Complex Health Care System Research Articles

Return on Investment With Health Care Simulation.

Delivering simulation across a health system can engage the entire workforce by moving beyond traditional educational delivery and focusing on broader organizational needs specific to a particular organization. The commonly known use of simulation as a form of life support education has progressed to include fully immersive simulation experiences focusing on team-based communication, leadership, fellowship, and clinical care. It continues beyond this point with the inclusion of patient safety strategies, root cause analysis investigation, leadership, and management training, and recently, it has included environments that catalyze innovation in complex healthcare systems. The focus on pure fiscal elements of simulation-based approaches does not give a health system the accurate nontangible benefits simulation can provide, and importantly, acknowledging that each location has differing needs is essential when considering what investment should be made and where. A small community hospital will have vastly different needs from specialty hospitals that deliver specialist care. It must also be understood that every simulation center, to some extent, will always be unique, as it should. The commonly quoted statement "when you have seen one simulation center, you have seen one simulation center" really does reflect the reality of this established and rapidly growing specialty. In this article, we reflect on the traditional use of simulation and discuss some wider uses that may engage a wider audience and, importantly, provide a greater return on investment for your facility, making the case for investment more reasonable and impactful to each part of a busy health system.

Sexual and Gender Diverse Healthcare Navigation Model: A Community-Participatory Delphi Adaptation of the Transitional Care Model for Sexual and Gender Diverse Individuals

ABSTRACT Health care transitions, movements between providers or settings, can lead to poor outcomes, higher resource utilization, and even higher costs. Health care transitions can be complex experiences for sexual and gender diverse (SGD) individuals, especially when there is a need for ongoing health care (e.g. gender-affirming therapy, depression). Engaging new providers can lead to setbacks in trust requiring self-disclosure SGD-identities all over again. The Transitional Care Model (TCM) supports improvement of outcomes associated with health care transitions; however, it has not been tailored to address the unique needs of SGD populations. A sample of adult SGD patients (n = 17) and SGD health experts (n = 11) from across the US completed a six cycle, electronic, modified Delphi process to adapt the TCM for the SGD population. The iterative process produced a TCM for SGD populations including eight refined and renamed components with SGD-specific descriptions and exemplars. The resulting model, the Sexual and Gender Diverse Healthcare Navigation Model, provides an eight-component adaptive model of transitional care that centers SGD patients and their support systems across complex health care systems. The consensus panel provided descriptions for each of the eight resulting components—identifying three foundational components—the right staffing, awareness of needs and risks, and engaging individuals and their support systems throughout transitions in care. This model stands to support improved health outcomes among SGD through a multi-component, patient centered approach to health care navigation.

Predictive analytics of complex healthcare systems using deep learning based disease diagnosis model

Cancer is a life-threatening disease resulting from a genetic disorder and a range of metabolic anomalies. In particular, lung and colon cancer (LCC) are among the major causes of death and disease in humans. The histopathological diagnoses are critical in detecting this kind of cancer. This diagnostic testing is a substantial part of the patient’s treatment. Thus, the recognition and classification of LCC are among the cutting-edge research regions, particularly in the biological healthcare and medical fields. Earlier disease diagnosis can significantly reduce the risk of fatality. Machine learning (ML) and deep learning (DL) models are used to hasten these cancer analyses, allowing researcher workers to analyze a considerable proportion of patients in a limited time and at a low price. This manuscript proposes the Predictive Analytics of Complex Healthcare Systems Using the DL-based Disease Diagnosis Model (PACHS-DLBDDM) method. The proposed PACHS-DLBDDM method majorly concentrates on the detection and classification of LCC. At the primary stage, the PACHS-DLBDDM methodology utilizes Gabor Filtering (GF) to preprocess the input imageries. Next, the PACHS-DLBDDM methodology employs the Faster SqueezeNet to generate feature vectors. In addition, the convolutional neural network with long short-term memory (CNN-LSTM) approach is used to classify LCC. To optimize the hyperparameter values of the CNN-LSTM approach, the Chaotic Tunicate Swarm Algorithm (CTSA) approach was implemented to improve the accuracy of classifier results. The simulation values of the PACHS-DLBDDM approach are examined on a medical image dataset. The performance validation of the PACHS-DLBDDM model portrays the superior accuracy value of 99.54% over other DL models.

“Going under the radar”: barriers to continuity in the rehabilitation trajectories of adults with acquired brain injury in North Norway

Purpose Acquired Brain Injury (ABI) is a major cause of disability, but rehabilitation services for adults with ABI discharged home remains deficient. This study explores barriers to continuity in the rehabilitation trajectories of this population in North Norway. Materials and methods Data were generated from focus groups consisting of individuals with ABI and family caregivers (n = 5) and healthcare professionals (n = 14). Purposeful sampling of participants (total n = 19) ensured diverse perspectives. A reflexive thematic analytical approach was applied to identify recurring themes. Results This study reveals significant misalignment between the support needs of home-dwelling adults with ABI and the existing healthcare system in North Norway. Four themes were identified: (1) A lack of awareness of patient rehabilitation needs in hospitals, (2) individuals with ABI slipping through the cracks during transitions, (3) constraints in municipal healthcare services’ capacity, and (4) unclear rehabilitation pathways for individuals with ABI. Conclusions Individuals with ABI need assistance navigating complex healthcare systems, gaining insight into their functional problems, and expressing needs and goals. The findings support calls for a paradigm shift in ABI rehabilitation, advocating for a transition from impairment-focused to reengagement-oriented practices as individuals with ABI transition from inpatient to home settings with increasingly stable residual impairments.

Implementation of bedside handover that includes patients or carers in hospital settings: A systematic review.

Increasing complexity in healthcare systems necessitates effective handover. While a universal structure is often recommended, many frameworks do not include the patient. A systematic review was completed examining outcomes following handover that included patients or carers using a realist-orientated paradigm. The research group used Covidence™ software and followed PRISMA guidelines. A librarian-led search of Embase, Medline, PsycINFO and SCOPUS yielded 5,790 relevant studies for screening. Included studies reported on peer-reviewed studies that assessed qualitative or quantitative outcomes resulting from patient-centred handover. To assess quality, we used the McMaster Mixed Methods Appraisal Tool (MMAT). Patient-orientated and quantitative outcomes are reported descriptively. For qualitative outcomes, we employed a deductive analytical approach. Braun and Clarke's steps were followed to develop themes with group work used to clarify and discuss the various codes. Heterogenous reporting precluded meta-analysis. Thirty studies were eligible (10 mixed methods; 11 quantitative; 9 qualitative) with variable quality and scope. Most studies related to nursing-led bedside handover and originated in Anglophone countries. Positive effects were reported for patient satisfaction, engagement, autonomy and effective information exchange. Providers reported a positive experience but also barriers to implementation, cognitive load and reducing compliance over time. There were contradicting findings for patient-orientated outcomes including falls risk. Publication bias may have led to under reporting of negative trials. There was limited reporting on physician-led handovers that included patients. Patient-centred handover was associated with self-reported benefits for patients and providers but potential advantages over conventional handover could be undermined by barriers such as time, implementation challenges and a perceived increase in staff workload.

Role of caregivers being trained in assisting in end of life care - Latin American perspective.

Palliative care in Latin America is evolving, but training for informal caregivers remains underexplored. This review summarizes recent interventions to educate or train caregivers in end-of-life care. The literature search identified three interventions published by 2023, two with reception evaluations, all with small sample sizes and no control groups. Needs of caregivers have been more frequently described and include training on aspects of the disease, nursing skills, how to handle patients´ and own emotions; help in navigating the complex healthcare systems in Latin America; help in conversations about the end of life and dying, still taboos in the region; help in finding additional caregivers or other types of support to make the caregiving role sustainable over time for the caregiver. Interventions mainly focused on emotional support and identifying additional caregivers without guilt; two included nursing skills training. There are very few formal interventions described and evaluated to assist caregivers in end-of-life care in Latin America described in the literature. This illustrates the rather invisible but very important role of these important stakeholders in the care for patients. Multidimensional interventions should be developed and evaluated to support caregivers.

Onboarding Foreign-Educated Nurses: Best Practices for Nurse Educators.

For foreign-educated nurses (FEN) to effectively adapt to the complex healthcare system that exists in the United States, they need effective onboarding and integration into the workforce and community. A positive transition to practice promotes loyalty, confidence in clinical competence, and professional development. Using best practice guidelines in the literature, nurse educators can develop, implement, and evaluate transition programs for FEN practicing in the United States.

Interrogating the effectiveness of service engagement for underserved populations in complex health and social care systems: towards an equitable engagement strategy

