Complex Health Care Delivery Systems Research Articles

Development and Implementation of an Experiential Longitudinal Health Systems Science Thread Into an Existing Medical School Curriculum.

Medical school graduates enter a complex health care delivery system involving interprofessional teamwork and multifaceted value-based patient care decisions. However, current curricula on health systems science (HSS) are piecemeal, lecture based, and confined to preclinical training. The VISTA program is a longitudinal, immersive learning curriculum integrated into the University of Chicago Pritzker School of Medicine curriculum between 2016 and 2018. Key components include a unit-based nursing interprofessional team experience, a discharge objective structured clinical examination (OSCE), a patient safety simulation, and the implementation of a Choosing Wisely SmartPhrase. Graduates before 2016-2017 and after 2018-2020 VISTA implementation completed a Likert-style survey assessing attitudes, knowledge, and behaviors on HSS topics. A free response question solicited improvement areas. The Association of American Medical Colleges (AAMC) Graduation Questionnaire (GQ) was also examined. The overall VISTA survey response rate was 59%, with 126 fourth-year medical student respondents before VISTA and 120 after VISTA. Compared with pre-VISTA graduates, post-VISTA graduates reported a significantly higher rate of competence on the HSS questions, with the greatest increases seen in effective communication at discharge (n = 73/126 [57.9%] to 116/120 [96.7%], P < .001), knowledge on safety event reporting (n = 53/126 [42.1%] to 96/120 [79.8%], P < .001), and considering costs in making health care decisions (n = 76/126 [60.3%] to 117/120 [97.5%], P < .001). All were directly addressed through experiential learning interventions, and 2 were intended practice behaviors. VISTA graduate responses to free-text questions demonstrated a more nuanced understanding of HSS compared with pre-VISTA responses. The AAMC GQ data showed increased agreement with an item that mapped to HSS understanding. The VISTA program provides a model for institutions to enhance HSS education between curricular overhauls. Next steps include implementing value-added roles and additional immersive learning exercises.

Poverty Post Pandemic, Lapsed Public Policy, and Rising Rates: A Call to Action for Nursing

Poverty is a pressing societal problem, adversely affecting the lives and livelihoods of millions of people in the United States and beyond. During this period of pandemic recovery, nurses, as the largest health workforce, are well positioned for action with the potential to improve health outcomes for many experiencing poverty. An actionable plan begins with an understanding of poverty and how poverty is experienced. It builds on nursing’s disciplinary perspective, patterns of knowing and a new model of professional nursing education advanced by the American Association of Colleges of Nursing. Finally, a feasible and sustainable plan is responsive to the challenges of a contemporary and complex health care delivery system.

Implementing Collaborative Project and E-Portfolio in an Online Graduate Course: A Case Study

The ability to work in teams is an imperative competency in today’s complex healthcare delivery system. Collaborative learning allows students to cultivate teamwork, communication, critical thinking, and problem-solving skills. Collaborative learning activity is an essential pedagogical approach to prepare students to meet the need of the healthcare workforce. This paper presents a research study in which a collaborative project was implemented in a redesigned healthcare administration course in an online graduate program. The objectives of this study were to evaluate the effectiveness of this revised course and uncover solutions to improve the implementation of the collaborative project and the usefulness of this course. Students’ perceptions of completing a collaborative project and other learning activities such as ePortfolio were explored. Even though some students enjoyed collaborating with their teammates, other students did not like the collaborative project. The barriers to a successful collaborative project discovered in this study were also revealed in prior empirical studies. Limitations of this research were also presented. The recommendation was proposed for better integration of collaborative projects into the curricula of a program.

Powershift and Teambuilding: Healthcare Is Now a Team Sport

To operate with maximum efficiency, the highly complex healthcare delivery system requires integrated knowledge management in a patient-centric context. With this technology-induced change comes a transformation in the culture and a necessarily fresh approach to relationships with peers and teams, new collaborative problem solving, shared leadership, and shared decision-making. This cultural transformation is a shift in power traditionally held by physicians in their professional role, from one focused on authority and autonomy to one focused on leadership and collaboration.

Need to review anaesthesia curriculum and education!

Need to review anaesthesia curriculum and education!

