RESUMO
BACKGROUND: Role clarification is consistently documented as a challenging process for inter professional healthcare teams, despite being a core tenet of interprofessional collaboration. This paper explores the role clarification process in two previously unexplored contexts: i) in the dissemination phase of a quality improvement (QI) program, and ii) as part of interorganizational partnerships for the care of chronic disease patients. METHODS: A secondary analysis using asynchronous purposive coding was conducted on an innovative pan-Canadian Chronic Obstructive Pulmonary Disease QI program. RESULTS: Our study reveals that the iterative structure of QI initiatives in the spread phase can offer numerous unique benefits to role clarification, with the potential challenge of time commitment. In addition, the role clarification process within interorganizational partnerships proved to be relatively well-structured, characterized by three phases: relationship conceptualization or early contact, familiarization, and finally, role division. Common strategies in the last stage included the establishment of working groups and new information-sharing networks. CONCLUSION: This article characterizes some ways in which providers and organizational partners negotiate their roles in a changing professional environment. As the movement towards integrated care continues, issues of role clarity are assuming increasing importance in healthcare contexts, and understanding role dynamics can provide valuable insight into the optimization of QI initiatives.
Assuntos
Relações Interprofissionais , Doença Pulmonar Obstrutiva Crônica/terapia , Melhoria de Qualidade/organização & administração , Canadá , Doença Crônica , Comportamento Cooperativo , Pessoal de Saúde/organização & administração , Humanos , Equipe de Assistência ao Paciente/organização & administração , Papel Profissional , Comportamento SocialRESUMO
Chronic obstructive pulmonary disease (COPD) is a leading cause of death, morbidity, and health-care spending. The Halifax, Nova Scotia-based INSPIRED COPD Outreach Program™ has proved highly beneficial for patients and the health-care system. With direct investment of <$1-million CAD, a pan-Canadian quality improvement collaborative (QIC) supported the spread of INSPIRED to 19 teams in the 10 Canadian provinces contingent upon participation in evaluation. The collaborative evaluation followed a mixed-methods summative approach relying on collated quantitative data, team documents, and surveys sent to core members of the 19 teams. Survey questions included a series of multiple-choice responses, Likert scale ratings, and open-ended questions. The qualitative evaluation entailed key informant interviews and focus groups undertaken between February and April 2016 post-collaborative. Teams reported that the year-long QIC helped bring focus to a needed, though often overlooked area of improvement, facilitating innovation spread. They report examples of new work practices as well as unanticipated cultural change (given the short QIC time frame). Most teams gained new skills in quality improvement (QI) and evidence-based medicine, showing progress in their ability to measure and implement COPD care improvements. Teams felt networking with other teams across the country toward a common solution as well as learning from a team of clinical innovators and evidence-based innovation were critical to their success. Factors affecting sustainability included local leadership support, involvement of frontline clinicians, and sharing milestones to motivate continued QI. The INSPIRED QIC enabled teams across Canada to adapt and implement a new COPD care model for high users of health-care with rapid improvements to work practices, cultural change, and skill sets, and at relatively low cost.
Assuntos
Comportamento Cooperativo , Atenção à Saúde , Doença Pulmonar Obstrutiva Crônica/terapia , Melhoria de Qualidade , Qualidade da Assistência à Saúde , Canadá , Humanos , Nova EscóciaRESUMO
The Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC) Quality Improvement Collaborative (QIC) in Eastern Canada provided an approach to spur system-level reform across multiple health systems for patients and families living with chronic disease. Developed and led by senior executives with a unique governance approach and involving clinical front-line teams, the AHC serves as a practical example of leadership creating and driving momentum for achieving success in collaborative health system improvements.
Assuntos
Doença Crônica/terapia , Comportamento Cooperativo , Liderança , Melhoria de Qualidade , Qualidade da Assistência à Saúde , Canadá , Atenção à Saúde/normas , Governo , Humanos , Aprendizagem , Equipe de Assistência ao PacienteRESUMO
BACKGROUND: A year-long pan-Canadian quality improvement collaborative (QIC) led by the Canadian Foundation for Healthcare Improvement (CFHI) supported the spread of the successful Halifax, Nova Scotia-based INSPIRED COPD Outreach Program™ to 19 teams in the 10 Canadian provinces. We describe QIC results, addressing two main questions: 1) Can the results of the Nova Scotia INSPIRED model be replicated elsewhere in Canada? 2) How did the teams implement and evaluate their versions of the INSPIRED program? METHODS: Collaborative faculty selected measures that were evidence-based, relatively simple to collect, and relevant to local context. Chosen process and outcome measures are related to four quality domains: 1) patient- and family-centeredness, 2) coordination, 3) efficiency, and 4) appropriateness. Evaluation of a complex intervention followed a mixed-methods approach. RESULTS: Most participants were nurse managers and/or COPD educators. Only 8% were physicians. Fifteen teams incorporated all core INSPIRED interventions. All teams carried out evaluation. Thirteen teams actively involved patients and families in customized, direct care planning, eg, asking them to complete evaluative surveys and/or conducting interviews. Patients consistently reported greater self-confidence in symptom management, a return to daily activities, and improvements to quality of life. Twelve teams collected data on care transitions using the validated three-item Care Transitions Measure (CTM-3). Twelve teams used the Lung Information Needs Questionnaire (LINQ). Admissions, emergency room visits, and patient-related costs fell substantially for two teams described in detail (combined enrollment 208 patients). Most teams reported gaining deeper knowledge around complexities of COPD care, optimizing patient care through action plans, self-management support, psychosocial support, advance care planning, and coordinating community partnerships. CONCLUSION: Quality-of-care gains are achievable in the short term among different teams across diverse geographical and social contexts. A well-designed, adequately funded public-private partnership can deliver widespread beneficial outcomes for the health care system and for those living with advanced COPD.
Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Doença Pulmonar Obstrutiva Crônica/terapia , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Canadá , Comportamento Cooperativo , Eficiência Organizacional , Humanos , Comunicação Interdisciplinar , Liderança , Assistência Centrada no Paciente/organização & administração , Relações Profissional-Família , Avaliação de Programas e Projetos de Saúde , Parcerias Público-Privadas/organização & administração , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Fluxo de TrabalhoRESUMO
With an aging population and a healthcare system that is overly reliant on providing expensive and sometimes problematic hospital-based care for older Canadians, driving improvements that promote elder-friendly care has never been more critical. The Acute Care for Elders (ACE) Strategy at Toronto's Mount Sinai Hospital is the focus of a pan-Canadian collaborative delivered by the Canadian Foundation for Healthcare Improvement in partnership with the Canadian Frailty Network. The intent is to spread the ACE Strategy's elder-friendly models of care and practices to 18 participating healthcare delivery organizations. A key element of the ACE Collaborative is the inclusion of patient advisors as members of the 18 teams. This article considers the development of elder-friendly care models and practices, with lessons for patient advisors and organizations on the necessary skill-mix, as well as lessons for providers and managers on ways to more effectively engage patient advisors in health system improvement to better serve an aging population.
Assuntos
Atenção à Saúde/organização & administração , Serviços de Saúde para Idosos/organização & administração , Defesa do Paciente , Idoso , Canadá , Humanos , Islândia , Assistência Centrada no PacienteRESUMO
Quality improvement collaboratives (QICs) are popular vehicles for supporting healthcare improvement; however, the effectiveness of these models and the factors associated with their success are not fully understood. This paper presents a QIC in the Canadian context, where provincial healthcare systems have historically faced difficulty in transcending their structural and political limitations as well as moving from reactive models of care (prioritizing illness treatment in a hospital-reliant system) to more proactive ones (prioritizing population health in a primary care-based system). In March 2012, in a move that has been described as "unprecedented," 17 health regions across four provinces in Atlantic Canada, together with the Canadian Foundation for Healthcare Improvement (CFHI), developed a collaborative to improve chronic disease prevention and management. This paper introduces the Atlantic Healthcare Collaboration for Innovation and Improvement in Chronic Disease (AHC), reflecting on the experience of developing and implementing the model, which involved teams of front-line clinicians and managers working with CFHI faculty, coaches and staff to assess, design, implement, evaluate and share healthcare improvements for people living with chronic diseases. The paper shares key results and lessons learned from the AHC QIC experience, thus far, for improving chronic disease prevention and management in healthcare in Canada.
Assuntos
Doença Crônica/terapia , Comportamento Cooperativo , Gerenciamento Clínico , Assistência Centrada no Paciente , Canadá , Atenção à Saúde/métodos , Atenção à Saúde/organização & administração , Humanos , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade/organização & administraçãoRESUMO
In Atlantic Canada, people live with greater risk factors and higher rates of chronic disease than the average Canadian; and health system costs have historically risen faster than other parts of the country. Many clinicians endorse self-management support (SMS) as a means to help patients manage their chronic conditions but often lack the confidence and proper expertise to do so due to limited literature on SMS implementation. This paper draws on two case examples from Atlantic Canada to address gaps between effective SMS interventions and the implementation and evaluation of such interventions that can support provider adoption.
Assuntos
Doença Crônica/terapia , Autocuidado , Canadá , Diabetes Mellitus Tipo 2/terapia , Comportamentos Relacionados com a Saúde , Pessoal de Saúde/educação , HumanosRESUMO
QUALITY PROBLEM: Many modern health systems strive for 'Triple Aim' (TA)-better health for populations, improved experience of care for patients and lower costs of the system, but note challenges in implementation. Outcomes of applying TA as a quality improvement framework (QI) have started to be realized with early lessons as to why some systems make progress while others do not. INITIAL ASSESSMENT: Limited evidence is available as to how organizations create the capacity and infrastructure required to design, implement, evaluate and sustain TA systems. CHOICE OF SOLUTION: To support embedding TA across Canada, the Canadian Foundation for Healthcare Improvement supported enrolment of nine Canadian teams to participate in the Institute for Healthcare Improvement's TA Improvement Community. IMPLEMENTATION: Structured support for TA design, implementation, evaluation and sustainability was addressed in a collaborative programme of webinars and action periods. Teams were coached to undertake and test small-scale improvements before attempting to scale. EVALUATION: A summative evaluation of the Canadian cohort was undertaken to assess site progress in building TA infrastructure across various healthcare settings. The evaluation explored the process of change, experiences and challenges and strategies for continuous QI. LESSONS LEARNED: Delivering TA requires a sustained and coordinated effort supported by strong leadership and governance, continuous QI, engaged interdisciplinary teams and partnering within and beyond the healthcare sector.
Assuntos
Controle de Custos/métodos , Prestação Integrada de Cuidados de Saúde/organização & administração , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Garantia da Qualidade dos Cuidados de Saúde/economia , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Canadá , Prestação Integrada de Cuidados de Saúde/economia , Humanos , Liderança , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Programas e Projetos de SaúdeRESUMO
Disconnects and defects in care - such as duplication, poor integration between services or avoidable adverse events - are costly to the health system and potentially harmful to patients and families. For patients living with multiple chronic conditions, such disconnects can be particularly detrimental. Lean is an approach to optimizing value by reducing waste (eg, duplication and defects) and containing costs (eg, improving integration of services) as well as focusing on what matters to patients. Lean works particularly well to optimize existing processes and services. However, as the burden of chronic illness and frailty overtake episodic care needs, health systems require far greater complex, adaptive change. Such change ought to take into account outcomes in population health in addition to care experiences and costs (together, comprising the Triple Aim); and involve patients and families in co-designing new models of care that better address complex, longer-term health needs.
Assuntos
Doença Crônica/terapia , Controle de Custos , Atenção à Saúde/normas , Serviços de Saúde/normas , Satisfação do Paciente , Comorbidade , Necessidades e Demandas de Serviços de Saúde , Humanos , Saúde PúblicaRESUMO
The 'Number Needed to Treat' (NNT) is a useful measure for estimating the number of patients that would need to receive a therapeutic intervention to avoid one of the adverse events that the treatment is designed to prevent. We explored the possibility of an adaption of NNT to estimate the 'Number Needed to $ave' (NN$) as a new, conceptual systems metric to estimate potential cost-savings to the health system from implementation of a treatment, or in this case, a program. We used the outcomes of the INSPIRED COPD Outreach ProgramTM to calculate that 26 patients would need to complete the program to avoid healthcare expenditures of $100,000, based on hospital bed days avoided. The NN$ does not translate into 'cost savings' per se, but redirection of resource expenditures for other purposes. We propose that the NN$ metric, if further developed, could help to inform system-level resource allocation decisions in a manner similar to the way that the NNT metric helps to inform individual-level treatment decisions.
Assuntos
Atenção à Saúde/economia , HumanosRESUMO
Recent trends show an increase in the prevalence and costs associated with managing individuals with multimorbidities. Enabling better care for these individuals requires system-level changes such as the shift from a focus on a single disease or single service to multimorbidities and integrated systems of care. In this paper, a novel patient-centred redesign framework that was developed to support system-level process changes in four service areas has been discussed. The novelty of this framework is that it is embedded in patient perspectives and in the chronic care model as the theoretical foundation. The aims of this paper are to present an application of the framework in the context of four chronic disease prevention and management services, and to discuss early results from the pilot initiative along with an overview of the spread opportunities for this initiative.
