A decade of change towards Value-Based Health Care at a Dutch University Hospital: a complexity-informed process study.

BACKGROUND: While healthcare organizations in several countries are embracing Value-Based Health Care (VBHC), there are limited insights into how to achieve this paradigm shift. This study examines the decade-long (2012-2023) change towards VBHC in a pioneering Dutch university hospital. METHOD: Through retrospective, complexity-informed process research, we study how a Dutch university hospital's strategy to implement VBHC evolved, how implementation outcomes unfolded, and the underlying logic behind these developments. Data include the hospital's internal documents (n = 10,536), implementation outcome indicators (n = 4), a survey among clinicians (n = 47), and interviews with individuals contributing to VBHC at the hospital level (n = 20). RESULTS: The change towards VBHC is characterized by three sequential strategies. Initially, the focus was on deep change through local, tailored implementation of multiple VBHC elements. The strategy then transitioned to a hospital-wide program aimed at evolutionary change on a large scale, emphasizing the integration of VBHC into mainstream IT and policies. Recognizing the advantages and limitations of both strategies, the hospital currently adopts a "hybrid" strategy. This strategy delicately combines deep and broad change efforts. The strategy evolved based on accumulated insights, contextual developments and shifts in decision-makers. The complexity of change was downplayed in plans and stakeholder communication. By the end of 2023, 68 (sub)departments engaged in VBHC, enabled to discuss patients' responses to Patient Reported Outcomes Measures (PROMs) during outpatient care. However, clinicians' use of PROMs data showed limitations. While pioneers delved deeper into VBHC, laggards have yet to initiate it. CONCLUSIONS: VBHC does not lend itself to linear planning and is not easily scalable. While there appears to be no golden standard for implementation, blending local and larger-scale actions appears advantageous. Local, deep yet harmonized and system-integrated changes culminate in large scale transformation. Embracing complexity and focusing on the ultimate aims of (re)institutionalization and (re)professionalization are crucial.

Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study.

Introduction: The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency. Purpose: This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units. Methods: A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data. Results: Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units. Conclusion: A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

The importance and feasibility of hospital interventions to prevent and manage patient aggression and violence against physicians in China: a Delphi study.

BACKGROUND: Aggression and violence by patient (and their relatives/friends) is widely acknowledged as a serious occupational hazard, with physicians being particularly susceptible to witnessing and experiencing such incidents within hospitals. Research has shown that the negative consequences of such aggression and violence are not only felt at the individual level, but also at the team and organizational levels. Understanding how to prevent and manage this behavior towards physicians in hospitals is urgent and not fully researched. While there are many potentially effective interventions, it is unclear which ones would be valuable and feasible for Chinese hospitals. Because patient aggression and violence may occur more frequently in Chinese hospitals than in other countries, this suggests that cultural differences play a role and that tailored interventions may be needed. METHOD: We conducted a Delphi study to reach a consensus on the importance and feasibility of hospital interventions to prevent and manage patient (and their relatives/friends) aggression and violence against physicians in Chinese hospitals. Seventeen experts in China were invited to complete online questionnaires over three rounds. RESULTS: After three rounds, consensus was achieved concerning 44 interventions, five other interventions were rejected, and no consensus was reached on another two. These interventions were clustered into eight categories: environment design, access and entrance, staffing and working practices, leadership and culture, training and education, support, during/after-the-event actions, and hospital policy. Each category is considered important in preventing and managing patient (and their relatives/friends) aggression and violence towards physicians in Chinese hospitals. This study also investigated the feasibility of the suggested interventions and found that 36 of the 44 interventions were considered not only relevant, but also feasible for implementation in Chinese hospitals. CONCLUSIONS: This study provides an overview of interventions that can be implemented in Chinese hospitals to prevent and manage patient (and their relatives/friends) aggression and violence before, during, and after a violent incident occurs.

The Effect of Long-Term (Im)balance of Giving Versus Receiving Support With Nonrelatives on Subjective Well-Being Among Home-Dwelling Older People.

