Social Community Teams' Creation of Service Integration Through Boundary Work and Play with Their Stakeholders.

In many European countries, responsibilities for social care have been shifted to municipalities to enhance accessibility and stimulate integration of care and social services, and to cut costs. Multidisciplinary local Social Community Teams (SCTs) have become increasingly responsible for the provision of these integrated services, requiring them to collaborate with local health and societal organisations. To collaborate and to integrate services the SCTs must work across their own and stakeholders' boundaries (e.g., domain specific boundaries). We investigated how boundary work in SCTs' practices contributes to service integration in a dynamic multi-stakeholder context. In our embedded case study, for 18 months, we followed three SCTs in their efforts to integrate services, and used data from multiple sources, including bi-weekly questionnaires in which SCT members reflect on their stakeholder-directed goal achievements. The case analysis yielded four takeaways. First, it demonstrates how SCTs' bottom-up formulation of a long-term service integration vision brought internal coherence (boundary reinforcement), while the short-term action-goals increased collaboration with stakeholders (boundary spanning). Second, only SCTs that managed to incorporate constraints into their action-goals and practices, and to span and play with boundaries, continued with integrating services just-by-doing. Third, two stakeholder characteristics facilitated the SCTs' boundary spanning: well-organized stakeholders and prior familiarity with the stakeholder. Fourth, a new boundary work type emerged, "boundary play", consisting of informal, experimental collaboration efforts with stakeholders contributing to emergent service integration.

Segmenting citizens according to their self-sufficiency: A tool for local government.

Identifying subgroups of citizens with varying levels of self-sufficiency in a large local or regional population provides local government with essential input for providing matching services and well-grounded spending of health and well-being expenditures. This paper identifies self-sufficiency levels of citizens by segmenting a broad adult population. We used data from a citizen survey based on a randomly selected response group containing questions on a wide range of topics, including finances, health and living conditions, and complemented these data with registration data, including information on housing type and household composition. We conducted a latent class cluster analysis using six indicators: perception of making ends meet, perceived health, quality of life, self-efficacy, access to socialsupport and social network. High scores on the indicators translate to high levels of self-sufficiency. We used a biased-adjusted, three-step approach to characterise the segments. Six meaningful segments were identified and labelled as 'highly self-sufficient,' 'self-sufficient - medium access to social support,' 'self-sufficient - medium self-efficacy,' 'moderately self-sufficient - low self-efficacy & high social network,' 'moderately self-sufficient - low access to social support/social network & high perceived health' and 'not self-sufficient.' At a macro level, perception of making ends meet and quality of life have discriminating value in assessing self-sufficiency. For a more detailed differentiation between groups with similar levels of self-sufficiency, perceived health, self-efficacy, access to socialsupport, and social network are valuable indicators. Overall, this study introduces a comprehensive tool to assess self-sufficiency in larger groups of citizens by using a parsimonious number of indicators. Local and regional governments can apply this tool to effectively assess the self-sufficiency levels of their population and signal potentially vulnerable groups. In this way, the tool makes the identification of self-sufficiency levels of larger populations more feasible and more efficient and can be widely adopted in different contexts.

The impact of interventions in the built environment on physical activity levels: a systematic umbrella review.

Physical activity is good for people's health. The relationship between the built environment and physical activity has been well documented. However, evidence is both scarce and scattered on specific urban interventions, i.e., intentional redesigns of the built environment that promote physical activity accompanied by pre- and post-effect measurement. This umbrella review aims to synthesize the findings of systematic reviews focused on these urban interventions. We followed the PRISMA 2020 and JBI umbrella review protocol guidelines and searched seven databases covering the period between Jan 2010 and April 2022 using keywords relating to the built environment, health, physical activity, and interventions. This yielded seven systematic reviews, in which we identified several urban interventions that can promote physical activity. We found positive effects of urban interventions on physical activity regarding park renovations, adding exercise equipment, introducing a (new) pocket park, improving cycling environments, improving walking & cycling environments, as well as multi-component initiatives for active travel and enhancing the availability & accessibility of destinations. The findings suggest that the urban environment can effectively promote physical activity, especially by adding various facilities and destinations and by making the environment better suitable for active use.

Health Self-Management Applications in the Work Environment: The Effects on Employee Autonomy.

