributes to an emerging subdiscipline of the organization and management of disaster and crisis healthcare.

Modelling a System to Help Improve It Comment on "Insights Gained From a Re-analysis of Five Improvement Cases in Healthcare Integrating System Dynamics Into Action Research".

The article that this commentary considers describes the use of systems modelling in an action research (AR) project that helped improvement teams to understand the dynamics of their service as a system. This commentary seeks to make the complex article easier to understand for those unfamiliar with the subjects. It describes the advantages, disadvantages and benefits, and suggests developments of this approach for research and practice using digital technologies. The conclusion of the commentary is that dynamic system modelling combined with AR is useful for certain purposes and can produce benefits in terms of a more sophisticated understanding of systems and feedback loops for practitioners. However, there are challenges for researchers unfamiliar with AR and dynamic system modelling as well workshop facilitation expertise.

Rapid implementation of remote digital primary care in Stockholm and implications for further system-wide implementation: practitioner's and manager's experience of the Always Open mobile application.

OBJECTIVE: To contribute actionable knowledge how to increase appropriate use of digital technologies in primary care by understanding clinical managers experiences with a digital connection system, Always Open, during the COVID-19 pandemic. DESIGN AND SUBJECTS: The overall design was a qualitative study with directed content analysis method. Data were collected from documents and focus group (n = 12) interviews with clinical managers (n = 99) of primary care. The seven domains of the Non-adoption, Abandonment, and challenges to the Scale-up, Spread and Sustainability (NASSS) framework was used to understand the implementation process, as described by the clinical managers. RESULTS: Focus group participants reported that their units made their own local decisions to make more use of the technology provided by the health system. Most participants considered that the technology was ready to use, despite some limitations, that included individual clinician's and patient preferences, and how ready their unit was for making changes to practice and organization. Some raised concerns about how standardizing some aspects possibly conflicted with the decentralized management model of the organization. The overall experience was reported to be positive, with an intention to sustain the achievements. CONCLUSION: Focus group interviews found that clinical unit managers reported that they and their staff were positive about the digital technology system for remote care. For the future, they wanted changes to be made at different levels of the health system to better combine digital and physical care. Possibilities to use digital technology to integrate primary and hospital health care were identified.

Rapid adoption of Always Open as a digital connection mHealth system for remote digital care was observed during the pandemic without a structured implementation program.Many factors could explain the rapid adoption and the intention to sustain the use of Always Open such as professional ethics, financial reimbursement, patient needs and support.Standardization needs to be balanced with flexibility to ensure that staff can decide what is appropriate for patients.The general experience was positive and a continual high use of Always Open was reported in units that adopted the system.The decentralized management model may have contributed to the capacity to provide flexible services suited to local needs.

Recognizing and Responding to Anti-Science in Environmental and Public Health Research and Practice.

This perspectives article considers the challenges posed by anti-science and how we can use research to respond more effectively. In public health, the challenges were more visible and the impact more serious during the COVID-19 pandemic. In part, this was due to a more organized anti-science and effective use of narrative methods. Regarding climate change, the role of anti-science represents a critical issue, but perhaps more recognized in environmental research and practice. The article draws on a narrative review to show some of the research into the nature of anti-science and the challenges it poses. It proposes that, as researchers, practitioners, and educationalists, we can be more effective if we make more use of recent research in the sciences of communications, behavior, and implementation, and shows some of the resources we can use to help our work be more relevant in the new era in which we are living.

Implementation Methods and Research for a Post-truth World with Growing Inequities.

The purpose of this article is to consider the changing context for implementation research and practice and new approaches which might now be more relevant for some implementation objectives. Factors that hindered implementation of evidence-based practices before the COVID-19 pandemic was an anti-science culture, strengthened by different media and appeals to emotion and identity. The article questions how effective are the rational-cognitive and individual models of change that frequency informs our research and practice. It describes challenges we face and considers methods we could use that might be more effective, including research-informed narrative methods, participatory research and practice, especially with culturally and linguistically diverse peoples, and adaptive implementation.

Improve-mentation for Faster Testing and Spread of Health Service Delivery Innovations.

Can we speed the testing, implementation and spread of management innovations in a systematic way to also contribute to scientific knowledge? Researchers and implementers have developed an approach to test and revise a local version of an innovation during its implementation. The chapter starts with a case example of an application of this combination of implementation and quality improvement sciences and practices (improve-mentation). It then summarizes four examples of this approach so as to help understand what improve-mentation is and how it is different from traditional quality improvement and traditional implementation of evidence-based practices. It considers gaps in knowledge that are hindering both more use of improve-mentation to generate scientific knowledge about spread and implementation, as well as more use of improve-mentation by health care service organizations and researchers. It closes by proposing fruitful research and development that can address these knowledge gaps to speed the implementation, sustainment and spread of care and management innovations.

Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial.

BACKGROUND: Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support. METHODS: Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis. RESULTS: Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028). CONCLUSIONS: Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

Aligning quality improvement efforts and policy goals in a national integrated health system.