OBJECTIVES: Although many studies have explored the benefits of support giving or receiving for older people, little is known about how the balance between giving and receiving instrumental support in nonrelative relationships affects home-dwelling older people. This study examines the relationship between long-term support balance and subjective well-being in relationships with nonrelatives among older people across 11 European countries. METHODS: A total of 4,650 participants aged 60 years and older from 3 waves of the Survey of Health and Retirement in Europe were included. Support balance was calculated as the intensity difference between support received and support given across 3 waves. Multiple autoregressive analyses were conducted to test the relationship between support balance and subjective well-being, as indicated by quality of life, depression, and life satisfaction. RESULTS: The impact of balanced versus imbalanced support on all subjective well-being measurements was not significantly different. Compared to balanced support, imbalanced receiving was negatively related to subjective well-being and imbalanced giving was not related to better subjective well-being. Compared to imbalanced receiving, imbalanced giving showed to be the more beneficial for all subjective well-being measures. DISCUSSION: Our results highlight the beneficial role of imbalanced giving and balanced support for older people compared to imbalanced receiving. Policies and practices should prioritize creating an age-friendly environment that promotes active participation and mutual support among older people, as this may be effective to enhance their well-being.

Implementation and dissemination of home- and community-based interventions for informal caregivers of people living with dementia: a systematic scoping review.

BACKGROUND: Informal caregivers of people with dementia (PwD) living at home are often the primary source of care, and, in their role, they often experience loss of quality of life. Implementation science knowledge is needed to optimize the real-world outcomes of evidence-based interventions (EBIs) for informal caregivers. This scoping review aims to systematically synthesize the literature that reports implementation strategies employed to deliver home- and community-based EBIs for informal caregivers of PwD, implementation outcomes, and the barriers and facilitators to implementation of these EBIs. METHODS: Embase, MEDLINE, Web of Science, and Cochrane Library were searched from inception to March 2021; included studies focused on "implementation science," "home- and community-based interventions," and "informal caregivers of people with dementia." Titles and abstracts were screened using ASReview (an innovative AI-based tool for evidence reviews), and data extraction was guided by the ERIC taxonomy, the Implementation Outcome Framework, and the Consolidated Framework for Implementation Science Research; each framework was used to examine a unique element of implementation. RESULTS: Sixty-seven studies were included in the review. Multicomponent (26.9%) and eHealth (22.3%) interventions were most commonly reported, and 31.3% of included studies were guided by an implementation science framework. Training and education-related strategies and provision of interactive assistance were the implementation strategy clusters of the ERIC taxonomy where most implementation strategies were reported across the reviewed studies. Acceptability (82.1%), penetration (77.6%), and appropriateness (73.1%) were the most frequently reported implementation outcomes. Design quality and packaging (intervention component suitability) and cosmopolitanism (partnerships) constructs, and patient's needs and resources and available resources (infrastructure) constructs as per the CFIR framework, reflected the most frequently reported barriers and facilitators to implementation. CONCLUSION: Included studies focused largely on intervention outcomes rather than implementation outcomes and lacked detailed insights on inner and outer setting determinants of implementation success or failure. Recent publications suggest implementation science in dementia research is developing but remains in nascent stages, requiring future studies to apply implementation science knowledge to obtain more contextually relevant findings and to structurally examine the mechanisms through which implementation partners can strategically leverage existing resources and regional networks to streamline local implementation. Mapping local evidence ecosystems will facilitate structured implementation planning and support implementation-focused theory building. TRIAL REGISTRATION: Not applicable.

Clinical leaders crossing boundaries: A study on the role of clinical leadership in crossing boundaries between specialties.

BACKGROUND: Due to the growing number of complex (multimorbid) patients, integrating and coordinating care across medical specialties around patient needs is an urgent theme in current health care. Clinical leadership plays an important role in stimulating coordination both within and between specialty groups, which results in better outcomes in terms of job satisfaction and quality of care. PURPOSE: In this light, this study aims to understand the relation between physicians' clinical leadership and outcomes, focusing on the sequential mediation of relationships and coordination with physicians within their own medical specialty group and from other specialties. METHODOLOGY: A cross-sectional self-administered survey among physicians in a Dutch hospital (n = 107) was conducted to measure clinical leadership, relational coordination at two levels (medical specialty group and between different specialties), quality of care, and job satisfaction. RESULTS: Clinical leadership was related to better quality of care through more relational coordination within the medical specialty group. Clinical leadership was related to more job satisfaction through more relational coordination within the medical specialty group, through more relational coordination between specialties, and sequentially through both kinds of relational coordination. CONCLUSION: Physicians who act as clinical leaders are important for crossing specialist boundaries and increasing care outcomes. PRACTICAL IMPLICATIONS: To improve multidisciplinary collaboration, managers should encourage clinical leadership and pay attention to the strong relationships between physicians from the same specialty.

