Canadian Healthcare Organizations Research Articles

Internal versus external knowledge sourcing of organizational rules: an exploratory study of CPGs in a healthcare organization

Abstract In this study, we examine how organizational rules source knowledge. By knowledge sourcing of a rule, we mean the formation of reference ties from the rule to knowledge sources located outside of the focal rule. Rules can source knowledge from sources within the organization (e.g., other rules) and outside (e.g., research publications, policies, standards, etc.). Our theoretical model proposes that knowledge sourcing of rules is driven by inherent incompleteness of rules as a result of bounded rationality of rule makers and rule making process. Incomplete rules can lead to experiences of insufficient rule knowledge, termed “knowledge gaps,” which are shaped by rule dynamics at the levels of individual rules, the rule system, and rule networks. Our theoretical model leads to several hypotheses that we test with longitudinal archival data of clinical practice guideline (CPG) changes in a Canadian healthcare organization. The findings support our theoretical model of incomplete organizational rules which encounter knowledge gaps and close them through internal and external knowledge sourcing. The theoretical and practical implications of the findings are discussed.

Characterization of Safety Events Involving Technology in Primary and Community Care.

The adoption of technology in health care settings is often touted as an opportunity to improve patient safety. While some adverse events can be reduced by health information technologies, technology has also been implicated in or attributed to safety events. To date, most studies on this topic have focused on acute care settings. To describe voluntarily reported safety events that involved health information technology in community and primary care settings in a large Canadian health care organization. Two years of safety events involving health information technology (2016-2018) were extracted from an online voluntary safety event reporting system. Events from primary and community care settings were categorized according to clinical setting, type of event, and level of harm. The Sittig and Singh sociotechnical system model was then used to identify the most prominent sociotechnical dimensions of each event. Of 104 reported events, most (n = 85, 82%) indicated the event resulted in no harm. Public health had the highest number of reports (n = 45, 43%), whereas home health had the fewest (n = 7, 7%). Of the 182 sociotechnical concepts identified, many events (n = 61, 59%) mapped to more than one dimension. Personnel (n = 48, 46%), Workflow and Communication (n = 37, 36%), and Content (n = 30, 29%) were the most common. Personnel and Content together was the most common combination of dimensions. Most reported events featured both technical and social dimensions, suggesting that the nature of these events is multifaceted. Leveraging existing safety event reporting systems to screen for safety events involving health information technology, and applying a sociotechnical analytic framework can aid health organizations in identifying, responding to, and learning from reported events.

Recommendations to Enhance Physical Health for Individuals with Severe Mental Illness in Canadian Healthcare Organizations.

As Canadians with severe mental illness remain underserved and experience a high burden of physical health challenges and premature mortality, there is an unprecedented need to provide better physical healthcare to this population. Ways of addressing this gap include the delivery of physical healthcare in mental health settings ("reverse integration"). However, there is limited guidance on how to enact this integration. In this article, we outline the development of an integrated care strategy in Canada's largest mental health hospital and discuss system- and policy-level recommendations that healthcare organizations could consider in their initiatives.

A qualitative study exploring how patient engagement activities were sustained or adapted in Canadian healthcare organizations during the COVID-19 pandemic.

The COVID-19 pandemic caused disruptions across healthcare systems globally exposing the precarious state of patient engagement across all levels of healthcare. While evidence is emerging to describe how engagement was affected across various settings, insights about how some organizations at the policy and practice level of healthcare were able to sustain or adapt patient engagement activities is lacking. This paper addresses the following research question: "How were healthcare, government, and patient partner organizations able to sustain or adapt patient engagement activities during the COVID-19 pandemic?" A qualitative descriptive study was conducted to understand how patient engagement activities were maintained or adapted in a variety of healthcare, government, and patient partner organizations in Canada throughout the pandemic. This analysis was part of a larger qualitative, multiple case study where one-to-one interviews were conducted with organizational leaders, managers and patient partners. The following themes were identified as key aspects of maintaining or adapting patient engagement activities: 1) having an embedded organizational culture of patient engagement; 2) adapting patient engagement activities to focus on COVID-19 response efforts; 3) having patient partners who exercised leadership and advocacy to support patient care and experiences during the pandemic; and 4) leveraging virtual technology as a communication tool to engage patient partners. This paper highlights important insights that may be useful to other health care organizations on how to sustain or adapt patient engagement activities during a healthcare crisis. Having patient engagement embedded within an organization's culture supported by, but not limited to, infrastructure, resources, investments in dedicated staff and patient partner leadership, and communication strategies and tools enabled continued patient engagement activities during the pandemic.

