International approaches for implementing accreditation programmes in different healthcare facilities: a comparative case study in Australia, Botswana, Denmark, and Jordan.

Healthcare accreditation programmes have been adopted internationally to maintain the quality and safety of services. Accreditation assesses the compliance of organizations to a series of standards. The evidence base supporting the benefits of accreditation is mixed, potentially influenced by differences in local implementation and operationalization of standards. Successful implementation is associated with optimizing regulation, funding, and government commitment. Implementation of accreditation is a complex intervention that needs to be tailored to meet contextual differences across settings. Comparing why and how accreditation is implemented across countries supports the effective implementation of new programmes and refinements to existing systems. This article presents four case studies from Australia, Botswana, Denmark, and Jordan to consider a geographic spread and mix of high- and upper-middle-income countries. The data were derived from a review of accreditation programme documents and follow-up discussions with directors of the accrediting bodies in the countries of interest. Each case study was summarized according to a standardized framework for comparison: (i) goals (why), (ii) programme implementation (how), (iii) outcomes based on pre-post measures (what), and (iv) lessons learned (enablers and barriers). The accreditation programmes were all introduced in the 2000s to improve quality and safety. Documents from each country outlined motivations for introducing an accreditation programme, which was predominantly initiated by the government. The programmes were adopted in demarcated healthcare sectors (e.g. primary care and hospital settings), with a mix of mandatory and voluntary approaches. Implementation support centred on the interpretation and operationalization of standards and follow-up on variation in compliance with standards, after announced surveys. Most standards focused on patient safety, patient centredness, and governance but differed between using standard sets on quality management or supportive processes for patient care. Methods for evaluation of programme success and outcomes measured varied. Frequently reported enablers of successful implementation included strong leadership and ownership of the process. A lack of awareness of quality and safety, insufficient training in quality improvement methods, and transfer of staff represented the most common challenges. This case analysis of accreditation programmes in a variety of countries highlights consistent strategies utilized, key enabling factors, barriers, and the influence of contextual differences. Our framework for describing why, how, what, and lessons learned demonstrates innovation and experimentation in approaches used across high- and upper-middle-income countries, hospital and primary care, and specialist clinics.

Learners' experience and perceived impact of a health literacy program in adult basic education: a qualitative study.

Objectives and importance of the study: Adult literacy programs aim to empower learners to participate more effectively in everyday life. This includes programs with health content embedded in curricula to target health literacy. Adult learners who attend these programs represent a heterogeneous population, but include a high proportion of hard-to-reach or socially disadvantaged groups in terms of age, ethnicity, educational background, language and prevalence of learning disabilities. In 2014, we conducted a cluster-randomised controlled trial of a health literacy program in adult basic education classes across New South Wales, Australia. This paper reports findings from a qualitative study exploring learners' experience of the course and its perceived impact on their lives, as well as their understanding and confidence about health. STUDY TYPE: Qualitative interview study. METHOD: We conducted semistructured interviews as part of the evaluation of the 18-week health literacy program, with participants purposively recruited from six health literacy classes (n = 22). Researchers trained in qualitative methods interviewed adult learners either face to face or over the phone using a topic guide. Data was analysed using the Framework method, a matrix-based approach to thematic analysis. RESULTS: The majority of interviewees were female, lived in metropolitan areas and were from non-English-speaking backgrounds. Most had existing self-reported health problems and inadequate functional health literacy. Most participants described positive impacts of the health literacy course on their language, literacy and numeracy skills, functional health literacy skills, and health knowledge. They also reported being able to translate this into health actions including interacting with providers, accessing and using healthcare, and managing health and illness (e.g. making healthier food choices). Learners also described positive social outcomes of the course, including feelings of connectedness and interpersonal trust within a new network of learners, and reported sharing new knowledge with others in their communities. CONCLUSIONS: The findings add value to existing limited evidence that has demonstrated the untapped potential of adult basic education to develop health literacy skills among socially disadvantaged groups. Learners valued the opportunity to share experiences in structured group learning, and reported confidence to transfer new knowledge into their home and wider social network.

Evaluation of an Australian Health Literacy Program Delivered in Adult Education Settings.

