Patient Perspectives of IBD Care and Services: An Integral Part of a Pan-Canadian Quality Improvement Initiative.

BACKGROUND: As beneficiaries of health service improvement initiatives, patients should have their perspectives of and gaps in care elicited to inform and guide the development of quality indicators to assess health care services. The purpose of this study was to identify patient perspectives amenable for conversion into measurable inflammatory bowel disease (IBD) care quality indicators. METHODS: Crohn's and Colitis Canada's Promoting Access and Care through Centres of Excellence (PACE) program organized four patient focus groups in three Canadian provinces in 2016 to capture the perspective of patients on IBD care services. The RQDA package in R was used for transcript analysis, theme identification and for building a theme hierarchy based on the number of citations. The main themes were converted into patient-derived quality indicators. RESULTS: Several perceived unmet needs were elicited from participants that could be converted into measurable quality indicators. These unmet needs addressed the need for information, access to multidisciplinary services and specialized care, and access to psychological support. Patient unmet needs informed the selection of nine quality indicators that were included in the final list of PACE indicators to assess IBD care services across Canada. CONCLUSIONS: Our study provides a detailed description of patient perspectives on IBD care services that were an integral part of the development of measurable indicators of the quality of care in the context of a universal health care system.

Selection of Quality Indicators in IBD: Integrating Physician and Patient Perspectives.

Background: Variation in clinical practice exists in many aspects of inflammatory bowel disease (IBD) care. Our aim was to develop a comprehensive set of quality indicators (QIs) to be measured in view of improving the quality of IBD care provided in clinical practice. This initiative was part of a global Canadian quality initiative PACE (Promoting Access and Care through Centres of Excellence). Methods: A modified RAND appropriateness method was used to identify and rate structure, process, outcome, and patient-derived QIs of IBD care. The process included a comprehensive literature search yielding a broad list of QIs, the online selection of QIs by a core expert panel, the selection of patient-derived QIs from 4 patient focus groups, and the subsequent selection of QIs by a multidisciplinary panel, followed by a moderated in-person multidisciplinary meeting during which each indicator was rated for importance and feasibility of measurement. Predetermined cutoffs for mean score and degree of disagreement were used to select the final list of QIs. Results: Forty-five QIs, including 6 that were patient-derived, were selected. Nine structure QIs addressed aspects related to the services and specialist care offered at an IBD unit or clinic. Thirty process indicators included administrative and workflow processes, features related to IBD therapy, surveillance, vaccination, and risk management. Six outcome QIs included measures of healthcare utilization, steroid use, and patient satisfaction. Conclusions: Forty-five QIs including patient-derived indicators were selected through an iterative process. These indicators can be used to measure and improve the quality of care provided to IBD patients. 10.1093/ibd/izy259_video1izy259.video15828250213001.

Interprofessional collaboration and family member involvement in intensive care units: emerging themes from a multi-sited ethnography.

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature.

Use of natural health products: how does being "natural" affect choice?

INTRODUCTION: Little is currently known about how and why consumers choose to use natural health products (NHPs), such as herbs and vitamins. OBJECTIVE: The objective of this study was to explore how the product attributes of NHPs and conventional pharmaceutical sleep aids are linked to consequences and values in consumers' decision making. METHODS: During the spring and summer of 2007, 60- to 90-minute semistructured, laddering interviews based on the means-ends chain approach were conducted with 25 participants experiencing sleep problems in Toronto, Canada, who were selected to have a range of demographic characteristics. RESULTS: Participants varied considerably in the complexity of their decision processes, as between 3 and 14 attribute-consequence-value associations were elicited per interview. The factors found to be most important in determining the type of sleep aid chosen by consumers were whether the product was natural or chemical, whether it was perceived to work or have side effects, and participants' perceptions of the impact of product use on their relationships and, subsequently, on their quality of life. Participants described making different tradeoffs between product attributes (e.g., naturalness) and perceived consequences (e.g., efficacy and side effects) depending on the situational context and indicated that these tradeoffs were done in an effort to maximize values such as overall quality of life. CONCLUSIONS: The naturalness and associated perceived lack of side effects of a product were more important than perceived efficacy for consumers selecting sleep aids for regular use. Only in special cases where efficacy was deemed essential (e.g., prior to important life or work events) did efficacy become a more important factor in the decision-making process.

Understanding the role of scientific evidence in consumer evaluation of natural health products for osteoarthritis an application of the means end chain approach.