Internal vs. External Knowledge Sourcing of Organizational Rules: An Exploratory Study

In this study, we examine how organizational rules source knowledge from intra- and extra-organizational contexts. By knowledge sourcing of rules, we mean that rules reference knowledge sources located outside of rules. Knowledge sourcing of rules can be captured by formation of citation ties to the referenced knowledge sources within (i.e., other rules) and outside the organization (e.g., research publications, policies, standards, etc.). Our theoretical model proposes that knowledge sourcing of rules is driven by inherent incompleteness of rules as a result of bounded rationality of rule makers and rule making process. Incomplete rules can lead to experiences of insufficient rule knowledge, termed ‘knowledge gaps’, which are shaped by rule dynamics at the levels of rule system, individual rules, and rule networks. Our theoretical model leads to several hypotheses that we test with longitudinal archival data of clinical practice guideline (CPG) changes in a Canadian healthcare organization. We find evidence that provides overall support to our theoretical model. The theoretical and practical implications of the findings are discussed.

Seizing the opportunity: the emergence of shared leadership during the deployment of an integrated performance management system

BackgroundPerformance management systems have been introduced in health and social services institutions to improve organizational performance, supporting the emergence of new management behaviors that are more rooted in collaborative management practices. This study aims to understand how different leadership styles emerge through the implementation of a performance management system and its related tools, and how these can foster distributed leadership.MethodsOver two years, the implementation of an integrated performance management system supporting the integration of social services for children, youth, and families was studied at a recently merged Canadian healthcare organization. Qualitative analysis of data collected from 15 interviews, 3 focus groups, and over 350 h of non-participant observation was conducted.ResultsThe results show that leadership evolved to adapt to the context of organizational integration and was no longer confined to a single manager. Transformational leadership was needed to encourage the emergence of a new integrated performance management system and new behaviors among middle managers and team members. Transactional leadership was legitimized through the use of a status sheet when the integration project did not deliver the expected results. Both transformational and transactional leadership paved the way to distributed leadership, which in turn promoted collaborative practices associated with activities in control rooms and dialogue stemming from the status sheets. Distributed leadership among team members made a difference in the outcome of the integration project, which became a driver of collaboration.ConclusionsThe integrated performance management system and the use of its tools can help renew leadership in health and social service organizations. The results lend credence to the importance of distributed leadership in promoting collaborative practices to improve services for children, youth, and families. The results also highlight how various leadership styles can contribute to the emergence of distributed leadership over time.

Developing the first pan-Canadian survey on patient engagement in patient safety

BackgroundPatient safety is a worldwide problem, and the patient contribution to mitigate the risk of patient harm is now recognized as a cornerstone to its solution. In order to understand the nature of integrating patients into patient safety and healthcare organizations and to monitor their integration, a Canadian survey tool has been co-constructed by patients, researchers and the Canadian Patient Safety Institute (CPSI). This questionnaire has been adapted from the French version of the patient engagement (PE) in patient safety (PS) questionnaire created for the province of Quebec, Canada.MethodologyThe pan-Canadian PE in PS survey tool was developed in a five-step process: (1) a literature review and revision of the initial tool developed in the province of Quebec; (2) translation of the French questionnaire into an English version tool; (3) creation of a Canadian expert advisory group; (4) adaptation of the English version tool based on feedback from the expert advisory group (assessment and development of the construct’s dimensions, wording assessment and adaptation for pan-Canadian use, technical testing of the online platform for the survey); and (5) pilot testing and pre-validation of the tool before pan-Canadian use.Results and conclusionEight pan-Canadian PE in PS surveys were completed from five Canadian provinces by the expert advisory group and six surveys were completed during the pilot project by participants from different provinces in Canada. This survey tool comprises 5 sections: (1) demographic identification of the participants (Q1 to Q5); (2) general questions (Q6 to Q17); (3) the patient engagement process (experience level of participants and organizational incentives for PE in general) (Q18 to Q33); (4) PE in PS processes, such as current activities, strategies, structures, resources and factors (Q34 to Q67); and (5) the context and impact of PE in PS initiatives in Canadian healthcare organizations (CHOs) (Q68 to Q75), including outcome identification, improvement mechanisms and strategies, evaluation mechanisms, and indicators.