Organizations increasingly use Health Self-Management Applications (HSMAs) that provide feedback information on health-related behaviors to their employees so that they can self-regulate a healthy lifestyle. Building upon Self-Determination Theory, this paper empirically investigates the basic assumption of HSMAs that their self-management feature provides employees with autonomy to self-regulate their health-related behavior. The two-phase experimental study contained a 4-weeks HSMA intervention in a healthcare work environment with a feedback factor (performance vs. developmental) and pretest and posttest measurements of participants' perceived autonomy. Following the experiment, interviews were conducted with users to gain an in-depth understanding of the moderating roles of feedback and BMI (a proxy for health) in the effects of HSMA on perceived autonomy. Findings reveal that the use of an HSMA does not significantly increase perceived autonomy, and may even reduce it under certain conditions. Providing additional developmental feedback generated more positive results than performance feedback alone. Employees with higher BMI perceived a greater loss of autonomy than employees with lower BMI. The reason for this is that higher-BMI employees felt external norms and standards for healthy behavior as more salient and experienced more negative emotions when those norms are not met, thereby making them more aware of their limitations in the pursuit of health goals.

Triggers of defensive medical behaviours: a cross-sectional study among physicians in the Netherlands.

OBJECTIVES: This study investigated whether the attitudes of physicians towards justified and unjustified litigation, and their perception of patient pressure in demanding care, influence their use of defensive medical behaviours. DESIGN: Cross-sectional survey using exploratory factor analysis was conducted to determine litigation attitude and perceived patient pressure factors. Regression analyses were used to regress these factors on to the ordering of extra tests or procedures (defensive assurance behaviour) or the avoidance of high-risk patients or procedures (defensive avoidance behaviour). SETTING: Data were collected from eight Dutch hospitals. PARTICIPANTS: Respondents were 160 physicians and 54 residents (response rate 25%) of the hospital departments of (1) anaesthesiology, (2) colon, stomach and liver diseases, (3) gynaecology, (4) internal medicine, (5) neurology and (6) surgery. PRIMARY OUTCOME MEASURES: Respondents' application of defensive assurance and avoidance behaviours. RESULTS: 'Disapproval of justified litigation' and 'Concerns about unjustified litigation' were positively related to both assurance (ß=0.21, p<0.01, and ß=0.28, p<0.001, respectively) and avoidance (ß=0.16, p<0.05, and ß=0.18, p<0.05, respectively) behaviours. 'Self-blame for justified litigation' was not significantly related to both defensive behaviours. Perceived patient pressures to refer (ß=0.18, p<0.05) and to prescribe medicine (ß=0.23, p<0.01) had direct positive relationships with assurance behaviour, whereas perceived patient pressure to prescribe medicine was also positively related to avoidance behaviour (ß=0.14, p<0.05). No difference was found between physicians and residents in their defensive medical behaviour. CONCLUSIONS: Physicians adopted more defensive medical behaviours if they had stronger thoughts and emotions towards (un)justified litigation. Further, physicians should be aware that perceived patient pressure for care can lead to them adopting defensive behaviours that negatively affects the quality and safety of patient care.

Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review.

BACKGROUND: The decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital's emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest. OBJECTIVE: To provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions. DATA SOURCES: A mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included. STUDY ELIGIBILITY CRITERIA: Only studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included. SETTING: Prehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance. STUDY APPRAISAL AND SYNTHESIS METHODS: The Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a 'best fit' framework synthesis approach. RESULTS: ED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male-female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision's outcomes. CONCLUSION: Many non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.

Explaining the unexplainable - the impact of physicians' attitude towards litigation on their incident disclosure behaviour.

RATIONALE, AIMS AND OBJECTIVES: This study aims to provide in-depth insight into the emotions and thoughts of physicians towards malpractice litigation, and how these relate to their incident disclosure behaviour. METHODS: Thirty-one Dutch physicians were interviewed and completed short questionnaires regarding malpractice litigation. We used hierarchical cluster analysis to identify physician clusters. Additional qualitative data were analysed. RESULTS: Physicians vary largely in their attitude towards malpractice litigation, and their attitude is not straightforward related to their disclosure behaviour. Based on their responses physicians could be divided into two clusters: one with a positive and one with a negative attitude. Physicians with a negative attitude showed often, but also 6 out of 15 not, a reluctance to disclose, whereas the majority in the positive attitude cluster (12 out of 16) showed no reluctance. If, what and how physicians disclose incidents depends on a complex interplay of their emotions and thoughts regarding litigation, and not only on their fear of litigation as many studies assume. CONCLUSIONS: Due to the variation among physicians in their litigation attitude and behaviour in terms of incident disclosure the oft-heard call for 'openness' about medical incidents will not be easy to achieve. A coaching system in which physicians can share and discuss their differing attitudes and disclosure principles, teaching medical students and junior physicians about disclosure, and explaining how to organize emotional and legal support for oneself in case of litigation could decrease stress feelings and support open disclosure behaviour.