Factors and interventions determining the functioning of health care teams in county-level hospitals in less affluent areas of China: a qualitative study.

Background: Teamwork is essential for the quality and safety of care, and research on teamwork in health care has developed rapidly in many countries. However, evidence from less affluent, non-Western countries is scarce, while improving teamwork may be especially relevant to be able to increase the quality of care in these settings. This study aims to understand the main factors that influence, and interventions used to improve, the functioning of health care teams in the context of county-level hospitals in less affluent areas of China. Methods: We conducted semistructured interviews to explore the factors that influence team functioning and the interventions implemented to improve team functioning in these hospitals. 15 hospital presidents and 15 team leaders were selected as respondents. Results: From the interviews, we have identified five main factors that influence team functioning in these hospitals: "stuck in the middle", local county setting, difficulty in attracting and retaining talent, strong focus on task design, and strong focus on leadership. The interventions for improving team functioning can mostly be categorized as the following: 1) measures to attract and retain talent (e.g., increase salary, train talent in national or provincial level hospitals, and provide fast-track promotions), 2) interventions focused on monodisciplinary teams (e.g., changing the team structure and leadership, and skill training), and 3) interventions to establish and improve multidisciplinary teams (e.g., simulation training and continuous team process improvements). Conclusion: With the introduction of multidisciplinary teams, interventions into team processes have started to receive more attention. The findings depict an overview of the main factors and interventions as specifically relevant for team functioning in county-level hospitals in less affluent areas of China and may help these hospitals benefit from additional process interventions to improve teamwork and the quality of care.

[Structurally supporting health care professionals' well-being: the relevance of a national program Caring for Healthcare Professionals.] / Het welzijn van zorgprofessionals onder druk.

Stressful working conditions in health care put the well-being of healthcare professionals at risk. This well-being is increasingly being supported by diverse initiatives in the Netherlands. However, these initiatives are dispersed across micro-, meso- and macro-levels and not equally accessible to all health care professionals. A national, integral approach is lacking in which initiatives across levels are more effectively combined. Therefore, we suggest the initiation of a national program "Caring for Healthcare Professionals", which structurally supports the well-being of healthcare professionals. We reflect on science- and practice-based insights from interventions in three domains: (a) workplace management, (b) self-care, and (c) treatment and recovery. We propose to translate the lessons learned in these domains into a national program combining best practices, aiming to structurally support healthcare professionals' well-being.

Towards Process-Oriented Hospital Structures; Drivers behind the Development of Hospital Designs.

Hospitals have been encouraged to develop more process-oriented designs, structured around patient needs, to better deal with patients suffering from multi-morbidity. However, most hospitals still have traditional designs built around medical specialties. We aimed to understand how hospital designs are currently developing and what the important drivers are. We built a typology to categorize all Dutch general hospitals (61), and we interviewed hospital managers and staff. The inventory showed three types of hospital building blocks: units built around specific medical specialties, clusters housing different medical specialty units, and centers; multi-specialty entities provide the most suitable structure for a process-oriented approach. Only some Dutch hospitals (5) are mainly designed around centers. However, most hospitals are slowly developing towards hybrid designs. Competitive drivers are not important for stimulating these redesigns. Institutional pressures from within the health care sector and institutional 'mimicking' are the main drivers, but the specific path they take is dependent on their 'heritage'. We found that hospital structures are more the result of incremental, path-dependent choices than 'grand-designs'. Although the majority of the Dutch general hospitals still have a general design built around medical specialties, most hospitals are moving towards a more process-oriented design.

Identifying consensus on activities that underpin value-based healthcare in outpatient specialty consultations, among clinicians.