Incident Management in Health Care: A Pan-Canadian Perspective.

Nearly 10% of patients experience a harmful patient safety incident in the hospital setting. Current evidence focuses on incident reporting, whereas little is known about how incidents are managed within organizations. The aim of this study was to explore processes, tools, and resources for incident management in Canadian health care organizations. Qualitative focus groups were conducted with key stakeholders, representing clinicians, managers, executives, governors, patients, and families (n = 45). Qualitative data were thematically analyzed and presented as 3 themes: (1) variations in incident reporting and management; (2) simplification of the incident management process; and (3) need for leadership to support just culture and redefine harm. The study findings support and inform efforts to create a patient safety culture in Canadian and international health care organizations. There is a need to develop a standardized, accessible incident reporting and management system for use across health care sectors to promote continuous learning and improvement about patient safety.

Electronic Health Record-Related Burnout among Clinicians: Practical Recommendations for Canadian Healthcare Organizations.

The use of electronic health record (EHR) systems has led to numerous discussions about their possible contribution to clinician burnout. However, discussions regarding effective strategies to reduce burnout of this nature have been few. This article reviews initiatives and strategies aimed at combatting EHR-related burnout and provides recommendations for Canadian contexts. While approaches for measuring and reducing EHR-related physician burnout were identified, this paper highlights a paucity of evidence surrounding EHR-associated burnout among non-physician clinicians and the efficacy of interventions aimed at reducing burnout. Based on the findings, this article proposes recommendations for optimizing EHR usage to potentially reduce burnout.

Pilot implementation of elder-friendly care practices in acute care setting: a mixed methods study

BackgroundFrail older patients are at risk of experiencing a decline in physical and cognitive function unrelated to the reason for admission. The Elder-Friendly Care (EFC) program was designed to improve the care, experiences, and outcomes of frail older adults. The project supported 8 Early Adoption Sites (EAS) in a large Canadian healthcare organization by providing multiple strategies, educational opportunities, and resources. The purpose of this study was to assess the usefulness of EFC educational materials and resources, staff practice changes and perceptions in pilot sites, and readiness for scale and spread.MethodsThe study was conducted from May 2017 to June 2018 using a mixed-methods approach incorporating the Kirkpatrick Model of Training/Evaluation. A total of 76 Direct Care Staff participated in the staff survey, which assessed their awareness of, satisfaction with, and utilization of EFC principles, resources, and practices. Additionally, 12 interviews were conducted with staff who were directly involved in site implementation of EFC.ResultsMost survey participants were aware (86%, n = 63) of the EFC program, and 85% (n = 41) indicated they or their site/unit had implemented EFC. Out of these 41 participants, the most common practice changes identified were: incorporating alternatives to restraint (81%, n = 33), decreased use of pharmacological restraint (78%, n = 32), and patient and family care planning (76%, n = 31). Participants that attended all 3 EFC Learning Workshops (LWs) were significantly more likely to recommend the EFC Toolkit to others (87% versus 40%; χ2 = 8.82, p < 0.01) compared to participants attending less than 3 EFC LWs. Interview participants indicated that the program was well structured and flexible as sites/units could adopt changes that suited their individual sites, needs, contexts, and challenges.ConclusionsThe educational materials and resources used for the EFC project are useful and appreciated by the Direct Care Staff. Further, participants perceive the EFC intervention as effective in creating positive practice change and useful in reducing hospital-related complications for older patients. Future implementation will investigate the impact of EFC on system-level outcomes in acute care.

Integrated (Enterprise) Risk Management in Canadian Healthcare Organizations: Common Barriers and a Shared Solution for Effective and Efficient Implementation in Canada.

Healthcare is a complex, high-risk industry as evidenced by frequent accounts of unintended patient and staff harm as well as other disruptions leading to financial, reputational and facility losses. Canadian healthcare organizations have struggled to adopt effective organization-wide risk management programs to reduce the likelihood and impact of these losses. This paper outlines an evidence-based initiative to spread, at scale, an effective and efficient program for integrated risk management. National results and benchmarks from the first three years of implementation are provided.