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety.

BACKGROUND: Practicing safe behavior regarding patients is an intrinsic part of a physician's ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians' risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians' behaviors. METHODS: We carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach. RESULTS: We identified four factors that could affect the relationship between malpractice litigation risk and physicians' behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals' response to physicians following incidents. CONCLUSION: In complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

How teams use indicators for quality improvement - a multiple-case study on the use of multiple indicators in multidisciplinary breast cancer teams.

A crucial issue in healthcare is how multidisciplinary teams can use indicators for quality improvement. Such teams have increasingly become the core component in both care delivery and in many quality improvement methods. This study aims to investigate the relationships between (1) team factors and the way multidisciplinary teams use indicators for quality improvement, and (2) both team and process factors and the intended results. An in-depth, multiple-case study was conducted in the Netherlands in 2008 involving four breast cancer teams using six structure, process and outcome indicators. The results indicated that the process of using indicators involves several stages and activities. Two teams applied a more intensive, active and interactive approach as they passed through these stages. These teams were perceived to have achieved good results through indicator use compared to the other two teams who applied a simple control approach. All teams experienced some difficulty in integrating the new formal control structure, i.e. measuring and managing performance, in their operational task, and in using their 'new' managerial task to decide as a team what and how to improve. Our findings indicate the presence of a network of relationships between team factors, the controllability and actionability of indicators, the indicator-use process, and the intended results.

Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions.

BACKGROUND: The main objective of this research is to identify, categorize, and analyze barriers perceived by physicians to the adoption of Electronic Medical Records (EMRs) in order to provide implementers with beneficial intervention options. METHODS: A systematic literature review, based on research papers from 1998 to 2009, concerning barriers to the acceptance of EMRs by physicians was conducted. Four databases, "Science", "EBSCO", "PubMed" and "The Cochrane Library", were used in the literature search. Studies were included in the analysis if they reported on physicians' perceived barriers to implementing and using electronic medical records. Electronic medical records are defined as computerized medical information systems that collect, store and display patient information. RESULTS: The study includes twenty-two articles that have considered barriers to EMR as perceived by physicians. Eight main categories of barriers, including a total of 31 sub-categories, were identified. These eight categories are: A) Financial, B) Technical, C) Time, D) Psychological, E) Social, F) Legal, G) Organizational, and H) Change Process. All these categories are interrelated with each other. In particular, Categories G (Organizational) and H (Change Process) seem to be mediating factors on other barriers. By adopting a change management perspective, we develop some barrier-related interventions that could overcome the identified barriers. CONCLUSIONS: Despite the positive effects of EMR usage in medical practices, the adoption rate of such systems is still low and meets resistance from physicians. This systematic review reveals that physicians may face a range of barriers when they approach EMR implementation. We conclude that the process of EMR implementation should be treated as a change project, and led by implementers or change managers, in medical practices. The quality of change management plays an important role in the success of EMR implementation. The barriers and suggested interventions highlighted in this study are intended to act as a reference for implementers of Electronic Medical Records. A careful diagnosis of the specific situation is required before relevant interventions can be determined.

Actionable indicators for short and long term outcomes in rectal cancer.

AIM OF THE STUDY: Although patient and tumour characteristics are the most important determinants for outcomes in rectal cancer care, actionable factors for improving these are still unclear. Therefore, the purpose of this study was to assess the impact of surgeon and hospital factors which can actually be influenced to improve on postoperative complications, disease-free survival (DFS) and relative survival (RS) in rectal cancer. METHODS: For 819 curatively operated rectal cancer patients, staged I-III and diagnosed between 2001 and 2005, data were derived from the population-based Cancer Registry of the Comprehensive Cancer Centre North East and supplemented by medical record examination. (Multilevel) Logistic regression analysis was performed to examine the influence of relevant factors on postoperative complications and time from diagnosis to first treatment. Besides, Cox regression analysis for DFS and relative survival analysis was performed. RESULTS: Postoperative complications were dependent on type of surgery (p=0.024) and hospital volume (p=0.029). DFS was mainly influenced by stage (p<0.001) and time to treatment (p=0.018). Actionable indicators related to RS were type of surgery (p=0.011) and time to treatment (p=0.048). Time to treatment was found to be related to co-morbidity (p=0.007), preoperative radiotherapy (p=0.003) and referral for operation (p=0.048). Nevertheless, 18.2% unexplained variation in time to treatment remained on hospital level. CONCLUSIONS: We conclude that optimal outcomes for rectal cancer care can be achieved by focusing on early detection and timely diagnosis, as well as adequate choice and timeliness of treatment in hospitals with optimal logistics for rectal cancer patients.