BACKGROUND: Over 30% of individuals use natural health products (NHPs) for osteoarthritis-related pain. The Deficit Model for the Public Understanding of Science suggests that if individuals are given more information (especially about scientific evidence) they will make better health-related decisions. In contrast, the Contextual Model argues that scientific evidence is one of many factors that explain how consumers make health-related decisions. The primary objective was to investigate how the level of scientific evidence supporting the efficacy of NHPs impacts consumer decision-making in the self-selection of NHPs by individuals with osteoarthritis. METHODS: The means-end chain approach to product evaluation was used to compare laddering interviews with two groups of community-dwelling Canadian seniors who had used NHPs to treat their osteoarthritis. Group 1 (n=13) had used only NHPs (glucosamine and/or chondroitin) with "high" scientific evidence of efficacy. Group 2 (n=12) had used NHPs (methylsulfonylmethane (MSM) and/or bromelain) with little or no scientific evidence supporting efficacy. Content analysis and generation of hierarchical value maps facilitated the identification of similarities and differences between the two groups. RESULTS: The dominant decision-making chains for participants in the two scientific evidence categories were similar. Scientific evidence was an important decision-making factor but not as important as the advice from health care providers, friends and family. Most participants learned about scientific evidence via indirect sources from health care providers and the media. CONCLUSIONS: The Contextual Model of the public understanding of science helps to explain why our participants believed scientific evidence is not the most important factor in their decision to use NHPs to help manage their osteoarthritis.

Unpacking the relationship between operational efficiency and quality of care in Ontario long-term care homes.

In this multiple-case study, we engaged directors of care of Ontario long-term care (LTC) homes in semi-structured interviews designed to increase our understanding of the influence exerted by organizational and extra-organizational factors on two key aspects of organizational performance: operational efficiency and quality of care. We also examined the influence of these factors on the relationship between efficiency and quality. Through a review of the health services and organization and management literatures, four broad factors identified a priori as influential for one or both performance outcomes were used to guide our data collection: staff characteristics, facility characteristics, extra-organizational influences, and the function of volunteers. Our findings suggest that while both high efficiency and high quality of care are achievable, there are aspects of a home's operations and realities associated with the LTC sector in Ontario that can make achieving both, simultaneously, exceedingly challenging.

Integrative medicine: a tale of two clinics.

BACKGROUND: Integrative medicine (blending the best of complementary and alternative medicine (CAM) with conventional medicine) is becoming increasingly popular. OBJECTIVES: The objectives of this paper are to compare and contrast the development of two teams that set out to establish integrative medical clinics, highlighting key issues found to be common to both settings, and to identify factors that appear to be necessary for integration to occur. METHODS: At St Michael's Hospital (an inner-city teaching hospital in Toronto, Canada), a total of 42 interviews were conducted between February 2004 and August 2006 wi18 key participants (4 administrators, 2 chiropractors, 2 physiotherapists and 10 family physicians). At the CARE (Complementary and Alternative Research and Education) Program at Stollery Children's Hospital, Edmonton, Canada, 44 interviews were conducted with 24 people on four occasions: June 2004, March 2005, November 2006, and June 2007. Basic content analysis was used to identify the key themes from the transcribed interviews. RESULTS: Despite the contextual differences between the two programs, a striking number of similar themes emerged from the data. The five most important shared themes were: 1) the necessity of "champions" and institutional facilitators to conceive of, advocate for, and bring the programs to fruition; 2) the credibility of these champions and facilitators (and the credibility of the program being established) was key to the acceptance and growth of the program in each setting; 3) the ability to find the "right" practitioners and staff to establish the integrative team was crucial to each program's ultimate success; 4) the importance of trust (both the trustworthiness of the developing program as well as the trust that developed between the practitioners in the integrative team); and 5) the challenge of finding physical space to house the programs. CONCLUSION: The programs were ultimately successful because of the credibility of the champions, institutional facilitators and the staff members. Selection of excellent clinicians who were able to work well as a team facilitated the establishment of trust both within the team itself as well as between the team and the host institution.

The professionalization of Western herbalists: response to new product regulations in Canada.

New Canadian Natural Health Products regulations (NHP regulations) came into law January 1st, 2004 and will be implemented over 6 years. These regulations have the potential to impact a variety of stakeholders, in particular complementary and alternative medicine (CAM) practitioners. In this article, we document Canadian Western herbalist leaders' responses to the new regulations, so as to provide insight into how new healthcare policy serves as a stimulus for the organization of an emerging healthcare profession. The data are derived from key informant interviews with Western herbalist leaders in Canada (n=9). The NHP regulations include "good manufacturing practices" and Western herbalist leaders are concerned that many small companies, often owned and run by Western herbalists, will find the regulations too costly to implement, causing them to reduce the number and diversity of products they manufacture, or go out of business all together. Furthermore, lack of availability of whole plant products could severely restrict the practice of Canadian Western herbalists. In response to this challenge, herbalists are attempting to (i) organize as a more cohesive group, (ii) define their unique body of knowledge and (iii) increase the perceived legitimacy of their practices in the eyes of the public, conventional healthcare practitioners, and regulators, in an attempt to protect their unique practices. An examination of the findings reveals the extent to which external factors (i.e., the new NHP regulations) both provoke and shape the professionalization of this group of healthcare practitioners.

Natural health product labels: is more information always better?