OBJECTIVE: To find a consensus on clinicians' and patients' activities that underpin an ideal value-based outpatient specialty consultation, among clinicians. METHODS: A three-round online Delphi study was conducted. A purposive sample of nineteen clinicians from a Dutch university hospital judged activities on importance. Consensus was defined at 80% agreement. Activities were thematically analyzed to derive conceptual themes. RESULTS: The expert panel agreed on 63 activities as being important for an ideal value-based outpatient specialty consultation and two activities as being unimportant. They failed to reach a consensus on 11 activities. Conceptual themes for activities that were considered important regard: 1) empowerment, 2) patient-reported biopsychosocial outcomes, 3) the patient as a person, 4) the patient's kin, 5) shared power and responsibility, 6) optimization, 7) coordination, 8) therapeutic relationships, and 9) resource-consciousness. CONCLUSION: A value-based outpatient specialty consultation requires contextual decision-making, is person-centered, and focusses attention on care optimization and intelligent resource allocation. No importance is attributed to healthcare's societal burden and climate footprint. Disparities existed in various areas including the role of patient reported experience measures, "patient-like-me" data, and healthcare costs. PRACTICE IMPLICATIONS: This study contributes a toolbox to guide and evaluate clinicians' and patients' behaviors in value-based outpatient specialty consultations and reveals opportunities to enhance facilitation.

Strategic human resource management and performance in public hospitals in Ethiopia.

Background: Ethiopian public hospitals struggle to meet health care needs of the Ethiopian population, in part because of the persistent human resources crisis. The health reforms and tight human resource management (HRM) regulation of the government have resulted in limited progress toward addressing this crisis. This study aims to analyze how the strategic HRM practices adopted by Ethiopian public hospitals influence employee outcomes, organizational outcomes, and patient outcomes. Methods: Structured interviews were conducted with 19 CEOs and HR managers from 15 hospitals. Four focus groups were also conducted, with 38 participants (professionals and line managers). The transcripts were thematically analyzed using ATLAS.ti 8. Deductive coding was used based on the Contextual SHRM framework, while remaining open for codes that emerged. Results: Intended HR practices are influenced by mandatory strict government regulations. Nevertheless, some room for self-selected (bundles of) HR practices is perceived by hospitals. Employees perceive that governmental steered HR practices may not match its intentions due to implementation issues, related to lack of support and skilled management and HR professionals. These problems are leading to dissatisfaction, demotivation, moonlighting and turnover of skilled professionals and perceived to consequently negatively influence performance (i.e., patient satisfaction and waiting time). Conclusions: There are considerable contextual challenges for SHRM in Ethiopian public hospitals. Hospital management can benefit from having more leeway and from exploiting it more effectively to improve actual and perceived strategic human resource management practices. Adoption of commitment based practices, in addition to mandatory control oriented practices can help to motivate and retain health care professionals and consequently improve outcomes.

Effect of Receiving Financial Support from Adult Children on Depression among Older Persons and the Mediating Role of Social Participation.

Older persons are vulnerable to depression SFduring the ageing process. Financial resources and social participation are expected to have an impact on depressive symptoms. This study investigated the relationship between financial support from children and depression among Chinese older persons, as well as the mediating effect of social participation in this relationship. Data from 7163 participants aged 60 and above were extracted from wave 2015 and 2018 of the China Health and Retirement Longitudinal Survey (CHARLS). A multivariate regression analysis was performed on both cross-sectional data and two-wave longitudinal data to test our hypotheses. The results revealed that financial support from children was negatively associated with depressive symptoms in both the short-term and the long-term. In addition, this relationship was partially mediated by social participation in the short-term association and fully mediated by social participation in the long-term, where financial support was positively related to social participation, and social participation was negatively associated with depressive symptoms. This study offers an in-depth insight into the relationship between financial support from children and depression among Chinese older persons. Policies and initiatives to stimulate social participation should be promoted to improve older persons' mental health.

Collaboration Between Physicians from Different Medical Specialties in Hospital Settings: A Systematic Review.

Health care today is characterized by an increasing number of patients with comorbidities for whom interphysician collaboration seems very important. We reviewed the literature to understand what factors affect interphysician collaboration, determine how interphysician collaboration is measured, and determine its effects. We systematically searched six major databases. Based on 63 articles, we identified five categories that influence interphysician collaboration: personal factors, professional factors, preconditions and tools, organizational elements, and contextual characteristics. We identified a diverse set of mostly unvalidated tools for measuring interphysician collaboration that focus on information being transferred and understood, frequency of interaction and tone of the relationship, and value judgements about quality or satisfaction. We found that interphysician collaboration increased clinical outcomes as well as patient and staff satisfaction, while error rates and length of stay were reduced. The results should, however, be interpreted with caution, as most of the studies provide a low level of evidence.