Special Report: Hispanic Community and COVID-19—Addressing Health Inequalities Can No Longer Be Delayed

<i>Special Report:</i> Hispanic Community and COVID-19—Addressing Health Inequalities Can No Longer Be Delayed

The Executive Nurse Leader in Service Line Management:: An Experience of a Hospital Health System

Complex health care delivery systems are often organized around the management of specific patient populations or service lines across ambulatory and inpatient settings and the executive nurse leader is the most suitable clinical professional to provide visionary leadership in a dyad with a senior physician for a service line. This article describes the unique experience of a system hospital and the successes of the executive nurse leader as the co-lead in service line management.

CN33 - Patient safety and the power of nursing presence

BackgroundThe goal of patient safety is to reduce and eliminate preventable harm resulting from processes of care including the safe delivery of medication. Patient and occupational safety challenges are increasing in cancer care with the expanded use of oral chemotherapy, immunotherapy, and other novel treatments. In the United States, the Food and Drug Administration approved 59 novel drugs in 2018 including 19 applications of new cancer drugs and biologics as well as 38 supplemental indications and four biosimilars. Many of these novel agents will be delivered in settings that may not include the presence of a cancer nurse. Presence is a fundamental concept of nursing practice that involves active listening to facilitate understanding and meaningful connection between the patient and family and other members of the healthcare team. The safe delivery of cancer treatment is a critical component of the EONS Cancer Nursing Education Framework which defines the pivotal role of the presence of the cancer nurse in educating patients and caregivers about the safe use of cancer and symptom management medications, early recognition of side effects, and appropriate self-management approaches. As cancer care moves from traditional settings of the hospital, ambulatory clinic, or oncology provider’s office, nurses will be confronted with the need to redefine nursing presence in an era of increasingly complex healthcare delivery systems. MethodsA literature search will be presented drawn from a review of PubMed, CINAHL, and EBSCO data bases using search terms related to “patient safety”, “nursing presence”, “vigilance”, and “medication safety”. ResultsNot applicable. ConclusionsThis presentation will explore current literature related to the role of presence of the cancer nurse in safeguarding patient outcomes and quality cancer care. The session will include discussion and recommendations to increase the effective use of nursing presence and intentional communication by cancer nurses in diverse settings. Legal entity responsible for the studyThe author. FundingHas not received any funding. DisclosureThe author has declared no conflicts of interest.

Physician Staffing in Emergency Rooms (ERs): Opening the Black-box of ER Care via a Multi-Class Multi-Stage Network

Problem Definition and Relevance: Characterized by time-varying arrivals, multi-stage service, and multi-class patient population, emergency rooms (ERs) are complex healthcare delivery systems, where optimizing the staffing levels of physicians is a challenge. In collaboration with Mayo Clinic, we study a staffing and an associated routing problem for ER physicians and propose a new staffing rule to meet tail probability of delay (TPoD) type service targets. Methodology: We capture the time-varying patient flow in the ER with a multi-class multi-stage queuing network, describing the ER care as sequences of treatment queues, where physicians serve, and groups of diagnostic medical processes. Treatment stations in ER are busy-server queues, where waiting before service is common, but experience negligible abandonments. Motivated by these queues, we propose a new staffing algorithm, translating the offered load into staffing decisions for efficiency-driven queues with TPoD targets and perfectly patient customers. Results: We analytically show the asymptotic effectiveness of our staffing rule on stabilizing TPoD for M/M/s queues, operating in efficiency-driven mode, and numerically demonstrate its robustness and optimality in various time-varying ER settings via realistic and data-driven simulation experiments. We further show that as the service complexity of an ER increases, hybrid routing rules, using pre-determined (static) priorities and (dynamic) current system state jointly, become necessary to meet TPoD targets. Managerial Implications: Instead of treating the entire patient length of stay as a black-box service model, our multi-stage network model provides more managerial control over the internal components of ER service and is easily implementable in practice.

