Developing a Common Understanding of Networks of Care through a Scoping Study.

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multi-method scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low- and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity.

High-performing primary health care (PHC) is essential for achieving universal health coverage. However, in many countries, PHC is weak and unable to deliver on its potential. Improvement is often limited by a lack of actionable data to inform policies and set priorities. To address this gap, the Primary Health Care Performance Initiative (PHCPI) was formed to strengthen measurement of PHC in low-income and middle-income countries in order to accelerate improvement. PHCPI's Vital Signs Profile was designed to provide a comprehensive snapshot of the performance of a country's PHC system, yet quantitative information about PHC systems' capacity to deliver high-quality, effective care was limited by the scarcity of existing data sources and metrics. To systematically measure the capacity of PHC systems, PHCPI developed the PHC Progression Model, a rubric-based mixed-methods assessment tool. The PHC Progression Model is completed through a participatory process by in-country teams and subsequently reviewed by PHCPI to validate results and ensure consistency across countries. In 2018, PHCPI partnered with five countries to pilot the tool and found that it was feasible to implement with fidelity, produced valid results, and was highly acceptable and useful to stakeholders. Pilot results showed that both the participatory assessment process and resulting findings yielded novel and actionable insights into PHC strengths and weaknesses. Based on these positive early results, PHCPI will support expansion of the PHC Progression Model to additional countries to systematically and comprehensively measure PHC system capacity in order to identify and prioritise targeted improvement efforts.

Randomized Trial of Reducing Ambulatory Malpractice and Safety Risk: Results of the Massachusetts PROMISES Project.

OBJECTIVE: Evaluate application of quality improvement approaches to key ambulatory malpractice risk and safety areas. STUDY SETTING: In total, 25 small-to-medium-sized primary care practices (16 intervention; 9 control) in Massachusetts. STUDY DESIGN: Controlled trial of a 15-month intervention including exposure to a learning network, webinars, face-to-face meetings, and coaching by improvement advisors targeting "3+1" high-risk domains: test result, referral, and medication management plus culture/communication issues evaluated by survey and chart review tools. DATA COLLECTION METHODS: Chart reviews conducted at baseline and postintervention for intervention sites. Staff and patient survey data collected at baseline and postintervention for intervention and control sites. PRINCIPAL FINDINGS: Chart reviews demonstrated significant improvements in documentation of abnormal results, patient notification, documentation of an action or treatment plan, and evidence of a completed plan (all P<0.001). Mean days between laboratory test date and evidence of completed action/treatment plan decreased by 19.4 days (P<0.001). Staff surveys showed modest but nonsignificant improvement for intervention practices relative to controls overall and for the 3 high-risk domains that were the focus of PROMISES. CONCLUSIONS: A consortium of stakeholders, quality improvement tools, coaches, and learning network decreased selected ambulatory safety risks often seen in malpractice claims.

Integrating: A managerial practice that enables implementation in fragmented health care environments.

BACKGROUND: How some organizations improve while others remain stagnant is a key question in health care research. Studies identifying how organizations can implement improvement despite barriers are needed, particularly in primary care. PURPOSES: This inductive qualitative study examines primary care clinics implementing improvement efforts in order to identify mechanisms that enable implementation despite common barriers, such as lack of time and fragmentation across stakeholder groups. METHODOLOGY: Using an embedded multiple case study design, we leverage a longitudinal data set of field notes, meeting minutes, and interviews from 16 primary care clinics implementing improvement over 15 months. We segment clinics into those that implemented more versus those that implemented less, comparing similarities and differences. We identify interpersonal mechanisms promoting implementation, develop a conceptual model of our key findings, and test the relationship with performance using patient surveys conducted pre-/post-implementation. FINDINGS: Nine clinics implemented more successfully over the study period, whereas seven implemented less. Successfully implementing clinics exhibited the managerial practice of integrating, which we define as achieving unity of effort among stakeholder groups in the pursuit of a shared and mutually developed goal. We theorize that integrating is critical in improvement implementation because of the fragmentation observed in health care settings, and we extend theory about clinic managers' role in implementation. We identify four integrating mechanisms that clinic managers enacted: engaging groups, bridging communication, sensemaking, and negotiating. The mean patient survey results for integrating clinics improved by 0.07 units over time, whereas the other clinics' survey scores declined by 0.08 units on a scale of 5 (p = .02). PRACTICE IMPLICATIONS: Our research explores an understudied element of how clinics can implement improvement despite barriers: integrating stakeholders within and outside the clinic into the process. It provides clinic managers with an actionable path for implementing improvement.

Evaluating ambulatory practice safety: the PROMISES project administrators and practice staff surveys.

BACKGROUND: Ambulatory practices deliver most health care services and contribute to malpractice risk. Yet, policymakers and practitioners often lack information about safety and malpractice risk needed to guide improvement. OBJECTIVE: To assess staff and administrator perceptions of safety and malpractice risk in ambulatory settings. RESEARCH DESIGN: We administered surveys in small-sized to medium-sized primary care practices in Massachusetts as part of a randomized controlled trial to reduce ambulatory malpractice risk. SUBJECTS: Twenty-five office practice managers/administrators and 482 staff, including [physicians, physician assistants, and nurse practitioners (MD/PA/NPs)], nurses, other clinicians, managers, and administrators. MEASURES: Surveys included structured questions about 3 high-risk clinical domains: referral, test result, and medication management, plus communication with patients and among staff. The 30-item administrator survey evaluated the presence of organizational safety structures and processes; the 63-item staff survey queried safety and communication concerns. RESULTS: Twenty-two administrators (88%) and 292 staff (61%) responded. Administrators frequently reported important safety systems and processes were absent. Suboptimal or incomplete implementation of referral and test result management systems related to staff perceptions of their quality (P<0.05). Staff perceptions of suboptimal processes correlated with their concern about practice vulnerability to malpractice suits (P<0.05). Staff was least positive about referral management system safety, talking openly about safety problems, willingness to report mistakes, and feeling rushed. MD/PA/NPs viewed high-risk system reliability more negatively (P<0.0001) and teamwork more positively (P<0.03) than others. CONCLUSIONS: Results show opportunities for improvement in closing informational loops and establishing more reliable systems and environments where staff feels respected and safe speaking up. Initiatives to transform primary care should emphasize improving communication among facilities and practitioners.

Achieving the HIV and AIDS National Strategic Plan: A practical calculator for local target setting in district health facilities.

The South African HIV National Strategic Plan (NSP) aims to provide access to appropriate treatment, care and support to 80% of the HIV-infected population by 2011. By mid-2008, highly active antiretroviral treatment (HAART) was being dispensed to about half the HIV-infected population in need. Reaching the NSP targets will require full mobilisation of all of South Africa's health facilities. While the NSP has broad political and programmatic support from the Department of Health and civil society, and managers are able to recite the national targets, it has been difficult for these managers to relate the targets to their own geographical areas of responsibility. National, regional and district targets for HIV care have been set from South Africa's relatively good census, modelling and epidemiological data. However, few practical tools are available to help clinicians and managers understand their facility's actual contribution to the district regional and national NSP targets for each step of the HIV care pathway (HIV testing, CD4 testing, HAART referral and initiation). The calculation of HAART initiation targets is complicated by the anticipated additional demand for treatment that will be generated by a change in the recommended CD4-count threshold for initiation of treatment.4 Accordingly, we provide a data-based tool that is readily available, and that district and facility managers can use to calculate their annual steady-state HIV testing, CD4 testing and HAART initiation requirements. These calculated values can be used for local and regional planning and to assess and improve current performance at facility level.