Human resource management in Ethiopian public hospitals.

BACKGROUND: In Ethiopia, public hospitals deal with a persistent human resource crisis, even by Sub-Saharan Africa (SSA) standards. Policy and hospital reforms, however, have thus far resulted in limited progress towards addressing the strategic human resource management (SHRM) challenges Ethiopia's public hospitals face. METHODS: To explore the contextual factors influencing these SHRM challenges of Ethiopian public hospitals, we conducted a qualitative study based on the Contextual SHRM framework of Paauwe. A total of 19 structured interviews were conducted with Chief Executive Officers (CEOs) and HR managers from a purposive sample of 15 hospitals across Ethiopia. An additional four focus groups were held with professionals and managers. RESULTS: The study found that hospitals compete on the supply side for scarce resources, including skilled professionals. There was little reporting on demand-side competition for health services provided, service quality, and service innovation. Governmental regulations were the main institutional mechanism in place. These regulations also emphasized human resources and were perceived to tightly regulate employee numbers, salaries, and employment arrangements at detailed levels. These regulations were perceived to restrict the autonomy of hospitals regarding SHRM. Regulation-induced differences in allowances and external employment arrangements were among the concerns that decreased motivation and job satisfaction and caused employees to leave. The mismatch between regulation and workforce demands posed challenges for leadership and caused leaders to be perceived as incompetent and unable when they could not successfully address workforce needs. CONCLUSIONS: Bottom-up involvement in SHRM may help resolve the aforementioned persistent problems. The Ethiopian government might better loosen regulations and provide more autonomy to hospitals to develop SHRM and implement mechanisms that emphasize the quality of the health services demanded rather than the quantity of human resources supplied.

Implementation and dissemination of home and community-based interventions for informal caregivers of people living with dementia: a systematic scoping review protocol.

INTRODUCTION: Ageing in place, supported by formal home and community services and informal caregivers, is the most used long-term care option for people with dementia (PwD). Informal caregivers are inundated by their caregiving responsibilities and resultantly suffer consequences. Despite the multitude of clinical effectiveness studies on interventions that support informal caregivers, there is a paucity of information regarding their implementation process. This scoping review aims to identify the implementation strategies, implementation outcomes, and barriers and facilitators that impede or support the dissemination and uptake of interventions that support informal caregivers of PwD at home. METHODS AND ANALYSIS: This protocol is guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Protocols, and the scoping review will follow the systematic steps of the PRISMA-Extension for Scoping Reviews guideline. The search strategy will include publications produced from inception to 8 March 2021 and will be conducted in the search engines Embase, Medline (Ovid), Web of Science and Cochrane Central Register of Controlled Trials (Wiley), followed by a three-stage approach. First, title and abstracts will be screened by two independent reviewers. Second, full-text articles will also be screened by both reviewers and, in case of disagreement, by a third reviewer. The first two stages are based on a set of inclusion and exclusion criteria. Reference lists of the final included studies will also be checked for relevant articles. Data from the final included studies will be extracted and synthesised using the Expert Recommendations for Implementing Change compilation and Proctor's implementation outcomes to ensure homogenous and standardised reporting of implementation information. ETHICS AND DISSEMINATION: The review findings will be published in a peer-reviewed journal and disseminated at geriatric and implementation conferences to inform researchers, health service planners and practice professionals with an overview of the existing literature to guide them in the effective implementation of caregiver-focused interventions in dementia support.

Patients as team members: Factors affecting involvement in treatment decisions from the perspective of patients with a chronic condition.