BACKGROUND: Adult education targeting health literacy (HL) may bring added value in the form of improved health. OBJECTIVE: This study evaluated the effects of a HL program as part of an adult education curriculum for adults with low literacy and numeracy. METHODS: This was a partial-cluster randomized controlled trial among 308 adults enrolled in basic education programs in Australia. Of the 308 participants, 141 (46%) were randomized to either the standard program (language, literacy, and numeracy [LLN]), or the HL intervention (LLN with embedded health content); the remainder (n = 167) were allocated to standard intervention programs by the education provider at the class level. The main outcomes were functional HL, self-reported confidence, patient activation, generic HL (ie, HLQ, health knowledge, and self-reported health behavior). Data were collected at baseline, immediately after, and at 6 months post-intervention. KEY RESULTS: Of the 308 participants, 71% had limited literacy and 60% spoke a language other than English at home. Both interventions benefited participants, with improvements from baseline to immediate follow up on individual-level functional HL (e.g., reading a thermometer; HL group 18.4% vs. standard group 7.2%; p = .001), confidence (HL group 0.34 vs. standard group 0.06; p = .014) and health literacy questionnaire (HLQ) subscales. At 6 months, improvements in confidence (p < .001) and some HLQ measures were retained. A consistent pattern of increased improvement in the HL program was observed compared to the standard program, although only some measures reached statistical significance: reading a food label (HL group 6.03/10 correct vs. standard group 5.49/10 correct; p = .022); confidence (p = .008); ability to actively manage health (HLQ) (p = .017), and health knowledge at 6 months (HL group 68% vs. standard group 60% correct, p = .052). HL participants reported being more likely to share course information and rated the program more useful to understand their health. CONCLUSIONS: Improving language, literacy, and numeracy generally has potential public health benefits that are retained at 6 months. Integrating health content adds further value to adult basic learning, is feasible, and potentially scalable. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S42-S57.]. PLAIN LANGUAGE SUMMARY: We compared the effect of an adult education-based health literacy (HL) program versus a standard language, literacy, and numeracy program on students' HL skills and psychosocial outcomes. Although students in both trial arms improved their skills, students in the HL program had better outcomes with higher HL, greater confidence, and higher health knowledge scores at 6 months.

Skills for Shared Decision-Making: Evaluation of a Health Literacy Program for Consumers with Lower Literacy Levels.

BACKGROUND: Shared decision-making (SDM) has been found to be significantly and positively associated with improved patient outcomes. For an SDM process to occur, patients require functional, communicative, and critical health literacy (HL) skills. OBJECTIVE: This study aimed to evaluate the impact of a program to improve health literacy skills for SDM in adults with lower literacy. METHODS: An HL program including an SDM component (HL + SDM) and teaching of the three "AskShareKnow" questions was delivered in adult basic education settings in New South Wales, Australia. The program was evaluated using a partially cluster-randomized controlled trial comparing it to standard language, literacy, and numeracy (LLN) training. We measured the effect of these programs on (1) HL skills for SDM (conceptual knowledge, graphical literacy, health numeracy), (2) types of questions considered important for health decision-making, (3) preferences for control in decision-making, and (4) decisional conflict. We also measured AskShareKnow question recall, use, and evaluation in HL + SDM participants. KEY RESULTS: There were 308 participants from 28 classes enrolled in the study. Most participants had limited functional HL (71%) and spoke a language other than English at home (60%). In the primary analysis, the HL + SDM program compared with the standard LLN program significantly increased conceptual knowledge (19.1% difference between groups in students achieving the competence threshold; p = .018) and health numeracy (10.9% difference; p = .032), but not graphical literacy (5.8% difference; p = .896). HL + SDM participants were significantly more likely to consider it important to ask questions that would enable SDM compared to standard LLN participants who prioritized nonmedical procedural questions (all p < .01). There was no difference in preferences for control in decision-making or in decisional conflict. Among HL + SDM participants, 79% (n = 85) correctly recalled at least one of the AskShareKnow questions immediately post-intervention, and 35% (n = 29) after 6 months. CONCLUSIONS: Teaching SDM content increased participants' HL skills for SDM and changed the nature of the questions they would ask health care professionals in a way that would enable shared health decisions. [HLRP: Health Literacy Research and Practice. 2019;3(Suppl.):S58-S74.]. PLAIN LANGUAGE SUMMARY: We developed a health literacy program that included a shared decision-making (SDM) section. The program was delivered in adult basic education classes by trained educators and compared to standard language, literacy, and numeracy training. Teaching SDM content increased participants' health literacy skills for SDM and changed the nature of the questions they would ask health care professionals.