Using Business Ontology to Integrate Business Architecture and Business Process Management for Healthcare Modeling

Patient safety and quality of health care services continue to be an issue within healthcare organizations. Quality improvement of healthcare processes at a systems level requires a shared language so the system is well understood across and between business areas. Business ontology provides the ability to create a shared language which can be used to integrate business process management (BPM) and business architecture (BA) concepts to identify, prioritize, and plan system wide improvement. The effective application of this comprehensive management approach has been demonstrated using medication management services within a publicly funded Canadian healthcare organization. This article illustrates how the foundational ontology developed by the Global University Alliance and the related Business Process Management Ontology (BPMO) can be used to facilitate the integration of BA and BPM concepts to improve quality of medication management. The development of business artefacts resulted in a prioritized list of improvement initiatives and an action plan to implement and monitor the initiatives. The integration of BPM and BA using an ontology in a healthcare setting yields improved services at the systems level.

Quality Bests Quantity.

The editor-in-chief discusses the central theme of this issue of the Canadian Journal of Nursing Leadership - advancing quality and safety in healthcare. As she explains, authors in this issue represent a range of perspectives and highlight nursing leadership strategies, competencies, and obligations to ensure quality and safety in Canadian healthcare organizations.

Best Practices in Oncology Distress Management: Beyond the Screen

The field of psychosocial oncology is a young discipline with a rapidly expanding evidence base. Over the past few decades, several lines of research have established that psychosocial problems, such as anxiety, depression, post-traumatic stress, fatigue, sexual dysfunction, and cognitive complaints, are common and consequential in patients with cancer. The word "distress" was chosen deliberately to capture a broad concept; consequently, distress screening is meant to function as an initial step in the more targeted evaluation of the source(s) of the patient's distress. In 2015, the American College of Surgeons' Commission on Cancer mandated psychosocial distress screening as part of their accreditation process. Similar screening requirements are in place internationally, including in Canada, where screening for distress is endorsed as the sixth vital sign and a standard of care that must be met by any Canadian health care organization providing cancer services that seeks to be accredited. Over the past few years, cancer centers around the world have been exploring optimum ways to implement and evaluate distress screening initiatives. This paper presents three approaches to distress screening implementation: (1) a model that incorporates the importance of shared values, perceived benefits, and relevant outcomes in the implementation of distress management protocols; (2) a Canadian knowledge translation application to distress screening, including triage considerations and interventions; and (3) a novel approach to distress management via the use of a mobile application to manage post-traumatic stress symptoms. In closing, future opportunities and challenges associated with the emergence of technology will be discussed.

The Medical Devices Special Access Program in Canada: A Scoping Study.

New health technologies enter Canadian healthcare organizations in various ways, and understanding them is essential to the development of a pan-Canadian Health Technology Management (HTM) Strategy, now a priority of governments across Canada. One way is through Health Canada's Medical Devices Special Access Program (MDSAP), which permits unlicensed devices to be obtained by healthcare professionals. However, the circumstances around and implications of the current use of this program are not clear. A scoping literature review was conducted to clarify these and identify important roles and issues related to the MDSAP. Limited information was found on the MDSAP. Nevertheless, three themes demonstrating the roles of the MDSAP in HTM emerged: arbiter in technology selection, a route to technology procurement and facilitator of health technology innovation. No information suggesting that MDSAP is used to circumvent licensing was found. Rather, it enables desired patient outcomes and product commercialization.

Reflections on Distributive Leadership for Work-Based Mobile Learning of Canadian Registered Nurses

The ubiquity, flexibility, and accessibility of mobile devices can transform how registered nurses in Canada learn beyond the confines of traditional education/training boundaries in their work settings. Many Canadian registered nurses have actively embraced mobile technologies for their work-based learning to meet their competency requirements for professional nursing practice. As self-directed learners, they are using these learning tools at point-of-need to access rich online healthcare resources, collaborate, and share information within their communities of practices. Yet, paradoxically, there are Canadian healthcare organizations that have not embraced work-based mobile learning and their contextual factors constrain and/or impede registered nurses' learning. Therefore, the goal of this reflective paper is to stimulate discussion on distributive leadership strategies for embedding this pedagogical mode of learning into Canadian healthcare workplaces for registered nurses' ongoing skills and continuing professional development.