BACKGROUND: Active patient involvement in treatment decisions is seen as a feature of patient-centred care that will ultimately lead to better healthcare services and patient outcomes. Although many factors have been identified that influence patient involvement in treatment decisions, little is known about the different views that patients have on which factors are most important. OBJECTIVE: This study explores the views of patients with a chronic condition on factors influencing their involvement in treatment decisions. DESIGN: Q-methodology was used to study the views of patients. Respondents were asked to rank a set of 42 statements from the least important to the most important for active patient involvement in treatment decision-making. The set of 42 statements was developed based on a literature search and a pilot in which two external researchers, 15 patients and four healthcare professionals participated. A total of 136 patients with one of three major chronic conditions were included: diabetes types 1 and 2, respiratory disease (i.e., chronic obstructive pulmonary disease and asthma) and cancer (i.e., breast cancer and prostate cancer). Data were collected in a face-to-face interview setting in the Netherlands. RESULTS: Four distinct views on the factors influencing active patient involvement were identified among patients with a chronic condition. (1) Enabled involvement: the extent to which patients are facilitated and empowered to participate will lead to patient involvement. (2) Relationship-driven involvement: the relationship between patients and healthcare professionals drives patient involvement. (3) Disease impact-driven involvement: the severity of disease drives patient involvement. (4) Cognition-driven involvement: knowledge and information drive patient involvement. DISCUSSION AND CONCLUSION: From the patients' perspective, this study shows that there is no one-size-fits-all approach to involving patients more actively in their healthcare journey. Strategies aiming to enhance active patient involvement among patients with a chronic condition should consider this diversity in perspectives among these patients. PATIENT CONTRIBUTION: Patients are the respondents as this study researches their perspective on factors influencing patient involvement. In addition, patients were involved in pilot-testing the statement set.

What Do We Really Know About Crew Resource Management in Healthcare?: An Umbrella Review on Crew Resource Management and Its Effectiveness.

OBJECTIVE: The aim of this article was to present an overview of the crew resource management (CRM) literature in healthcare. The first aim was to conduct an umbrella review on CRM literature reviews. The second aim was to conduct a new literature review that aims to address the gaps that were identified through the umbrella review. METHODS: First, we conducted an umbrella review to identify all reviews that have focused on CRM within the healthcare context. This step resulted in 16 literature reviews. Second, we conducted a comprehensive literature review that resulted in 106 articles. RESULTS: The 16 literature reviews showed a high level of heterogeneity, which resulted in discussing 3 ambiguities: definition, outcome, and information ambiguity. As a result of these ambiguities, a new comprehensive review of the CRM literature was conducted. This review showed that CRM seems to have a positive effect on outcomes at Kirkpatrick's level 1, 2, and 3. In contrast, whether CRM has a positive effect on level 4 outcomes and how level 4 should be measured remains undetermined. Recommendations on how to implement and embed CRM training into an organization to achieve the desired effects have not been adequately considered. CONCLUSIONS: The extensive nature of this review demonstrates the popularity of CRM in healthcare, but at the same time, it highlights that research tends to be situated within certain settings, focuses on particular outcomes, and has failed to address the full scope of CRM as a team intervention and a management concept.

Open organisational culture: what does it entail? Healthcare stakeholders reaching consensus by means of a Delphi technique.

OBJECTIVES: Open organisational culture in hospitals is important, yet it remains unclear what it entails other than its referral to 'open communication' in the context of patient safety. This study aims to identify the elements of an open hospital culture. METHODS: In this group consensus study with a Delphi technique, statements were constructed based on the existing patient safety literature and input of 11 healthcare professionals from different backgrounds. A final framework consisting of 36 statements was reviewed on inclusion and exclusion, in multiple rounds by 32 experts and professionals working in healthcare. The feedback was analysed and shared with the panel after the group reached consensus on statements (>70% agreement). RESULTS: The procedure resulted in 37 statements representing tangible (ie, leadership, organisational structures and processes, communication systems, employee attitudes, training and development, and patient orientation) and intangible themes (ie, psychological safety, open communication, cohesion, power, blame and shame, morals and ethics, and support and trust). The culture themes' teamwork and commitment were not specific for an open culture, contradicting the patient safety literature. Thereby, an open mind was shown to be a novel characteristic. CONCLUSIONS: Open culture entails an open mind-set and attitude of professionals beyond the scope of patient safety in which there is mutual awareness of each other's (un)conscious biases, focus on team relationships and professional well-being and a transparent system with supervisors/leaders being role models and patients being involved. Although it is generally acknowledged that microlevel social processes necessary to enact patient safety deserve more attention, research has largely emphasised system-level structures and processes. This study provides practical enablers for addressing system and microlevel social processes to work towards an open culture in and across teams.