OBJECTIVE: To describe the design and impact of a systematic, enterprise-wide process for engaging US Department of Veterans Affairs (VA) leadership in prioritizing scarce implementation and evaluation resources. DATA SOURCES: From 2017 to 2021, the VA Quality Enhancement Research Initiative (QUERI) identified priorities from local, regional, and national leaders through qualitative discussions and a national survey and tracked impacts via reports generated from competitively funded initiatives addressing these priorities. STUDY DESIGN: Guided by the Learning Health System framework and QUERI Implementation Roadmap, QUERI engaged stakeholders to nominate and rank-order priorities, peer-reviewed and funded initiatives to scale up and spread evidence-based practices (EBPs) using theory-based implementation strategies, and evaluated the impact of these initiatives using the QUERI Impact Framework. DATA COLLECTION/EXTRACTION METHODS: QUERI collected priority nominations through qualitative discussions and a web-based survey, and live voting was used to rank-order priorities. QUERI-funded teams regularly submitted progress reports describing the key activities, findings, and impacts of the quality improvement (QI) initiatives using a standardized form created in the VA Research Electronic Data Capture (REDCap). PRINCIPAL FINDINGS: QUERI launched five QI initiatives to address priorities selected by VA leadership. In partnership with 28 health system leaders, these initiatives are implementing 10 EBPs across 53 sites, supporting 1055 VA employees in delivering evidence-based care. The success of these initiatives led to an expansion of QUERI's process to address 2021 VA leadership priorities: virtual care, health disparities, delayed or suppressed care due to COVID-19, employee burnout, long-term and home care options, and quality and cost of community care. CONCLUSIONS: QUERI, a unique program embedded in a national integrated health system, deployed a novel approach to inform policy making and enhance the real-world impact of research through prioritization of limited resources, rigorous peer-review, and assessment of impacts on the health system, employees, and Veterans.

Patient-driven innovations reported in peer-reviewed journals: a scoping review.

BACKGROUND: Awareness of patients' innovative capabilities is increasing, but there is limited knowledge regarding the extent and nature of patient-driven innovations in the peer-reviewed literature. OBJECTIVES: The objective of the review was to answer the question: what is the nature and extent of patient-driven innovations published in peer-reviewed scientific journals? ELIGIBILITY CRITERIA: We used a broad definition of innovation to allow for a comprehensive review of different types of innovations and a narrow definition of 'patient driven' to focus on the role of patients and/or family caregivers. The search was limited to years 2008-2020. SOURCES OF EVIDENCE: Four electronic databases (Medline (Ovid), Web of Science Core Collection, PsycINFO (Ovid) and Cinahl (Ebsco)) were searched in December 2020 for publications describing patient-driven innovations and complemented with snowball strategies. CHARTING METHODS: Data from the included articles were extracted and categorised inductively. RESULTS: A total of 96 articles on 20 patient-driven innovations were included. The number of publications increased over time, with 69% of the articles published between 2016 and 2020. Author affiliations were exclusively in high income countries with 56% of first authors in North America and 36% in European countries. Among the 20 innovations reported, 'Do-It-Yourself Artificial Pancreas System' and the online health network 'PatientsLikeMe', were the subject of half of the articles. CONCLUSIONS: Peer-reviewed publications on patient-driven innovations are increasing and we see an important opportunity for researchers and clinicians to support patient innovators' research while being mindful of taking over the work of the innovators themselves.

Implementation Science for Managers and Healthcare Organizations Responding to Emergencies.

The purpose of the article is to illustrate how implementation science concepts and methods can be applied by researchers and implementers to understand and assist emergency management in a large primary and community healthcare organization. The article refers to a single-case implementation action evaluation of an emergency management system in a healthcare organization. It describes the methods used in this study and findings to explain how a joint healthcare and university research team were able to use the science and methods both to help implementation and contribute to science. We report two sets of findings. First, findings about implementation of emergency management to illustrate how the investigation adapted implementation science and concepts to achieve the objectives evaluation. We discovered that implementation science provides useful concepts to understand contextual factors and adds to knowledge about organizational change and emergency management in the uncertain and evolving situation we encountered. The second set of findings are the strengths and limitations of both implementation science and the action evaluation methods we used to achieve the dual objectives of practical help with implementation and to contribute to science. The article uses the first implementation action evaluation study of the response of large public primary and community healthcare organization to a pandemic to illustrate how implementation science can be applied. This type of study was able to improve implementation of the response as well as contribute to scientific knowledge about emergency healthcare management and organization.

Evaluating diabetes care quality improvement strategies used by clinical teams in five primary care practices in New Zealand.

BACKGROUND: Diabetes care is often sub-optimal. Quality improvement (QI) initiatives are intended to improve care processes and thereby improve patient outcomes. There is a need to assess the degree of implementation of QI strategies, as a prerequisite to managing implementation. AIMS: Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders). METHODS: A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice. RESULTS: Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process. CONCLUSIONS: It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible.

Combining Improvement and Implementation Sciences and Practices for the Post COVID-19 Era.

