Measure Twice, Change Once: Using Simulation to Support Change Management in Rural Healthcare Delivery.

This is a case study illustrating the wide variety of models for rural health care delivery found in a western "frontier" state. In response to a legislative mandate, the University of Nevada School of Medicine created the Office of Rural Health in 1977. Utilizing a cooperative, community development approach, this office served as a resource, as well as a catalyst, in the development and expansion of a variety of alternative practice models for health care delivery to small, underserved rural communities. These models included small, single, and multispecialty group practices; self-supporting and subsidized solo practices; contract physicians; midlevel practitioners; and National Health Service Corps personnel. The rural health care system that was created featured regional and consortial arrangements, urban and medical school outreach programs, and a "flying doctor" service.

Background: There is a significant shortage of physicians providing colonoscopies, especially in underserved and rural areas. Surgeons are increasingly filling this role by providing endoscopy services including colonoscopy in these areas. As a result, there has been discussion regarding the quality of colonoscopies performed by different provider specialties, specifically for non-gastroenterologists. The purpose of this study was to compare colonoscopy quality measures between gastroenterologists and surgeons in a rural central New York healthcare system. Methods: All colonoscopies performed by 23 endoscopists, 14 surgeons and 9 gastroenterologists, within a rural healthcare network in 2017 were included as samples within this study, totaling 6265 colonoscopies. These included all diagnostic, screening, and surveillance colonoscopies. Quality metrics including withdrawal times and adenoma detection rates were calculated for all providers and the two groups were statistically analyzed and compared using chi-squared testing. Results: 3113 colonoscopies were performed by surgeons (average of 222 per provider) and 3159 were performed by gastroenterologists (average of 351 per provider). Adenoma detection rates for surgeons and gastroenterologists were essentially the same at 31.38% and 31.82%, respectively (p=0.6882). Withdrawal times were slightly longer for surgeons at 13.19 minutes versus 11.02 minutes for gastroenterologists, though this difference was not statistically significant (0.2985). Conclusions: Our results show that surgeons are not inferior to gastroenterologists in performing colonoscopies using the quality metrics of adenoma detection rates and withdrawal times. With the ongoing shortage of endoscopists, surgeons may be able to alleviate some of the burden without reduction in quality.

This article invites for a scientific discussion while discussing the synergy between the process of change and the change management in the system of education and emphasizing that two different factors give larger impact and socioeconomic benefits if they are used together. In this article the concept of the process of change and change management in the educational institutions is analysed. It is noted that in a process of change it is very important to properly plan the changes and to identify the expected results but also it is very important to understand how all above mentioned process will be implemented. Questions to discuss: when the processes of change are implemented properly? Answer: when the changes are managed properly. How to ensure the implementation of the process of change management? Answer: the implementation of the process of change management is held in a field of change management systematically enabling all the processes of change management. The methodological construct of the research is presented in this article, revealing the synergy of the process of change and change management of the chosen school.

Orientation: Cross-border acquisitions are instrumental in international businesses’ expansions, even though 70% fail. This necessitates risk and change management as driving forces. The context of this case study is within a change management initiative implementation during a cross-border acquisition between a global organisation and its African subsidiary.Research purpose: The study explored the psychosocial factors that influence the successful implementation of a change management initiative. Also, recommendations are made towards mitigating psychosocial risks that should be incorporated as part of a well-thought-through change management initiative and process, in a multifaceted Africa context.Motivation for the study: To understand the psychosocial factors posing a risk and becoming impeding factors within a multifaceted African merger and during a cross-border change management initiative.Research approach/design and method: A qualitative approach and case study design, adopting a hermeneutic phenomenological paradigm, was applied. Data were collected through semi-structured interviews and analysed using Tesch’s content analysis.Main findings: Having an awareness of psychosocial factors influencing change initiatives, requires interconnectedness and co-construction, to enable successful implementation, while mitigating risk. The African context greatly values culture, relationship, trust, respect, and collaboration. Thus, risk cannot be managed without managing change and contrariwise.Practical/managerial implications: In multifaceted Africa, the importance of stakeholder inclusion and engagement are highlighted, and the importance of stakeholder and task integration towards mitigating risks and modifying psychosocial behaviour are emphasised.Contribution/value-add: Substantive evidence enables a better understanding of psychological risk factors impeding change within a multifaceted environment. Interconnectedness and co-construction enable effective risk mitigation and change implementation.