What Do We Know About Teamwork in Chinese Hospitals? A Systematic Review.

Background and Objective: Improving quality of care is one of the primary goals in current Chinese hospital reforms. Teamwork can play an essential role. Characteristics of teamwork and interventions for improving teamwork in hospitals have been widely studied. However, most of these studies are from a Western context; evidence from China is scarce. Because of the contextual differences between China and Western countries, empirical evidence on teamwork from Western hospitals may have limited validity in China. This systematic review aims to advance the evidence base and understanding of teamwork in Chinese hospitals. Methods: Both English (i.e., Embase, Medline, and Web of Science) and Chinese databases (i.e., CNKI, CQVIP, and Wanfang) were searched for relevant articles until February 6, 2020. We included the studies that empirically researched teamwork in Chinese hospitals. Studies were excluded if they (1) were not conducted in hospitals in Mainland China, (2) did not research teamwork on team interventions, (3) were not empirical, (4) were not written in English or Chinese, (5) were not published in peer-reviewed journals, and (6) were not conducted in teams that provide direct patient care. Both deductive and inductive approaches were used to analyze data. The Mixed Methods Appraisal Tool (MMAT) was used to assess their methodological quality. Results: A total of 70 articles (i.e., 39 English articles and 31 Chinese articles) were included. The results are presented in two main categories: Teamwork components and Team interventions. The evidence regarding the relationships among inputs, processes, and outcomes is scarce and mostly inconclusive. The only conclusive evidence shows that females perceive better team processes than males. Similar types of training and tools were introduced as can be found in Western literature, all showing positive effects. In line with the Chinese health reforms, many of the intervention studies regard the introduction of multidisciplinary teams (MDTs). The evidence on the implementation of MDTs reveals that they have led to lower complication rates, shorter hospital stays, higher diagnosis accuracy, efficiency improvement, and a variety of better disease-specific clinical outcomes. Evidence on the effect on patient survival is inconclusive. Conclusion: The Chinese studies on teamwork components mainly focus on the input-process relationship. The evidence provided on this relationship is, however, mostly inconclusive. The intervention studies in Chinese hospitals predominantly focus on patient outcomes rather than organizational and employee outcomes. The introduction of training, tools, and MDTs generally shows promising results. The evidence from primary hospitals and rural areas, which are prioritized in the health reforms, is especially scarce. Advancing the evidence base on teamwork, especially in primary hospitals and rural areas, is needed and can inform policy and management to promote the health reform implementation. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020175069, identifier CRD42020175069.

Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review.

Introduction: Healthcare systems increasingly move toward "value-based healthcare" (VBHC), aiming to further improve quality and performance of care as well as the sustainable use of resources. Evidence about healthcare professionals' contributions to VBHC, experienced job demands and resources as well as employee well-being in VBHC is scattered. This systematic review synthesizes this evidence by exploring how VBHC relates to the healthcare professional, and vice versa. Method: Seven databases were systematically searched for relevant studies. The search yielded 3,782 records, of which 45 were eligible for inclusion based on a two-step screening process using exclusion criteria performed by two authors independently. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool (MMAT). Based on inductive thematic analysis, the Job Demands-Resources (JD-R) model was modified. Subsequently, this modified model was applied deductively for a second round of thematic analysis. Results: Ten behaviors of healthcare professionals to enhance value in care were identified. These behaviors and associated changes in professionals' work content and work environment impacted the experienced job demands and resources and, in turn, employee well-being and job strain. This review revealed 16 constructs as job demand and/or job resource. Examples of these include role strain, workload and meaning in work. Four constructs related to employee well-being, including engagement and job satisfaction, and five constructs related to job strain, including exhaustion and concerns, were identified. A distinction was made between job demands and resources that were a pure characteristic of VBHC, and job demands and resources that resulted from environmental factors such as how care organizations shaped VBHC. Conclusion and Discussion: This review shows that professionals experience substantial job demands and resources resulting from the move toward VBHC and their active role therein. Several job demands are triggered by an unsupportive organizational environment. Hence, increased organizational support may contribute to mitigating or avoiding adverse psychosocial factors and enhance positive psychosocial factors in a VBHC context. Further research to estimate the effects of VBHC on healthcare professionals is warranted.