Implementing a collaborative return-to-work program: Lessons from a qualitative study in a large Canadian healthcare organization.

BACKGROUND: Comprehensive workplace return-to-work policies, applied with consistency, can reduce length of time out of work and the risk of long-term disability. This paper reports on the findings from a qualitative study exploring managers’ and return-to-work-coordinators’ views on the implementation of their organization’s new return-to-work program.OBJECTIVES: To provide practical guidance to organizations in designing and implementing return-to-work programs for their employees.METHODS: Semi-structured qualitative interviews were undertaken with 20 managers and 10 return-to-work co-ordinators to describe participants’ perspectives on the progress of program implementation in the first 18 months of adoption. The study was based in a large healthcare organization in Ontario, Canada. Thematic analysis of the data was conducted.RESULTS: We identified tensions evident in the early implementation phase of the organization’s return-to-work program. These tensions were attributed to uncertainties concerning roles and responsibilities and to circumstances where objectives or principles appeared to be in conflict.CONCLUSIONS: The implementation of a comprehensive and collaborative return-to-work program is a complex challenge. The findings described in this paper may provide helpful guidance for organizations embarking on the development and implementation of a return-to-work program.

The interactions of Canadian ethics consultants with health care managers and governing boards during times of crisis

ABSTRACTBackground: Health care organizations can be very complex, and are often the setting for crisis situations. In recent years, Canadian health care organizations have faced large-scale systemic medical errors, a nation-wide generic injectable drug shortage, iatrogenic infectious disease outbreaks, and myriad other crises. These situations often have an ethical component that ethics consultants may be able to address. Organizational leaders such as health care managers and governing boards have responsibilities to oversee and direct the response to crisis situations. This study investigates the nature and degree of involvement of Canadian ethics consultants in such situations. Methods: This qualitative study used semi-structured interviews with Canadian ethics consultants to investigate the nature of their interactions with upper-level managers and governing board members in health care organizations, particularly in times of organizational crisis. We used a purposive sampling technique to identify and recruit ethics consultants throughout Canada. Results: We found variability in the interactions between ethics consultants and upper-level managers and governing boards. Some ethics consultants we interviewed did not participate in managing organizational crisis situations. Most ethics consultants reported that they had assisted in the management of some crises and that their participation was usually initiated by managers. Some ethics consultants reported the ability to bring issues to the attention of upper-level managers and indirectly to their governing boards. The interactions between managers and ethics consultants were characterized by varying degrees of collegiality. Ethics consultants reported participating in or chairing working groups, participating in incident management teams, and developing decision-making frameworks. Conclusions: Canadian ethics consultants tend to believe that they have valuable skills to offer in the management of organizational crisis situations. Most of the ethics consultants we interviewed believed that they play an important role in this regard.

High performance in healthcare priority setting and resource allocation: A literature- and case study-based framework in the Canadian context

Priority setting and resource allocation, or PSRA, are key functions of executive teams in healthcare organizations. Yet decision-makers often base their choices on historical patterns of resource distribution or political pressures. Our aim was to provide leaders with guidance on how to improve PSRA practice, by creating organizational contexts which enable high performance. We carried out in-depth case studies of six Canadian healthcare organizations to obtain from healthcare leaders their understanding of the concept of high performance in PSRA and the factors which contribute to its achievement. Individual and group interviews were carried out (n = 62) with senior managers, middle managers and Board members. Site observations and document review were used to assist researchers in interpreting the interview data. Qualitative data were analyzed iteratively with the literature on empirical examples of PSRA practice, in order to develop a framework of high performance in PSRA.The framework consists of four domains - structures, processes, attitudes and behaviours, and outcomes - within which are 19 specific elements. The emergent themes derive from case studies in different kinds of health organizations (urban/rural, small/large) across Canada. The elements can serve as a checklist for ’high performance’ in PSRA. This framework provides a means by which decision-makers in healthcare might assess their practice and identify key areas for improvement. The findings are likely generalizable, certainly within Canada but also across countries. This work constitutes, to our knowledge, the first attempt to present a full package of elements comprising high performance in health care PSRA.

The use of Ethics Decision-Making Frameworks by Canadian Ethics Consultants: A Qualitative Study.

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants.