Mind the gap: governance mechanisms and health workforce outcomes.

Attempts at health system reform have not been as successful as governments and health authorities had hoped. Working from the premise that health system governance and changes to the workforce are at the heart of health system performance, we conducted a systematic review examining how they are linked. Key messages from the report are that: (1) leadership, communication and engagement are crucial to workforce change; (2) workforce outcomes need to be considered in conjunction with patient outcomes; and (3) decision-makers and researchers need to work together to develop an evidence base to inform future reform planning.

Exploring the relationship between governance mechanisms in healthcare and health workforce outcomes: a systematic review.

BACKGROUND: The objective of this systematic review of diverse evidence was to examine the relationship between health system governance and workforce outcomes. Particular attention was paid to how governance mechanisms facilitate change in the workforce to ensure the effective use of all health providers. METHODS: In accordance with standard systematic review procedures, the research team independently screened over 4300 abstracts found in database searches, website searches, and bibliographies. Searches were limited to 2001-2012, included only publications from Canada, the United Kingdom, the Netherlands, New Zealand, Australia, and the United States. Peer- reviewed papers and grey literature were considered. Two reviewers independently rated articles on quality and relevance and classified them into themes identified by the team. One hundred and thirteen articles that discussed both workforce and governance were retained and extracted into narrative summary tables for synthesis. RESULTS: Six types of governance mechanisms emerged from our analysis. Shared governance, Magnet accreditation, and professional development initiatives were all associated with improved outcomes for the health workforce (e.g., decreased turnover, increased job satisfaction, increased empowerment, etc.). Implementation of quality-focused initiatives was associated with apprehension among providers, but opportunities for provider training on these initiatives increased quality and improved work attitudes. Research on reorganization of healthcare delivery suggests that changing to team-based care is accompanied by stress and concerns about role clarity, that outcomes vary for providers in private versus public organizations, and that co-operative clinics are beneficial for physicians. Funding schemes required a supplementary search to achieve adequate depth and coverage. Those findings are reported elsewhere. CONCLUSIONS: The results of the review show that while there are governance mechanisms that consider workforce impacts, it is not to the extent one might expect given the importance of the workforce for improving patient outcomes. Furthermore, to successfully implement governance mechanisms in this domain, there are key strategies recommended to support change and achieve desired outcomes. The most important of these are: to build trust by clearly articulating the organization's goal; considering the workforce through planning, implementation, and evaluation phases; and providing strong leadership.

Organizational factors influencing inter-professional team functioning in primary care networks.

This study examined organizational factors influencing the functioning of inter-professional teams in select primary care networks (PCNs) in Alberta. Seven PCNs participated, each identifying two teams to be interviewed. The study used an exploratory qualitative approach to collect information from 118 physicians, managers and other clinical and non-clinical staff. Organizational factors affecting these teams included leadership and workplace culture, physical infrastructure, information technology infrastructure, organizational supports and employment models. The authors offer organizational strategies that enhance inter-professional team functioning based on interviewee recommendations and the existing literature. Further research is needed to link the strategies to measureable outcomes.

Incentives for improving human resource outcomes in health care: overview of reviews.

OBJECTIVES: To review the effectiveness of financial and nonfinancial incentives for improving the benefits (recruitment, retention, job satisfaction, absenteeism, turnover, intent to leave) of human resource strategies in health care. METHODS: Overview of 33 reviews published from 2000 to 2012 summarized the effectiveness of incentives for improving human resource outcomes in health care (such as job satisfaction, turnover rates, recruitment, and retention) that met the inclusion criteria and were assessed by at least two research members using the Assessment of Multiple Systematic Reviews quality assessment tool. Of those, 13 reviews met the quality criteria and were included in the overview. Information was extracted on a description of the review, the incentives considered, and their impact on human resource outcomes. The information on the relationship between incentives and outcomes was assessed and synthesized. RESULTS: While financial compensation is the best-recognized approach within an incentives package, there is evidence that health care practitioners respond positively to incentives linked to the quality of the working environments including opportunities for professional development, improved work life balance, interprofessional collaboration, and professional autonomy. There is less evidence that workload factors such as job demand, restructured staffing models, re-engineered work designs, ward practices, employment status, or staff skill mix have an impact on human resource outcomes. CONCLUSIONS: Overall, evidence of effective strategies for improving outcomes is mixed. While financial incentives play a key role in enhancing outcomes, they need to be considered as only one strategy within an incentives package. There is stronger evidence that improving the work place environment and instituting mechanisms for work-life balance need to be part of an overall strategy to improve outcomes for health care practitioners.

Use of a knowledge synthesis by decision makers and planners to facilitate system level integration in a large Canadian provincial health authority.

PURPOSE: The study is an examination of how a knowledge synthesis, conducted to fill an information gap identified by decision makers and planners responsible for integrating health systems in a western Canadian health authority, is being used within that organization. METHODS: Purposive sampling and snowball technique were used to identify 13 participants who were interviewed about how they are using the knowledge synthesis for health services planning and decision-making. RESULTS: The knowledge synthesis is used by those involved in the strategic direction of the provincial healthcare organization and those tasked with the operationalization of integration at the provincial or local level. Both groups most frequently use the 10 key principles for integration, followed by the sections on integration processes, strategies and models. The key principles facilitate discussion on priority areas to be considered and provide a reference point for a desired future state. Perceived information gaps relate to a lack of detail on 'how to' strategies, tools and processes that would lead to successful integration. DISCUSSION AND CONCLUSION: The current project demonstrates that decision makers and planners will effectively use a knowledge synthesis if it is timely, relevant and accessible. The information can be applied at strategic and operations levels. Attention needs to be paid to include more information on implementation strategies and processes. Including knowledge users in identifying research questions will increase information uptake.