Impact of Primary Payer on Survival in Patients

Prior studies have demonstrated better outcomes for cancer patients with health insurance coverage compared to those with none, but less has been reported regarding the effect of insurance type. The U.S. health insurance landscape is highly variable in patients <65 years old, given they do not have access to uniform coverage such as Medicare. We sought to determine whether the type of primary payer (private versus government-sponsored insurances [GSI]) impacted survival in insured patients younger than 65 with localized head and neck cancer undergoing definitive radiotherapy (RT). The National Cancer Data Base was queried for patients age <65 with stage I-IVB squamous cell carcinoma of the oropharynx, nasopharynx, hypopharynx, or larynx diagnosed from 2004 to 2014 and treated with definitive RT (total dose: 6600 – 8160 cGy) with or without chemotherapy. Patients with no insurance, unknown insurance status, or oropharynx cancer (OPC) with unknown HPV status were excluded. Multivariate Cox regression and propensity score matching were used to adjust for imbalances in covariates. A Bonferroni correction was applied to p-values from subgroup analyses to account for multiple hypothesis testing. The analysis included 27,292 HNSCC patients with median follow-up of 52.1 months. In propensity score-matched cohorts, 3-year overall survival (OS) was 75.2% versus 63.5% for privately insured versus government-insured patients, respectively (p<0.001). In multivariate analysis, private health insurance was associated with significantly improved OS (HR 0.61, 95% CI 0.57-0.65, p<0.001) in comparison to GSI after accounting for other covariates. In subgroup analysis, private insurance was associated with improved OS across all subgroups. However, the greatest impact of private insurance was observed among patients with HPV-positive OPC (interaction p<0.001), stage T1-2 tumors (interaction p<0.001), age ≤50 (interaction p=0.001), no comorbidity (interaction p=0.001), and those receiving chemotherapy (interaction p=0.001) when performing tests of interaction in multivariable models corrected for multiple hypothesis testing. For example, private insurance was associated with a 54% (95% CI 46%-62%) relative decrease in the risk of death for HPV-positive OPC, in comparison to a 37% (95% CI 34%-40%) relative decrease in mortality for HPV-negative cancers. Patients under 65 with HNSCC with private health insurance have improved OS relative to patients with GSI. Although this effect was observed in all subgroups, the relative survival difference was largest in young, healthy patients with HPV-positive OPC and those receiving chemotherapy. This illustrates a significant disparity in our complex healthcare-delivery system which may be mitigated with future policy changes.

&lt;b&gt;Therapeutic potential of cannabidiol and its underlying mechanisms&lt;/b&gt;

This paper examines the educational challenges created by the existence of complex health care delivery systems and the need to train analysts and problem solvers to work effectively within these systems. An undergraduate, interdisciplinary curriculum, based in the College of Engineering at the Georgia Institute of Technology, is described which addresses these challenges. One particular course is used to illustrate how cognitive and experiential learning approaches are combined to provide the student with a bridge between acquiring technical skills and applying them sensitively in a real world context.

Nurse Project Consultant: Critical Care Nurses Move Beyond the Bedside to Affect Quality and Safety.

A nurse project consultant role empowered 3 critical care nurses to expand their scope of practice beyond the bedside and engage within complex health care delivery systems to reduce harms in the intensive care unit. As members of an interdisciplinary team, the nurse project consultants contributed their clinical expertise and systems knowledge to develop innovations that optimize care provided in the intensive care unit. This article discusses the formal development of and institutional support for the nurse project consultant role. The nurse project consultants' responsibilities within a group of quality improvement initiatives are described and their challenges and lessons learned discussed. The nurse project consultant role is a new model of engaging critical care nurses as leaders in health care redesign.

Dissemination of scholarship across eight cohorts of doctor of nursing practice graduates

To evaluate the publication record across eight cohorts of post-master's Doctor of Nursing Practice graduates. Dissemination of findings from evidence-based practice is described in the American Association of the Colleges of Nursing, Doctor of Nursing Practice Essential III. Students in Doctor of Nursing Practice programmes are expected to generate deliverables (e.g., a manuscript) of evidence to improve practice or patient outcomes. A descriptive study was conducted to determine whether two key manuscripts (i.e., integrative review and an evidence-based quality improvement project) were disseminated in peer-reviewed journals, and if so, the length of time from graduation to publication. Co-authorship with faculty advisors and contributors was also examined. The number of evidence-based quality improvement publications outpaces the number of integrative reviews over this span of time. Time to publication from graduation has decreased in recent years. Expecting, rather than encouraging a publishable-ready manuscript as a course deliverable would further student's motivation to disseminate their scholarship. Focused attention on faculty co-authorship may help increase the number of successful student publications for both integrative reviews and evidence-based quality improvement projects and decrease the time from graduation for those publications. Dissemination of academic scholarly work is an expected outcome for Doctor of Nursing Practice graduates who impact clinical, operational and financial outcomes in complex healthcare delivery systems.