Assuntos
Doença Crônica/terapia , Comorbidade , Inovação Organizacional , Assistência Centrada no Paciente/organização & administração , Canadá , Doença Crônica/prevenção & controle , Atenção à Saúde/organização & administração , Humanos , Modelos Organizacionais , Melhoria de Qualidade/organização & administraçãoRESUMO
The well-documented gaps between needed and provided care for patients and families living with chronic obstructive pulmonary disease (COPD) mandate changes to clinical practice. The multifaceted evidence-based INSPIRED COPD Outreach Program™ was first implemented in Halifax, Nova Scotia, Canada in 2010 (INSPIRED = Implementing a Novel and Supportive Program of Individualized care for patients and families living with REspiratory Disease) and undergoes ongoing evaluation. By enhancing patient confidence to manage their illness more effectively in their homes and communities, there has been a sustained and substantial reduction in facility-based care in comparison with patient care experience pre-INSPIRED. Sustaining and spreading a program recently designated a leading practice by Accreditation Canada, and especially modifying the program as new evidence emerges, requires integrating and modeling at the 'bedside' both evidence-based medicine ('doing the right things') and quality improvement ('doing them right'). In Canada, where COPD care gaps are common, a new pan-Canadian INSPIRED-based quality improvement program is supporting multidisciplinary healthcare teams to bridge the chasm between evidence and practice by working together to 'do the right things right' in COPD care.
Assuntos
Relações Comunidade-Instituição , Doença Pulmonar Obstrutiva Crônica/terapia , Humanos , Nova Escócia , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de SaúdeRESUMO
In the policy environment, the news media play a powerful and influential role, determining not only what issues are on the broad policy agenda, but also how the public and politicians perceive these issues. Ensuring that reporters and editors have access to information, that is, credible and evidence-based is critical for stimulating healthy public discourse and constructive political debates. EvidenceNetwork.ca is a non-partisan web-based project that makes the latest evidence on controversial health-policy issues available to the Canadian news media. This article introduces EvidenceNetwork.ca, the benefits it offers to journalists and researchers, and the important niche it occupies in working with the news media to build a more productive dialogue around healthcare.
Assuntos
Medicina Baseada em Evidências , Disseminação de Informação , Canadá , Política de Saúde , Humanos , Meios de Comunicação de Massa/normasRESUMO
This paper provides a reflection on the findings of Canada's first-ever chartbook on the quality of healthcare in Canada. Quality of Healthcare in Canada: A Chartbook was published in 2010 by the Canadian Health Services Research Foundation in partnership with the Canadian Institute for Health Information and the Canadian Patient Safety Institute, and with support from Statistics Canada. This paper, by the chartbook authors (Sutherland and Leatherman) and colleagues (Law, Verma and Petersen), presents selected key findings and lessons from the chartbook and aims to serve as a catalyst for ideas and discussion in the papers that follow. The chartbook identified a lack of common language and indicators on quality across Canada's provinces and territories, underscoring the need to create and coordinate core measures. The Canadian chartbook and this issue of Healthcare Papers provide an update on the existing quality measures and the state of healthcare quality in Canada, and create the opportunity for jurisdictions to learn from one another and to contemplate the steps required to improve quality across the country.
Assuntos
Atenção à Saúde/organização & administração , Atenção à Saúde/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/estatística & dados numéricos , Canadá , Doença Crônica , Gastos em Saúde/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Humanos , Sistemas de Informação/organização & administração , Sistemas de Informação/estatística & dados numéricos , Programas Nacionais de Saúde/organização & administração , Programas Nacionais de Saúde/estatística & dados numéricos , Segurança do Paciente , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Estatísticas Vitais , Listas de EsperaRESUMO
Canada's population is aging, and the authors of this issue's lead article, Neena Chappell and Marcus Hollander, present a policy prescription for how to design a healthcare system that better responds to needs of older Canadians. The timing of this issue of Healthcare Papers is important: the first of the baby boomers turned 65 in January 2011. There is a pressing need to develop policies and implement sustainable reforms that will allow older adults to stay healthier and maintain their independence longer in their place of choice, while also creating efficiencies and quality improvements in our overall healthcare system that will benefit Canadians of all ages.
Assuntos
Envelhecimento , Prestação Integrada de Cuidados de Saúde/organização & administração , Política de Saúde , Serviços de Saúde para Idosos/provisão & distribuição , Adulto , Idoso , Canadá/epidemiologia , Reforma dos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Pessoa de Meia-Idade , Dinâmica PopulacionalRESUMO
Neutrophil counts continued to rise after reaching 0.5x10(9)/L in 78 allograft recipients receiving granulocyte colony-stimulating factor (G-CSF) post-transplant. This was confirmed in 44 subsequent patients not receiving G-CSF. This suggests that the first day of neutrophils >or=0.5x10(9)/L can be considered a valid definition of myeloid recovery after allogeneic transplantation.