Health systems integration: state of the evidence.

INTRODUCTION: Integrated health systems are considered a solution to the challenge of maintaining the accessibility and integrity of healthcare in numerous jurisdictions worldwide. However, decision makers in a Canadian health region indicated they were challenged to find evidence-based information to assist with the planning and implementation of integrated healthcare systems. METHODS: A systematic literature review of peer-reviewed literature from health sciences and business databases, and targeted grey literature sources. RESULTS: Despite the large number of articles discussing integration, significant gaps in the research literature exist. There was a lack of high quality, empirical studies providing evidence on how health systems can improve service delivery and population health. No universal definition or concept of integration was found and multiple integration models from both the healthcare and business literature were proposed in the literature. The review also revealed a lack of standardized, validated tools that have been systematically used to evaluate integration outcomes. This makes measuring and comparing the impact of integration on system, provider and patient level challenging. DISCUSSION AND CONCLUSION: Healthcare is likely too complex for a one-size-fits-all integration solution. It is important for decision makers and planners to choose a set of complementary models, structures and processes to create an integrated health system that fits the needs of the population across the continuum of care. However, in order to have evidence available, decision makers and planners should include evaluation for accountability purposes and to ensure a better understanding of the effectiveness and impact of health systems integration.

Ten key principles for successful health systems integration.

Integrated health systems are considered part of the solution to the challenge of sustaining Canada's healthcare system. This systematic literature review was undertaken to guide decision-makers and others to plan for and implement integrated health systems. This review identified 10 universal principles of successfully integrated healthcare systems that may be used by decision-makers to assist with integration efforts. These principles define key areas for restructuring and allow organizational flexibility and adaptation to local context. The literature does not contain a one-size-fits-all model or process for successful integration, nor is there a firm empirical foundation for specific integration strategies and processes.

Inquiring minds: women's approaches to evaluating complementary and alternative therapies for menopausal symptoms.

OBJECTIVE: To examine how women gather, evaluate, and use information on complementary and alternative medicine (CAM) options for managing menopausal symptoms. DESIGN: Qualitative study. SETTING: Calgary, Alta. PARTICIPANTS: Twenty-two women with a mean age of 52 years (range 42 to 58 years) who sought information on CAM therapies to manage menopausal symptoms. METHOD: In-depth semistructured interviews. Category coding and thematic analysis were used to interpret the data. MAIN FINDINGS: Four major themes emerged: how women gathered information, how they evaluated the information, how they used the information, and the challenges they experienced in making informed decisions. Information gathering was an on going process; as women's symptoms changed, their information needs changed also. Their preferred sources of information included physicians, CAM practitioners, staff at health food stores, and personal contacts. They sought information about the process of menopause and about both CAM and conventional treatments. Study participants were highly educated. Most of them systematically evaluated information from many sources using such criteria as whether information was biased, where the information came from, and whether the information was current. Information was used to validate their symptoms and to choose treatment based on cost-benefit analysis, risk-benefit analysis, and possible negative side effects or interactions between medications. Finding reliable information was considered a challenge due to structural or information-related barriers. Several of the women cited a lack of time as a challenge: time to search for and evaluate information and the pressure of time to find relief from the symptoms of menopause. CONCLUSION: There is a need for reliable information about menopause and the risks and benefits of CAM options for menopausal symptoms in a format accessible to the range of women who will experience or are experiencing this transition. As a trusted source, family physicians have a role in disseminating this information.

How important is research-based practice to chiropractors and massage therapists?

OBJECTIVE: This study evaluated the perceptions of research, frequency of use of research findings in practice, and the level of research skills of chiropractors and massage therapists in Canada. Predictors of application of research findings in clinical practice were also explored. METHODS: A survey was mailed to members of the College of Chiropractors of Alberta (n = 833) and the Massage Therapist Association of Alberta (n = 650). Univariate and logistic regression analysis were conducted with SPSS and Stata. RESULTS: A total of 483 questionnaires were returned (response rate, 32.6%). Chiropractors and massage therapists reported an overall positive perception toward research, acknowledging the importance of research to validate their practice. Although both groups felt comfortable using the library, they had little confidence in their research skills and overall application of research in practice was limited. Significant differences were found between the 2 professional groups, with chiropractors reporting more research skills and evidence-based practice. Primary discipline, frequent referral to peer-reviewed journals, and strong agreement with the statement that "research adds credibility to my discipline" were predictors of research application in practice. CONCLUSION: It appears that in Canada neither chiropractors nor massage therapists consistently apply research in practice, which may result from a lack of research education and research skills. The differences between the 2 professional groups may be attributed to the chiropractic profession's relatively more research-focused professional training. Strategies to encourage greater research uptake and evidence-based behavior by practitioners include professional association incentives, such as education credits or practitioner cooperatives that would provide time and support for research.