Improving type 2 diabetes (T2D) care is key to managing and reducing disease burden due to the growing prevalence of diabetes worldwide, but research on this topic, specifically from rural areas, is limited. This study uses standardized patients (SPs) to assess T2D care quality among primary care providers to access the healthcare system in rural China. Using multi-stage random sampling, health facilities, providers, and households were selected. SPs were used to evaluate providers' T2D care quality and a questionnaire survey was used to collect patient sorting behaviors from households. Logistic regression was used to explore factors correlated with T2D care quality. Provider referral and treatment rates were combined with patient sorting behaviors to assess the overall quality of T2D management by rural China's healthcare system. A total of 126 providers, 106 facilities, and 750 households were enrolled into this study. During SP interactions, 20% of rural providers followed the national guidelines for T2D consultation, 32.5% gave correct treatment, and 54.7% provided lifestyle suggestions. Multi-variable regression results showed that providers who had earned practicing certificates (β = 1.56, 95% CI: 0.44, 2.69) and saw more patients (β = 0.77, 95%: 0.25, 1.28) were more likely to use a higher number of recommended questions and perform better examinations, whereas providers who participated in online training were less likely to practice these behaviors (β = -1.03, 95%: -1.95, -0.11). The number of recommended questions and examination (NRQE) was the only significant correlated factor with correct treatment (marginal effect = 0.05, 95%: 0.01, 0.08). Throughout the rural healthcare system, 23.7% of T2D patients were treated correctly. The quality of T2D care in rural western China, especially throughout the consultation and treatment process during a patient's first visit, is poor. Online training may not improve T2D care quality and low patient volume was likely to indicate poor care quality. Further research is needed to explore interventions for improving T2D care quality in rural China's healthcare system.

Accessibility and effective functioning of the rural health care primary link in the rural settlement system is considered in the article as a necessary condition for ensuring the competitiveness of the rural able-bodied population and a component of the social well-being of the rural population as a whole. The aim of the article is to analyze the structural elements of the rural primary health care at various territorial levels, which allows us to draw a scientifically sound conclusion about how similar the elements of the territorial rural health care systems are to each other. Their differences are considered by the author as evidence of the adaptation of primary links to the characteristics of rural settlement. Theoretical scientific provisions are formulated in the framework of the concept of civic-oriented management and the new role of the state as a source of basic social benefits, which have been recognized in the domestic and international scientific community. Basing on general theoretical propositions, a methodology has been developed that allows using the mathematical theory of measurements to identify and compare the structural elements of the primary links of rural health care at various territorial levels. During the study, the method to assess the volume of structural elements in relative terms was used. We used publications of foreign and domestic authors, indicators shown in materials and collections of state and departmental statistics as sources. As a result of the study, it was proved that at the level of the Russian Federation, the structures of the primary rural health care consist of: outpatient clinics - 11.1%, local hospitals - 3.2%, feldsher-midwife centers - 80.6%, feldsher (rural paramedic) stations - 5.1%. Similar primary link structures were identified in most federal districts of the Russian Federation. An exception is only a few districts located in specific climatic conditions. A study of the structure of the rural health care system at the territorial level of a constituent entity of the Russian Federation, using the example of the Saratov Region, did not reveal significant deviations from the all-Russian standard. In the structure of the regional primary link of rural health care, outpatient clinics account for 9.0%, local hospitals - 1.3%, feldsher-midwife stations - 89.7%; feldsher stations are absent. The undertaken research and comparison of the structural elements of rural health care, carried out at the level of the Russian Federation, federal districts and constituent entities of the Russian Federation, allowed to gain new knowledge about the structural homogeneity of the primary links of the rural health system at all levels. The hypothesis formulated by the author about the structural uniformity of the primary links of the territorial systems of rural health care in most federal districts is confirmed, which indicates their inconsistency with the characteristics of rural settlement. The practical result of the study, which can be used to develop managerial decisions in the process of forming the primary links of territorial rural health systems that correspond to the characteristics of rural settlement, are the proposed in the article indicators that characterize the type of settlements in the rural settlement system. The priority of theoretical and methodological studies as the basis for developing managerial decisions in the field of rural health policy is justified; this involves the formation and support of primary structures of territorial rural health systems, including traditional and innovative types of medical services, corresponding to the peculiarities of rural settlement and scientifically based criteria that ensure the full functioning of medical primary health care organizations in rural health systems.