Doctor of Nursing Practice Curricula Redesign: Challenge, Change and Collaboration

Changes in health care, including an increasingly complex health care delivery system, require advanced practice nurses to lead the charge toward meeting the triple aim target of improved cost-effective, patient-centered care. Nurse educators are challenged with developing curricula that meet national core competencies while addressing leadership, policy, and compassionate care skills. This article presents 1 university’s experience with curriculum revision including assessment, collaboration, and transition with application to both the redesign process and curricular outcomes.

Introduction of a quality improvement curriculum in the Department of Internal Medicine, Lincoln Medical Center

ABSTRACTCommunity hospitals with limited resources struggle to engage physicians in Quality improvement initiatives. We introduced Quality Improvement (QI) curriculum for residents in response to ACGME requirements and surveyed the residents understanding of QI and their involvement in QI projects before and after the introduction of the curriculum. The current article describes our experiences with the process, the challenges and possible solutions to have a successful resident led QI initiative in a community hospital.Methods: A formal QI curriculum was introduced in the Department of Internal Medicine from September to October 2015 using the Model for Improvement from Institute for Health care Improvement (IHI). Learners were expected to read the online modules, discuss in small group sessions and later encouraged to draft their QI projects using the Charter form and PDSA form available on the HI website. Online surveys were conducted a week prior and 3 months after completion of the curriculumResults: 80% (100/117) of residents completed the pre-curriculum survey and 52% (61/117) completed the survey post curriculum. 96.7% of residents report that physicians should lead QI projects and training rather than the hospital administrators. Residents had 20% increase in understanding and confidence in leading quality improvement projects post curriculum once initiated. Most Residents (72%) feel QI should be taught during residency. Active involvement of residents with interest was seen after the initiation of Open School Institute of health improvement (IHI) curriculum as compared to Institutional led QI’s. The resident interventions, pitfalls with change processes with an example of PDSA cycle are discussed.Conclusion: A Dedicated QI curriculum is necessary to prepare the physicians deliver quality care in an increasing complex health care delivery system. The strength of the curriculum is the ease of understanding the material, easily available to all, and can be easily replicated in a Community Hospital program with limited resources. Participation in QI by residents may promote constructive competitiveness among related hospitals in public system to improve delivery of safe care.Abbreviations: ACGME: Accreditation Council for Graduate Medical Education; IHI: Institute of Healthcare Improvement; PDSA: Plan-Do-Study-Act; PGY: QI: Quality improvement

Global Health Systems

Changing world conditions impact health and health services across nations. The design of a specific country's national health system historically evolved, but many times cannot cope with pressures of new social epidemics, growth in aging cohorts, and the spiraling access, cost, and quality problematic, which all nations face to varying degrees. Analysts have investigated global health systems and compared and contrasted their salient characteristics, which can aid in devising better means to address health needs in populations amidst the challenges common to all nations. This essay seeks to briefly present complex and ever-changing health care delivery systems that are increasingly being recognized for interventions in the policy and programmatic realms to improve effectiveness. It is often difficult to grasp overall national health systems in their societal contexts. A number of scholars have attempted to provide students with sufficient background for work in international health, which texts are mentioned below.

Oversight of Medical Care Quality:

Not long after physicians began to gather in organized groups and form professional societies in the 19th century, it became clear that education, training and practices were highly variable and that oversight to prevent outright quackery was needed. Although the situation is quite different today, experience has shown that continued oversight of medical care is still necessary. Some modern physicians may allow their knowledge, skills, and practices to become out of date, resulting in ineffective, unnecessary and expensive care. They may engage in any number of unprofessional behaviors, ranging from substance abuse to billing and insurance fraud, leading to disciplinary actions by external agencies. That said, providing oversight in today's highly complex health care delivery system is not a simple task to accomplish. Many rules, regulations, structures and processes have been put into place, all trying to ensure that medical care is safe, affordable and of high quality. This essay briefly describes the history and evolution of medical oversight — from its relatively simple beginnings in licensing and accreditation initiated over a century ago to the multiplex of oversight programs currently in place — including a look at some of the new, innovative and data-driven approaches being used today.