OBJECTIVE: To explore how the information provided on labels as mandated by the new Canadian natural health product (NHP) regulations impacts consumers' perceptions of risks associated with using NHPs. METHODS: Six focus groups were conducted in three locations across Ontario. Consumers were asked to react to two labels for a fictitious product called Saturnflower that represented the "old" standards (label 1) and the new standards (label 2). Groups were audio-taped and transcribed verbatim. Qualitative content analysis was used to identify key themes. RESULTS: The 38 participants criticized label 1 for lacking information about the uses of the product and discussed their frustration at trying to obtain good quality information about NHPs. The lack of risk information on label 1 reinforced their perceptions of NHPs as natural, mild and safe. The majority of participants found label 2 much more informative, but a few were unsettled by the extent of the risk information, questioning if it was necessary. CONCLUSION: The label requirements of the new NHP regulations were generally viewed positively by the consumers who participated in this study. PRACTICE IMPLICATIONS: The additional risk information may generate more NHP-related questions for health care practitioners especially with respect to possible interactions between NHPs and conventional medicines.

The Canadian Natural Health Products (NHP) regulations: industry compliance motivations.

This qualitative study explores corporations' motivations to comply with new natural health products (NHP) Regulations in Canada. Interviews were conducted with representatives from 20 Canadian NHP companies. Findings show that the rationale for compliance differs for large compared to small and medium-sized enterprises (SMEs). Large firms are motivated to comply with the regulations because of the deterrent fear of negative media coverage, social motivations, ability to comply and maintaining a competitive market advantage. In contrast, SMEs are motivated to comply due to the deterrent fear of legal prosecution and a sense of duty.

The Canadian Natural Health Products (NHP) regulations: industry perceptions and compliance factors.

BACKGROUND: The use of natural health products, such as vitamins, minerals, and herbs, by Canadians has been increasing with time. As a result of consumer concern about the quality of these products, the Canadian Department of Health created the Natural Health Products (NHP) Regulations. The new Canadian regulations raise questions about whether and how the NHP industry will be able to comply and what impact they will have on market structure. The objectives of this study were to explore who in the interview sample is complying with Canada's new NHP Regulations (i.e., submitted product licensing applications on time); and explore the factors that affect regulatory compliance. METHODS: Twenty key informant interviews were conducted with employees of the NHP industry. The structured interviews focused on the level of satisfaction with the Regulations and perceptions of compliance and non-compliance. Interviews were tape recorded and then transcribed verbatim. Data were independently coded, using qualitative content analysis. Team meetings were held after every three to four interviews to discuss emerging themes. RESULTS: The major finding of this study is that most (17 out of 20) companies interviewed were beginning to comply with the new regulatory regime. The factors that contribute to likelihood of regulatory compliance were: perceptions and knowledge of the regulations and business size. CONCLUSION: The Canadian case can be instructive for other countries seeking to implement regulatory standards for natural health products. An unintended consequence of the Canadian NHP regulations may be the exit of smaller firms, leading to industry consolidation.

New Canadian natural health product regulations: a qualitative study of how CAM practitioners perceive they will be impacted.

BACKGROUND: New Canadian policy to regulate natural health products (NHPs), such as herbs and vitamins were implemented on January 1st, 2004. We explored complementary and alternative medicine (CAM) practitioners' perceptions of how the new regulations may affect their practices and relationships with patients/consumers. METHODS: This was an applied ethnographic study. Data were collected in fall 2004 via qualitative interviews with 37 Canadian leaders of four CAM groups that use natural products as a core part of their practises: naturopathic medicine, traditional Chinese medicine (TCM), homeopathic medicine and Western herbalism. All interviews were transcribed verbatim and coded independently by a minimum of two investigators using content analysis. RESULTS: Three key findings emerged from the data: 1) all CAM leaders were concerned with issues of their own access to NHPs; 2) all the CAM leaders, except for the homeopathic leaders, specifically indicated a desire to have a restricted schedule of NHPs; and 3) only naturopathic leaders were concerned the NHP regulations could potentially endanger patients if they self-medicate incorrectly. CONCLUSION: Naturopaths, TCM practitioners, homeopaths, and Western herbalists were all concerned about how the new NHP regulations will affect their access to the products they need to practice effectively. Additional research will need to focus on what impacts actually occur as the regulations are implemented more fully.

Before the white coat: perceptions of professional lapses in the pre-clerkship.

BACKGROUND: It has been shown that the professional development of clinical clerks is influenced by their experiences of unprofessional behaviour, but the perceptions of pre-clerkship students have received relatively little attention. Our purpose was to develop a greater contextual understanding of the situations in which pre-clerkship students encounter professional challenges, and to investigate what pre-clerkship students consider to be professional lapses in these situations. METHODS: We conducted 4 focus groups (n = 22 students); transcripts were analysed by 3 researchers using grounded theory. RESULTS: Pre-clerkship students reported lapses in the areas of communicative violation, role resistance, objectification, accountability and harm, validating our previous clerkship-based framework. However, they also reported numerous lapses committed by fellow students and many instances of lack of accountability to students, which were not reported by clerks. Many of their reports involved non-health care professionals. CONCLUSIONS: The willingness of pre-clerkship students to report on fellow students was associated with a tendency to blame their colleagues, at the expense of a more reflective analysis, and their views on professionalism appeared to be generic rather than medicine-specific. We should reinforce students' appreciation of these generic values and add on medicine-specific values as the students progress, in order to better cultivate professionalism without entitlement.