Our company has discovered that regular auditing of the management of change (MOC) process is essential in enforcing its proper use. We have developed an audit system or process that can be performed by plant personnel to identify the effectiveness of our MOC process in two critical categories: (1) identifying changes and initiate MOCs for them and (2) after MOC is initiated, following the process to be sure that the methods are correct and complete. In addition, we have a set of measures associated with these audits that we track to get an overall picture of how effectively our MOC process is operating and to identify systemic problems. The audit form, process data collection, and analysis system are explained in this article. © 2011 American Institute of Chemical Engineers Process Saf Prog, 2011

Site-neutral payment reforms offer a strategic approach to standardise reimbursement rates across care settings, aiming to reduce inefficiencies and enhance fiscal accountability within the US healthcare system. While these reforms target excessive payments to hospital outpatient departments (HOPDs) and promise substantial savings for Medicare and private insurers, they present critical operational and financial challenges for rural healthcare providers. Rural hospitals, already constrained by limited resources and narrow margins, face heightened risks of service reductions and closures under uniform payment models. This paper examines the unintended consequences of site-neutral payment policies on rural healthcare delivery, emphasising how these reforms, without appropriate safeguards, may accelerate hospital-physician consolidation, inflate costs and erode patient choice, particularly in underserved regions. Drawing on empirical data and policy analysis, the study highlights the systemic vulnerabilities exposed by current reform efforts. To address these challenges, we propose a management-focused policy framework that balances cost containment with rural healthcare sustainability. Major recommendations include phased implementation strategies tailored to rural contexts, enhanced federal reimbursement support, preservation incentives for independent physician practices and strengthened antitrust oversight to mitigate consolidation pressures. For healthcare executives, policymakers and system managers, this research underscores the necessity of integrating adaptive regulatory mechanisms and targeted financial interventions to ensure that efficiency-driven reforms do not compromise equitable access to care. A proactive, rural-conscious management strategy is essential to align national payment reforms with the long-term viability and competitiveness of rural healthcare systems. This article is also included in The Business & Management Collection which can be accessed at https:// hstalks.com/business/.