Health services made many changes quickly in response to the SARS-CoV-2 pandemic. Many more are being made. Some changes were already evaluated, and there are rigorous research methods and frameworks for evaluating their local implementation and effectiveness. But how useful are these methods for evaluating changes where evidence of effectiveness is uncertain, or which need adaptation in a rapidly changing situation? Has implementation science provided implementers with tools for effective implementation of changes that need to be made quickly in response to the demands of the pandemic? This perspectives article describes how parts of the research and practitioner communities can use and develop a combination of implementation and improvement to enable faster and more effective change in the future, especially where evidence of local effectiveness is limited. We draw on previous reviews about the advantages and disadvantages of combining these two domains of knowledge and practice. We describe a generic digitally assisted rapid cycle testing (DA-RCT) approach that combines elements of each in order to better describe a change, monitor outcomes, and make adjustments to the change when implemented in a dynamic environment.

Can management decentralisation resolve challenges faced by healthcare service delivery organisations? Findings for managers and researchers from a scoping review.

PURPOSE: Decentralisation of decision-making from central to lower level organisation has been proposed as a way to increase innovation and make services more responsive to local needs. The purpose of this study was to discover research that can contribute to understanding decentralisation as one strategy for resolving challenges in healthcare service delivery organisations. This scoping review provides examples and research-informed guidance for decentralisation research, planning and implementation. FINDINGS: There is limited empirical research into management decentralisation within primary and community care, but some useful frameworks for assessing and planning decentralisation. Rapid changes are being made to workforce redesign, substitution and patient co-production. Research into such 'micro-decentralisation' is not considered in the decentralisation literature. Neither is how the context of culture, systems and regulations affects implementation of this type of decentralisation. Our recent experience suggests that management decentralisation can enable fast and effective local changes to respond to the evolving Severe acute respiratory syndrome coronavirus 2 (SARS COV-2) pandemic. CONCLUSIONS: Decentralisation can create conditions that support innovation and improvement locally to develop primary and community care. Managers and policy makers can use an appropriate decentralisation strategy to address challenges in workforce retention and recruitment, rising care demands and expectations of patients. There are opportunities for researchers to provide actionable knowledge about changes in organisations and management which could address current challenges in healthcare.

Management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in Stockholm, Sweden, and winter preparations.

INTRODUCTION Sweden is unique in adopting a 'no-lockdown' public health approach to the SARS-CoV-2 (COVID-19) outbreak. There were fears that health services would not be able to care for high numbers of COVID-19 patients. AIM To describe and review the emergency response of a public primary and community health-care organisation in Stockholm, Sweden, to the demand for care for COVID-19 and non-COVID-19 patients during March-July 2020, and summarise preparations for the months to follow. METHODS This was a rapid implementation action research case study, which also draws on one author's experience as Chief Executive Officer and other members' experience in an emergency management group. RESULTS Sweden experienced similar mortality per million population to the UK, despite the different public health strategy used to address the COVID-19 outbreak. The Stockholm-integrated public primary and community health-care service, serving a population of 2.3 million, made many changes quickly. One change included coordinating non-acute private health-care services, following the local government emergency directive to do so. DISCUSSION It is possible that the fast and effective response by management and services in primary and community health care reduced infection and hospital demand, which contributed to a lower mortality than otherwise expected. The actions and preparations described for Stockholm's response may provide ideas for other health-care systems. The partnership research approach between the Karolinska Medical University and the Region Stockholm health-care system used in this project shows that rapid research methods have advantages for both partners in an emergency situation.

Implementation researchers can improve the responses of services to the COVID-19 pandemic.

This article describes a rapid implementation research project with the Stockholm health care system to assist the system to respond to the COVID-19 pandemic. It uses this example to illustrate some ways in which implementation research and knowledge can contribute to improving service responses to the pandemic and its consequences as these evolve over the coming months. A sub-specialty of rapid implementation science is proposed to provide practical assistance and as one way to develop implementation research. PLAIN LANGUAGE ABSTRACT: This article describes a rapid implementation research project with the Stockholm health care system to assist the system to respond to the COVID-19 pandemic. It uses this example to illustrate some ways in which implementation research and knowledge can contribute to improving service responses to the pandemic and its consequences as these evolve over the coming months. A sub-specialty of rapid implementation science is proposed to provide practical assistance and as one way to develop implementation research.

DIGITAL TECHNOLOGY: Opportunities and barriers for usage of personal health records in hospital - report from a -workshop of the Health Informatics Unit at the Royal -College of Physicians.

Personal health records (PHRs) are thought to offer benefits and are promoted by health policy makers and some healthcare systems. Evidence for usage by patients in hospital is limited. This article reports a one-day workshop hosted by the Royal College of Physicians that considered the evidence of the value to patients and others, the challenges to adoption and use of PHRs and sought to identify the practical and research questions that need to be answered. The purpose of this article is to provide readers with an overview of the issues and possible future for hospital application of PHRs in the UK's NHS, especially for supporting self-care, family carers and advancing person-centred care. It aims to share the experience and ideas of those taking part in the workshop and reference resources that we have found useful while highlighting areas for future research.