Hospitalization from the patient perspective: a data linkage study of adults in Australia.

OBJECTIVE: Evidence of the patient experience of hospitalization is an essential component of health policy and service improvement but studies often lack a representative population sample or do not examine the influence of patient and hospital characteristics on experiences. We address these gaps by investigating the experiences of a large cohort of recently hospitalized patients aged 45 years and over in New South Wales (NSW), Australia who were identified using data linkage. DESIGN: Cross-sectional survey. SETTING: Hospitals in NSW, Australia. PARTICIPANTS: The Picker Patient Experience Survey (PPE-15) was administered to a random sample of 20 000 patients hospitalized between January and June 2014. MAIN OUTCOME MEASURE: Multivariable negative binomial regression was used to investigate factors associated with a higher PPE-15 score. RESULTS: There was a 40% response rate (7661 completed surveys received). Respondents often reported a positive experience of being treated with dignity and respect, yet almost 40% wanted to be more involved in decisions about their care. Some respondents identified other problematic aspects of care such as receiving conflicting information from different care providers (18%) and feeling that doctors spoke in front of them as if they were not there (14%). Having an unplanned admission or having an adverse event were both very strongly associated with a poorer patient experience (P < 0.001). No other factors were found to be associated. CONCLUSIONS: Patient involvement in decision-making about care was highlighted as an important area for improvement. Further work is needed to address the challenges experienced by patients, carers and health professionals in achieving a genuine partnership model.

Improving health literacy through adult basic education in Australia.

Adults with low literacy are less empowered to take care of their health, have poorer health outcomes and higher healthcare costs. We facilitated partnerships between adult literacy teachers and community health providers to deliver a health literacy training program in adult basic education classrooms. Following course completion we interviewed 19 adult education teachers (15 delivering the health literacy program; 4 delivering standard literacy classes) and four community health providers (CHPs) about their experiences, and analysed transcripts using Framework analysis. Written feedback from eight teachers on specific course content was added to the Framework. Health literacy teachers reported a noticeable improvement in their student's health behaviours, confidence, vocabulary to communicate about health, understanding of the health system and language, literacy and numeracy skills. CHP participation was perceived by teachers and CHPs as very successful, with teachers and CHPs reporting they complemented each other's skills. The logistics of coordinating CHPs within the constraints of the adult education setting was a significant obstacle to CHP participation. This study adds to existing evidence that health is an engaging topic for adult learners, and health literacy can be successfully implemented in an adult basic learning curriculum to empower learners to better manage their health. Health workers can deliver targeted health messages in this environment, and introduce local health services. Investment in adult literacy programs teaching health content has potential both to meet the goals of adult language and literacy programs and deliver health benefit in vulnerable populations.

Qualitative insights into the experience of teaching shared decision making within adult education health literacy programmes for lower-literacy learners.

BACKGROUND: Enhancing health literacy can play a major role in improving healthcare and health across the globe. To build higher-order (communicative/critical) health literacy skills among socially disadvantaged Australians, we developed a novel shared decision making (SDM) training programme for adults with lower literacy. The programme was delivered by trained educators within an adult basic education health literacy course. OBJECTIVE: To explore the experience of teaching SDM within a health literacy programme and investigate whether communicative/critical health literacy content meets learner needs and teaching and institutional objectives. DESIGN AND PARTICIPANTS: Qualitative interview study with 11 educators who delivered the SDM programme. Transcripts were analysed using the Framework approach; a matrix-based method of thematic analysis. RESULTS: Teachers noted congruence in SDM content and the institutional commitment to learner empowerment in adult education. The SDM programme was seen to offer learners an alternative to their usual passive approach to healthcare decision making by raising awareness of the right to ask questions and consider alternative test/treatment options. Teachers valued a structured approach to training building on foundational skills, with language reinforcement and take-home resources, but many noted the need for additional time to develop learner understanding and cover all aspects of SDM. Challenges for adult learners included SDM terminology, computational numerical risk tasks and understanding probability concepts. DISCUSSION AND CONCLUSIONS: SDM programmes can be designed in a way that both supports teachers to deliver novel health literacy content and empowers learners. Collaboration between adult education and healthcare sectors can build health literacy capacity of those most in need.

Developing Verbal Health Literacy with Adult Learners Through Training in Shared Decision-Making.

BACKGROUND: Health literacy skills are often assessed in relation to written health materials; however, many important communications are in other formats, especially verbal communication with health care providers. OBJECTIVE: This qualitative study sought to examine adult learners' experiences of developing verbal health literacy skills within an Australian adult basic education program, and to explore verbal communication and shared decision-making as a constituent domain of health literacy. METHODS: We conducted a semi-structured qualitative interview study between September and November 2014 with adult learners who had participated in a single-semester health literacy program that included an integrated shared decision-making component. We analyzed interviews using the Framework method; a matrix-based approach to thematic analysis. A hybrid process of inductive and deductive coding was used to interpret raw data. KEY RESULTS: Interviewees were 22 students from six health literacy classes and ranged in age from 18 to 74 years (mean, 48.3). The majority were women (n = 15) and born outside Australia (n = 13). Health literacy was generally limited according to the Newest Vital Sign screening tool (n = 17). The health literacy program appeared to serve two key functions. First, it stimulated awareness that patients have the right to participate in decision-making concerning their treatment and care. Second, it facilitated verbal skill development across the domains of functional (e.g., communicating symptoms), communicative (e.g., asking questions to extract information about treatment options), and critical (e.g., integrating new knowledge with preferences) health literacy. CONCLUSIONS: Our findings support the conceptualization of health literacy as a modifiable health asset that is subject to change and improvement as a result of deliberate intervention. Results reinforce verbal health literacy as an important component of health literacy, and draw attention to the hierarchy of verbal skills needed for consumers to become more actively involved in decisions about their health. We present a revised model of health literacy based on our findings. [Health Literacy Research and Practice. 2017;1(4):e257-e268.]. PLAIN LANGUAGE SUMMARY: We developed a health literacy program for adults with lower literacy to help learners develop skills to talk to health care providers and share health decisions. The program was taught in Australian adult education settings. The article explores the range of health literacy skills needed for communication and decision-making in this study, and presents a model in which verbal skills are an important part of health literacy.

Incorporating health literacy in education for socially disadvantaged adults: an Australian feasibility study.

BACKGROUND: Adult education institutions have been identified as potential settings to improve health literacy and address the health inequalities that stem from limited health literacy. However, few health literacy interventions have been tested in this setting. METHODS: Feasibility study for an RCT of the UK Skilled for Health Program adapted for implementation in Australian adult education settings. Implementation at two sites with mixed methods evaluation to examine feasibility, test for change in participants' health literacy and pilot test health literacy measures. RESULTS: Twenty-two socially disadvantaged adults with low literacy participated in the program and received 80-90 hours of health literacy instruction. The program received institutional support from Australia's largest provider of vocational education and training and was feasible to implement (100 % participation; >90 % completion; high teacher satisfaction). Quantitative results showed improvements in participants' health literacy skills and confidence, with no change on a generic measure of health literacy. Qualitative analysis identified positive student and teacher engagement with course content and self-reported improvements in health knowledge, attitudes, and communication with healthcare professionals. CONCLUSIONS: Positive feasibility results support a larger RCT of the health literacy program. However, there is a need to identify better, multi-dimensional measures of health literacy in order to be able to quantify change in a larger trial. This feasibility study represents the first step in providing the high quality evidence needed to understand the way in which health literacy can be improved and health inequalities reduced through Australian adult education programs.

Can adults with low literacy understand shared decision making questions? A qualitative investigation.

OBJECTIVE: Participation in shared decision-making (SDM) may be difficult for adults with lower literacy. Tools to support consumers to engage in SDM are rarely designed for or evaluated with adults with lower literacy and/or poor English language. METHODS: Qualitative interviews were conducted with 26 adults with lower literacy and/or poor English language skills to investigate (a) whether participants where able to read and understand two generic SDM consumer support tools (Smart Health Choices and AskShareKnow question-sets), (b) which question-set was easier for participants and, (c) perceived usefulness of the question-sets and barriers to use. Interviews were analysed using Framework Analysis. RESULTS: Participants had difficulties understanding terms embedded within both the AskShareKnow and Smart Health Choices questions. Our findings suggest that the AskShareKnow question-set was easier for our participants than the Smart Health Choices questions, and clarification using a structured response was reasonably effective. While participants appreciated the usefulness of the questions, they identified important barriers to use. CONCLUSIONS: Generic question-sets alone are not sufficient to support SDM for adults with lower literacy and/or poor English-language skills. PRACTICE IMPLICATIONS: To ensure that SDM is accessible to all, we must consider how best to support adults with low literacy and/or poor English-language skills to participate in this process.

Evaluation of an Australian health literacy training program for socially disadvantaged adults attending basic education classes: study protocol for a cluster randomised controlled trial.

BACKGROUND: People with low literacy and low health literacy have poorer health outcomes. Literacy and health literacy are distinct but overlapping constructs that impact wellbeing. Interventions that target both could improve health outcomes. METHODS/DESIGN: This is a cluster randomised controlled trial with a qualitative component. Participants are 300 adults enrolled in basic language, literacy and numeracy programs at adult education colleges across New South Wales, Australia. Each adult education institute (regional administrative centre) contributes (at least) two classes matched for student demographics, which may be at the same or different campuses. Classes (clusters) are randomly allocated to receive either the health literacy intervention (an 18-week program with health knowledge and skills embedded in language, literacy, and numeracy training (LLN)), or the standard Language Literacy and Numeracy (LLN) program (usual LLN classes, specifically excluding health content). The primary outcome is functional health literacy skills - knowing how to use a thermometer, and read and interpret food and medicine labels. The secondary outcomes are self-reported confidence, more advanced health literacy skills; shared decision making skills, patient activation, health knowledge and self-reported health behaviour. Data is collected at baseline, and immediately and 6 months post intervention. A sample of participating teachers, students, and community health workers will be interviewed in-depth about their experiences with the program to better understand implementation issues and to strengthen the potential for scaling up the program. DISCUSSION: Outcomes will provide evidence regarding real-world implementation of a health literacy training program with health worker involvement in an Australian adult education setting. The evaluation trial will provide insight into translating and scaling up health literacy education for vulnerable populations with low literacy. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12616000213448 .

Development and field testing of a consumer shared decision-making training program for adults with low literacy.

OBJECTIVE: Given the scarcity of shared decision-making (SDM) interventions for adults with low literacy, we created a SDM training program tailored to this population to be delivered in adult education settings. METHODS: Formative evaluation during program development included a review of the problem and previous efforts to address it, qualitative interviews with the target population, program planning and field testing. RESULTS: A comprehensive SDM training program was developed incorporating core SDM elements. The program aimed to improve students' understanding of SDM and to provide them with the necessary skills (understanding probabilistic risks and benefits, personal values and preferences) and self-efficacy to use an existing set of questions (the AskShareKnow questions) as a means to engage in SDM during healthcare interactions. CONCLUSIONS: There is an ethical imperative to develop SDM interventions for adults with lower literacy. Generic training programs delivered direct-to-consumers in adult education settings offer promise in a national and international environment where too few initiatives exist. PRACTICE IMPLICATIONS: Formative evaluation of the program offers practical insights into developing consumer-focused SDM training. The content of the program can be used as a guide for future efforts to engage consumers in SDM.

Improving clinician-carer communication for safer hospital care: a study of the 'TOP 5' strategy in patients with dementia.

OBJECTIVE: To examine the impact of implementing a clinician-carer communication tool for hospitalized patients with dementia. DESIGN: Surveys were conducted with clinicians and carers about perceptions and experiences. Implementation process and costs were explored through surveys of local staff. Time series analysis was conducted on incident-reported falls, usage of non-regular anti-psychotics and one-to-one nursing. SETTING: Twenty-one hospitals in Australia. PARTICIPANTS: Surveys were returned by 798 clinicians, 240 carers and 21 local liaison staff involved in implementation. INTERVENTION: Implementation of a communication tool over 12 months. MAIN OUTCOME MEASURES: The process of implementation was documented. Outcome measures included clinician and carer perceptions, safety indicators (incident-reported falls and usage of non-regular anti-psychotics), resource use and costs. RESULTS: Clinicians and carers reported high levels of acceptability and perceived benefits for patients. Clinicians rated confidence in caring for patients with dementia as being significantly higher after the introduction of TOP 5, (M = 2.93, SD = 0.65), than prior to TOP 5 (M = 2.74, SD = 0.75); F(1,712) = 11.21, P < 0.05. When analysed together, there was no change in incident-reported falls across all hospitals. At one hospital with a matched control ward, an average of 6.85 fewer falls incidents per month occurred in the intervention ward compared with the matched control ward (B = -6.85, P < 0.05). CONCLUSIONS: Our findings indicate that the use of a simple, low-cost communication strategy for patient care is associated with improvements in clinician and carer experience with potential implications for patient safety. Minimally, TOP 5 represents 'good practice' with a low risk of harm for patients.

Healthcare system performance improvement: a comparison of key policies in seven high-income countries.

PURPOSE: Evidence suggests that healthcare system performance may be improved with policy emphasis on primary care, quality improvement, and information technology. The authors therefore sought to investigate the extent to which policy makers in seven countries are emphasizing these areas. DESIGN/METHODOLOGY/APPROACH: Policies in these three areas in seven high-income countries were compared. A comparative descriptive approach was taken in which each of the country-specialist authors supplied information on key policies and developments pertaining to primary care, quality improvement and information technology, supplemented with routine data. FINDINGS: Each of the seven countries faces similar challenges with healthcare system performance, yet differs in emphasis on the three key policy areas; efforts in each are, at best, patchy. The authors conclude that there is substantial scope for policy makers to further emphasize primary care, quality improvement and information technology if aiming for high-performing healthcare systems. ORIGINALITY/VALUE: This is the first study to investigate policy-makers' commitment to key areas known to improve health system performance. The comparative method illustrates the different emphases that countries have placed on primary care, quality improvement and information technology development.

The World Health Report 2008 - Primary Healthcare: How Wide Is the Gap between Its Agenda and Implementation in 12 High-Income Health Systems?

BACKGROUND: The World Health Organization's 2008 report asserted that the focus on primary healthcare (PHC) within health systems should increase, with four sets of reforms required. The WHO's PHC advocacy is well founded, yet its report is a policy document that fails to address adoption and implementation questions within WHO member countries. This paper examines the prospects for the WHO PHC agenda in 12 high-income health systems from Asia, Australasia, Europe and North America, comparing performances against the WHO agenda. METHODS: A health policy specialist on each of the 12 systems sketched policy activities in each of the four areas of concern to the WHO: (a) whether there is universal coverage, (b) service delivery reforms to build a PHC-oriented system, (c) reforms integrating public health initiatives into PHC settings and (d) leadership promoting dialogue among stakeholders. FINDINGS: All 12 systems demonstrate considerable gaps between the actual status of PHC and the WHO vision when assessed in terms of the four WHO reform dimensions, although many initiatives to enhance PHC have been implemented. Institutional arrangements pose significant barriers to PHC reform as envisioned by the WHO. CONCLUSIONS: PHC reform requires more attention from policy makers. Meanwhile, the WHO PHC report is perhaps too idealistic and fails to address the fundamentals for successful policy adoption and implementation within member countries.

CONTEXTE : Le rapport 2008 de l'Organisation mondiale de la Santé affirme qu'il faut mettre plus d'accent sur les soins de santé primaires (SSP) dans les systèmes de santé, au moyen de quatre séries de réformes. Cette position de l'OMS est bien fondée, cependant le rapport est un document de politiques qui n'aborde pas les questions d'adoption et de mise en œuvre dans les pays membres de l'OMS. Cet article étudie le potentiel du programme de l'OMS sur les SSP dans 12 systèmes de santé à revenu élevé en Asie, en Australasie, en Europe et en Amérique du Nord, en y comparant le rendement en fonction du programme de l'OMS. MÉTHODE : Pour chacun des 12 systèmes de santé, un spécialiste des politiques de santé a brossé le tableau des activités politiques liées aux champs d'intérêt de l'OMS : (a) présence ou non d'une couverture universelle, (b) réformes des prestations de services pour créer un système axé sur les SSP, (c) réformes qui intègrent les mesures de santé publique au sein des établissements de SSP et (d) leadership qui favorise le dialogue au sein des intervenants. RÉSULTATS : Après évaluation en fonction des quatre volets de réforme proposés par l'OMS, chacun des 12 systèmes présente des écarts considérables entre le statut réel des SSP et la vision de l'OMS, bien que plusieurs initiatives d'accroissement des SSP y aient été mises en place. Les arrangements institutionnels constituent des obstacles considérables pour la réforme des SSP telle qu'envisagée par l'OMS. CONCLUSIONS : La réforme des SSP nécessite plus d'attention de la part des responsables de politiques. Par ailleurs, le rapport de l'OMS sur les SSP est peut-être trop idéaliste et ne permet pas d'aborder les aspects fondamentaux qui visent une pleine adoption et la mise en œuvre des politiques dans les pays membres.

Reducing time to diagnosis does not improve outcomes for women with symptomatic ovarian cancer: a report from the Australian Ovarian Cancer Study Group.

PURPOSE: To determine if time to diagnosis is associated with stage of disease at diagnosis or survival among women with symptomatic ovarian cancer. METHODS: A representative sample of Australian women (n = 1,463) with ovarian cancer diagnosed between 2002 and 2005 who participated in a population-based case-control study were interviewed regarding the events leading to their diagnosis and were observed for mortality for 5 years. RESULTS: Of the 1,318 women (90%) who presented to a medical practitioner with symptoms, 55% presented within 1 month, 70% in less than 2 months, and 92% within 6 months of symptom onset. There were no significant differences in the time from symptom onset to first medical practitioner consultation (P = .19) or symptom onset to diagnosis (P = .64) among women with borderline, early (International Federation of Gynecology and Obstetrics [FIGO] stages I to II) or late (FIGO stages III to IV) disease. There was also no association between time to diagnosis and survival; adjusted hazard ratio for long delay (> 12 months from symptom onset to diagnosis) versus short delay (≤ 1 month) was 0.94 (95% CI, 0.68 to 1.30). Women who had asymptomatic cancers diagnosed incidentally (n = 145) were younger and were more likely to have borderline or stage I disease compared with women who had symptomatic ovarian cancer. CONCLUSION: The results of this study suggest that, once ovarian cancer is symptomatic, reducing the time to diagnosis would not greatly alter stage of disease at diagnosis or survival.

Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience.

OBJECTIVE: To investigate organizational facilitators and barriers to patient-centered care in US health care institutions renowned for improving the patient care experience. DESIGN: A qualitative study involving interviews of senior staff and patient representatives. Semi-structured interviews focused on organizational processes, senior leadership, work environment, measurement and feedback mechanisms, patient engagement and information technology and access. SETTING: Eight health care organizations across the USA with a reputation for successfully promoting patient-centered care. PARTICIPANTS: Forty individuals, including chief executives, quality directors, chief medical officers, administrative directors and patient committee representatives. RESULTS: Interviewees reported that several organizational attributes and processes are key facilitators for making care more patient-centered: (i) strong, committed senior leadership, (ii) clear communication of strategic vision, (iii) active engagement of patient and families throughout the institution, (iv) sustained focus on staff satisfaction, (v) active measurement and feedback reporting of patient experiences, (vi) adequate resourcing of care delivery redesign, (vii) staff capacity building, (viii) accountability and incentives and (ix) a culture strongly supportive of change and learning. Interviewees reported that changing the organizational culture from a 'provider-focus' to a 'patient-focus' and the length of time it took to transition toward such a focus were the principal barriers against transforming delivery for patient-centered care. CONCLUSIONS: Organizations that have succeeded in fostering patient-centered care have gone beyond mainstream frameworks for quality improvement based on clinical measurement and audit and have adopted a strategic organizational approach to patient focus.

Multidisciplinary cancer care in Australia: a national audit highlights gaps in care and medico-legal risk for clinicians.

AIM: Multidisciplinary care (MDC) is accepted as best practice in cancer treatment planning and care. Despite recognition of the importance of a team approach, limited data are available about the extent to which MDC has been implemented in Australia. The aim of the audit was to investigate the implementation of MDC for five main cancer types across Australia in line with best practice. METHODS: A sample of 155 hospitals was surveyed to investigate the status of MDC for cancer treatment planning in Australia across five cancer types (breast, gynecological, lung, prostate and colorectal). The survey investigated team structure, meetings, patient consent, documentation of team recommendations and communication with the patient. RESULTS: Two-thirds of hospitals surveyed did not have a multidisciplinary team. Of those with such a team; in one-third patients were not informed their case would be discussed by the team, in half patient consent was not sought for all cases discussed by the team, in one-quarter the team's recommended treatment plan was not noted in the patient record. Less than 1% of teams reported routine attendance by the tumour-specific minimum core team. CONCLUSION: MDC is not being implemented in line with best practice or applied consistently across Australia. This audit has highlighted gaps in care delivery, despite national recommendations about MDC. Areas being neglected can affect the quality of care provided and may put clinicians at medico-legal risk. Recommendations to improve uptake and effectiveness of MDC are provided.