Purpose: The objective of this paper is to propose a conceptual framework that will assess the scope of social business to collaborate with government through Public-Private Partnership (PPP) model in the rural health care system. Design/methodology/approach: This work is a conceptual paper. The study is mainly qualitative in nature which followed systematic literature review including grey literature and developed a conceptual framework on PPP theory for Social Business. Apart from using secondary data, the research is also based on personal observation through visiting different rural part of the country. Findings: The conceptual framework of this paper provides a greater prospect of access to the rural health care through a Social Business-PPP project while indicating the determinants that integrate demand and supply-side-factors all along the process of obtaining health care and benefiting from the services. Limitations: This is a theoretical paper where the validity of the conceptual model can be established by testing the research proposition. Implications: Improving the health and longevity is not only a part of development goals, but also a fundamental object to achieve the economic progress of a nation. Therefore, health care must be addressed in any comprehensive development strategy for a country. Bangladesh is one of the developing countries which has given special attention on its health care policy, but it has failed to improve the health care system significantly especially for the rural people. Similar to many developing countries, majority of the population in Bangladesh lives in rural areas; but they lack the basic public health infrastructure and quality service at an affordable cost. The deficiencies of the public health sector have forced the poor people to seek health services from the private sector which are better equipped but mostly are driven by profit motives and also unregulated. On the other hand, NGOs working in rural health sector have limited coverage and also subject to the availability of foreign aid or donor’s fund. Given the inefficiencies and lack of existing players in country’s health care sectors, Social Business can be a straightforward solution to address the growing rural public health issue. Social Business, introduced by Professor Muhammad Yunus in 2007, is a competitive business model which is formed with the aim of solving a social problem faced by the poor ensuring adequate profit generation for the sustainability of the firm. As the target group of social business is poor people, operational activities is mainly based on rural areas and is financially self-sustainable, therefore it can be an instrumental factor for the development of the health care system in rural area. In addition, a partnership with government can strengthen the health care activities towards fulfilling the basic health care needs of the poor people. And ultimately, this Public-Private Partnership (PPP) between government and social business firm would make the health care more accessible and affordable to the poor people mostly living in rural area. Contribution: This would bring a greater understanding of the role of ‘Social Business’ in the business of providing health care to disadvantaged populations. Moreover, our conceptual framework is to guide the discourse and decision making by communities, clinicians, managers and policy makers, with a focus on health care system around the world where rural and poor people are expected to have greater and improved healthcare facilities.

Management of change (MOC) is a safety process and an essential part of organizations safety framework. This process is mandated by all safety governing systems. It consists of multiple development and approval stages where it is subject to comment and through assessment. The nature of MOC along with other factors of the requests can be used as features to predict the convergence of the requests to avoid future re-work which results in loss of efforts and manhours if the requests fail to meet the minimum requirements of QA/QC. Considering needs to adapt to economic conditions and market trends, technical development and their evolution change is inevitable in industry, and it is inherent part of the business however to achieve these changes safely and efficiently the MOC process has multiple standardized stages to capture any risks or area for improvement in the potential change. This poses several challenges includes Requests stagnations, missing risk assessments, missing or bypassing steps, underestimating or over estimating costs and schedules. This paper presents a case study of developing a digitized MOC process, covers the design considerations to assure the smooth and efficient workflow of MOC is achieved along with incorporating machine learning predictive capabilities to help predicting scope, cost and schedule compliance level prior authorizing change and focus the review on potential area of improvement. Considering the importance of the development of the deployed MOC platform the process of the design and implementation followed the agile methodology through multiple iterations of setting requirements, deploying the design test and validation and re-adjust the steps and fine tune the requirement on iterative approach. The followed iterative approach enabled the enhancement and streamlining the process to achieve maximum efficiency prior lunching the platform. The main strategies of the devlopment included: Cover the 6 key steps and eliminate repetition and stagnation.Design the process to have each MOC requests pass multiple gates till closure to assure each step are met prior moving forward.Utilize the existing MOC records as training data for a prediction model.Include primary QA/QC steps in the process.Include ML algorithms to support decision making in review and approval cycle. As part of the deployment the key aspects of MOC scope definition identified and engineered which includes Durability, Category, Risk Assessment (methodology), Planned cost, Planned Execution Duration, Shutdown requirement, Number of Unit-to-Unit interfaces Material requirement… etc. The ultimate qualitative outcome of this analysis is predicting whether the proposed change is sanctioned to proceed. The data were pre-processed and included data cleaning to code and correct missing inputs, feature engineering involves creating new variables or features from the existing data to capture complex relationships or enhance the predictive power of the data. For instance, deriving new metrics to quantify employee engagement levels or change readiness can provide valuable insights for change management analysis. Several models were utilized and below is the outcomes of the tested models: According to the outcomes of the modelling the SVM was selected to be the advisory basis of the system to predict MOC convergence and compliance or not for both submitters and reviewers. In conclusion, the deployed design of MOC WF helped in streamlining the process and address the key challenges of the common MOC shortcomings this is attributed mainly to following gate-based WF so no steps can be skipped moreover the applied review and approval constraints eliminated the root causes of requests stations. The incorporation of predicative capabilities helped in avoiding/ minimizing potential requests re-work as it predict the convergence and guide submitter for potential reviewer's concerns in addition to maximize the efficiency of the review cycle as the reviews will be guided to potential failures in term of schedule, scope or cost definitions. The best modeling algorithms for MOC process definition, scope and schedule compliance prediction based on the selected average is found to be support vector machine with accuracy of 93%. The deployed system helped in eliminating the overlapping steps and streamline the process in addition to achieve +98% digitalize MOC control and tracking where predictive capabilities increase MOC convergence by + 30%.

Rural hospitals are confronting continuing and increasing threats to their viability. A demonstration project for the Washington-Alaska-Montana-Idaho region to address the problems of the rural hospital and health system is described. The assumptions underlying the project are that the rural hospital represents the most important component of the rural health care system, and the role of the rural hospital must be defined in relation to the broad health care needs of the population it serves. However, since the elements of community health services are also interdependent, a comprehensive approach to addressing the broad array of problems which besiege rural health services has been developed. The phases of this comprehensive health services development model are described. This approach is having a substantial impact on the ability of community health care leaders to work together, identify important problems, and initiate a range of interventions, with results that are encouraging for the future of the rural hospital and health care system.

A methodology for the analysis of rural primary health care delivery systems

To describe a screening and intervention program for geriatric syndromes instituted at a rural healthcare system that utilizes the 4Ms of an age-friendly health system, and to provide exercise and cognitive stimulation therapy (CST) as part of an age-friendly health program. Retrospective evaluation of clinical data. Rural primary healthcare system. Older adults aged 65 years and older in Perry County, Missouri. Screening for geriatric syndromes was done using the Rapid Geriatric Assessment (RGA), which includes the FRAIL, SARC-F, Simplified Nutritional Appetite Questionnaire (SNAQ), and Rapid Cognitive Screen (RCS). Outcomes for exercise and CST included the Five Times Sit to Stand (FTSS) and Timed Up and Go (TUG) tests, Cornell Scale for Depression in Dementia (CSDD), Saint Louis University Mental Status Examination (SLUMS), and Quality of Life in Alzheimer's Disease (QoL-AD) measures. The RGA was administered to 1,326 individuals of which 36.5% were frail, 42.1% were sarcopenic, 26.1% were at risk for anorexia, and 20.8% had dementia. Of these receiving exercise therapy, both the FTSS and the TUG were improved at 3 months and 12 to 24 months. In the CST group, SLUMS, QoL-AD, and CSDD were improved at 7 weeks and 6 to 12 months. It is feasible to introduce a screening program for geriatric syndromes and respond to the results with successful exercise and cognitive stimulation therapy programs.

Clinical–pathological characteristics and health care for Tibetan women with breast cancer: a cross-sectional survey

Looks at a specific variant of systems thinking, called critical systems thinking, which is an approach that was developed in the UK during the 1980s. In particular, consideration is given to “rule‐bound” systems – scenarios where the possibilities for change have been found to be problematic. The characteristics of such situations will initially be set out, focusing on the power relations that appear to pervade such situations. A prison‐based change management initiative is used to show how critical systems thinking can be employed, and provide some reflections on the process of change management and the outcomes achieved. These reflections point to some difficulties experienced that emerged from the rule‐bound nature of the problem situation and ways in which such difficulties might be addressed in similar situations in the future are suggested. Insights for both private and public sector organizations are drawn throughout the paper.