Impact Of Inter-Professional Education On Nursing Student Outcomes In The Online Environment

The implementation and integration of inter-professional education (IPE) into a curriculum is supported by the National Council of State Boards of Nursing (NCSBN), the Inter-professional Education Collaborative (IPEC), and the Institute of Medicine’s (IOM) Future of Nursing report. While there is support for implementation, there is a lack of data and guidelines which to follow currently. The purpose of this nursing research study was to investigate the impact of inter-professional collaboration on nursing student outcomes in the online environment. A co-teaching model was implemented within an online environment to provide inter-professionally lead nursing sciences courses to nursing students in a baccalaureate program. In the four sessions following the implementation of interdisciplinary collaborative teaching, 605 students completed the courses with 179 submitting the end of course survey. Results indicated that the overall student satisfaction rating with the pathophysiology online course was significant at p &lt; 0.05 following the implementation of inter-professional teaching methodology. Prior to implementation of collaborative teaching, the total enrollment in pathophysiology was 194. After the institution of collaborative teaching, the total student enrollment was 605. This reflected a significant increase in student enrollment of 311%. Today, the complex healthcare delivery system necessitates a shift from traditional education to an inter-professional collaborative teaching model that generates knowledge from interaction with a variety of educators from a variety of disciplines (Hean, Craddock, &amp; Hammick, 2012). Nursing curricula is needed which fosters both an inter-professional learning of shared knowledge and the discipline-specific learning essential for professional practice.

Applying Dynamic Simulation Modeling Methods in Health Care Delivery Research—The SIMULATE Checklist: Report of the ISPOR Simulation Modeling Emerging Good Practices Task Force

Health care delivery systems are inherently complex, consisting of multiple tiers of interdependent subsystems and processes that are adaptive to changes in the environment and behave in a nonlinear fashion. Traditional health technology assessment and modeling methods often neglect the wider health system impacts that can be critical for achieving desired health system goals and are often of limited usefulness when applied to complex health systems. Researchers and health care decision makers can either underestimate or fail to consider the interactions among the people, processes, technology, and facility designs. Health care delivery system interventions need to incorporate the dynamics and complexities of the health care system context in which the intervention is delivered. This report provides an overview of common dynamic simulation modeling methods and examples of health care system interventions in which such methods could be useful. Three dynamic simulation modeling methods are presented to evaluate system interventions for health care delivery: system dynamics, discrete event simulation, and agent-based modeling. In contrast to conventional evaluations, a dynamic systems approach incorporates the complexity of the system and anticipates the upstream and downstream consequences of changes in complex health care delivery systems. This report assists researchers and decision makers in deciding whether these simulation methods are appropriate to address specific health system problems through an eight-point checklist referred to as the SIMULATE (System, Interactions, Multilevel, Understanding, Loops, Agents, Time, Emergence) tool. It is a primer for researchers and decision makers working in health care delivery and implementation sciences who face complex challenges in delivering effective and efficient care that can be addressed with system interventions. On reviewing this report, the readers should be able to identify whether these simulation modeling methods are appropriate to answer the problem they are addressing and to recognize the differences of these methods from other modeling approaches used typically in health technology assessment applications.

Using discrete event computer simulation to improve patient flow in a Ghanaian acute care hospital

ObjectivesCrowding and limited resources have increased the strain on acute care facilities and emergency departments worldwide. These problems are particularly prevalent in developing countries. Discrete event simulation is a computer-based tool that can be used to estimate how changes to complex health care delivery systems such as emergency departments will affect operational performance. Using this modality, our objective was to identify operational interventions that could potentially improve patient throughput of one acute care setting in a developing country. MethodsWe developed a simulation model of acute care at a district level hospital in Ghana to test the effects of resource-neutral (eg, modified staff start times and roles) and resource-additional (eg, increased staff) operational interventions on patient throughput. Previously captured deidentified time-and-motion data from 487 acute care patients were used to develop and test the model. The primary outcome was the modeled effect of interventions on patient length of stay (LOS). ResultsThe base-case (no change) scenario had a mean LOS of 292 minutes (95% confidence interval [CI], 291-293). In isolation, adding staffing, changing staff roles, and varying shift times did not affect overall patient LOS. Specifically, adding 2 registration workers, history takers, and physicians resulted in a 23.8-minute (95% CI, 22.3-25.3) LOS decrease. However, when shift start times were coordinated with patient arrival patterns, potential mean LOS was decreased by 96 minutes (95% CI, 94-98), and with the simultaneous combination of staff roles (registration and history taking), there was an overall mean LOS reduction of 152 minutes (95% CI, 150-154). ConclusionsResource-neutral interventions identified through discrete event simulation modeling have the potential to improve acute care throughput in this Ghanaian municipal hospital. Discrete event simulation offers another approach to identifying potentially effective interventions to improve patient flow in emergency and acute care in resource-limited settings.