Consequences of participating in multidisciplinary medical team meetings for surgical, nonsurgical, and supporting specialties.

This study examines the consequences for medical specialists of participating in multidisciplinary medical team meetings in terms of perceived clinical autonomy, domain distinctiveness, and professional accountability. These consequences may influence their willingness to cooperate and the quality of teamwork. The authors hypothesized that multidisciplinary medical team meetings would be more of a threat to the professional identity of surgical specialists than to the professional identity of nonsurgical and supporting specialists. A survey among 1,827 Dutch medical specialists supported the authors' hypotheses. However, a few specific specialties had response patterns that deviated from our expectations. The results are related to specialty choice, to the training of medical specialties, and to having a role in leading team meetings.

Improving client-centred care and services: the role of front/back-office configurations.

AIM: This paper is a report of a study conducted to explore the application of designing front- and back-office work resulting in efficient client-centred care in healthcare organizations that supply home care, welfare and domestic services. BACKGROUND: Front/back-office configurations reflect a neglected domain of design decisions in the development of more client-centred processes and structures without incurring major cost increases. METHOD: Based on a literature search, a framework of four front/back-office configurations was constructed. To illustrate the usefulness of this framework, a single, longitudinal case study was performed in a large organization, which provides home care, welfare and domestic services for a sustained period (2005-2006). FINDINGS: The case study illustrates how front/back-office design decisions are related to the complexity of the clients' demands and the strategic objectives of an organization. The constructed framework guides the practical development of front/back-office designs, and shows how each design contributes differently to such performance objectives as quality, speed and efficiency. CONCLUSIONS: The front/back-office configurations presented comprise an important first step in elaborating client-centred care and service provision to the operational level. It helps healthcare organizations to become more responsive and to provide efficient client-centred care and services when approaching demand in a well-tuned manner. In addition to its applicability in home care, we believe that a deliberate front/back-office configuration also has potential in other fields of health care.

How health care complexity leads to cooperation and affects the autonomy of health care professionals.

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held informal discussions and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient's problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors.

The usefulness and feasibility of a reflexivity method to improve clinical handover.

OBJECTIVE: The evaluation of the usefulness and feasibility of the reflexivity method (RM), which encourages dialogue and reflections between doctors, and enables change. METHODS: On the basis of literature research into effective medical professional learning and reflection, essential elements that stimulate reflection and learning were distinguished and converted into the basic elements of a method developed for this purpose, the RM. The method is used as a tool to stimulate reflection processes, which, in turn, will enable change. It was used 20 times in a large university medical centre in the Netherlands. Clinical handovers were the subject of reflection. The evaluation of the usefulness and feasibility of the RM is based on analysing the improvements realized by using the method, and a questionnaire to measure the experiences of the users of the method. RESULTS: Each of the 17 departments evaluated received 10 recommendations on average. Fifty-eight per cent of these were realized after 6-9 months, and 18% were in the working-out phase. Improvements in the structure, rules and protocols concerning handovers were realized as well as in the atmosphere. The users of the method evaluated the method overall positively: they appreciated the created context for reflection, that is, having a dialogue with a colleague working at the same hierarchical level, the non-normative character of the method and the 'doctor-ownership' of the method. They also reported an effect on their handling and thinking regarding handovers. CONCLUSIONS: The RM seems to be a useful and feasible method to stimulate the doctors' reflection processes, resulting in implemented improvements.

Improvement of best practice in early breast cancer: actionable surgeon and hospital factors.

To identify actionable elements for improving best practice, this study examined the relative effects of patient, surgeon and hospital factors on surgical treatment variation of 2,929 early breast cancer patients, diagnosed from January 1998 to January 2002 in the region of the Comprehensive Cancer Centre North-Netherlands. Multilevel logistic regression was used to analyze the hierarchically structured data. Apart from the patient level, 43.3% of the treatment variation was due to the hospital and 56.7% to the surgeon, after adjustment for patient characteristics. Although hospital factors like volume, teaching status, and management and policy contributed to this variation, multidisciplinary care seemed the most important actionable hospital factor. Although the surgeon was shown to be an important starting point for quality improvement, actionable elements seemed difficult to identify as factors like surgeon experience and volume were not conclusive and significant variance on this level remained (sigma2 = 0.149, SE 0.053). We conclude that multidisciplinary care can improve best practice and that further research into actionable surgeon factors is needed.