There are increased sector-wide efforts within health and social care systems to engage those with lived experience in service design, delivery, and monitoring – aiming to secure more equitable health outcomes. However, critical knowledge gaps persist around how national whole-system engagement strategies can account for the challenges experienced by populations that encounter exclusion within complex multi-layered systems. This includes a failure to delineate shared challenges across groups, and to develop transferable cross-group frameworks to assist sector-wide change. There is, therefore, a danger that those groups already least heard will be collectively left behind. With a view to informing a more inclusive engagement strategy in Ireland, this national study aims to investigate multi-level (policy and strategic, operational, on-the-ground services, individual) shared challenges impacting engagement for five populations who have been identified as underserved groups in a complex health and social care system, including: (1) those who misuse drugs and alcohol, (2) those who are experiencing homelessness, (3) those experiencing mental health, (4) migrants and those of minority ethnicies, and (5) Irish Travellers. Adopting a mixed-methods approach which draws on an evidence-informed multistakeholder perspective, this study employs data from: focus groups and life-course interviews with lived-experience populations (n=136), five focus groups (n=39) and a national on-line survey (n=320) with population-specific services providers; and national-level stakeholder interviews (n=9). Two cross-group participatory consultative forums with lived-experience and provider participants (n=28) were used to co-produce priority action areas based on study findings. This article presents findings on shared challenges in engaging these groups around leadership and commitment, implementation and action, population capacities, trust, and representation, stigma, and discrimination. Derived from these challenges, six development areas are presented to advance an inclusive equitable engagement approach in Ireland. These comprise: 1) balancing top-down prioritisation, and bottom-up direction; 2) sustaining multi-level, multi-form implementation; 3) measuring effectiveness and action; 4) embedding inclusive equitable engagement; 5) trust as a prerequisite, and outcome; and 6) an equalising, agency empowering agenda.

Conceptual Considerations for Understanding Resilience in Healthcare Students.

Increasing attention has been given to the concept resilience in the context of healthcare especially during and post the COVID pandemic. Much of the inquiry and evidence reported has focused on promoting or enhancing resilience in healthcare for improving the quality of care and reducing medical negligence. This discursive paper aims to highlight how resilience is conceptualised and identify any potential limitations or gaps in the context of healthcare students, acknowledging considerations for further development and research into this topic. This discursive discussion draws on relevant theoretical underpinnings from the fields of adjustment and coping psychology, and research and evidence from health sciences, for facilitating an understanding of resilience in supporting healthcare students to adapt into professional practice. Investigation of resilience in healthcare students is mainly identified at an individual level as personal traits or skills for working within complex healthcare systems and clinical environments. Less attention has been given to examining resilience at the organisation or systemic level. This is primarily because of limited frameworks for investigating resilience from a multidimensional perspective recognising a wider systemic level influenced by external factors including socioecological determinants, for example, available support services for healthcare students. The link between resilience and its function to mitigate against associated neuropsychological distress and subsequent pathopsychological disorders in healthcare student cohorts is recognised; however, greater understanding of resilience as a multidimensional construct is warranted. A multidimensional investigation of resilience is critical for the preparation and readiness of healthcare structures and organisations in facilitating the needs of healthcare students entering challenging and diverse healthcare working environments. No patient or public contribution.

New horizons in systems engineering and thinking to improve health and social care for older people.

Existing models for the safe, timely and effective delivery of health and social care are challenged by an ageing population. Services and care pathways are often optimised for single-disease management, while many older people are presenting with multiple long-term conditions and frailty. Systems engineering describes a holistic, interdisciplinary approach to change that is focused on people, system understanding, design and risk management. These principles are the basis of many established quality improvement (QI) tools in health and social care, but implementation has often been limited to single services or condition areas. Newer engineering techniques may help reshape more complex systems. Systems thinking is an essential component of this mindset to understand the underlying relationships and characteristics of a working system. It promotes the use of tools that map, measure and interrogate the dynamics of complex systems. In this New Horizons piece, we describe the evolution of systems approaches while noting the challenges of small-scale QI efforts that fail to address whole-system problems. The opportunities for novel soft-systems approaches are described, along with a recent update to the Systems Engineering Initiative for Patient Safety model, which includes human-centred design. Systems modelling and simulation techniques harness routine data to understand the functioning of complex health and social care systems. These tools could support better-informed system change by allowing comparison of simulated approaches before implementation, but better effectiveness evidence is required. Modern systems engineering and systems thinking techniques have potential to inform the redesign of services appropriate for the complex needs of older people.

Raising the Flag of Vigilance on Mpox Outbreak in Indonesia: Are We Prepared?

In the wake of the COVID-19 pandemic, the world has become acutely aware of the devastating impact of infectious diseases on public health, economies, and societies. As we gradually recover from the aftermath of COVID-19, another potential threat looms on the horizon, mpox, formerly known as monkeypox. The recent surge in mpox cases worldwide has prompted health authorities to sound an alarm, and Indonesia, as a populous nation with a complex healthcare system, must ask itself: Are we prepared for this emerging challenge?. The question "Are we prepared?" may not have a simple yes or no answer. Instead, it should serve as a reminder of the need for vigilance, adaptation, and continuous improvement in public health systems. As we navigate this new health challenge, the true measure of Indonesia's preparedness is its ability to respond swiftly, effectively, and equitably to protect the health and well-being of all citizens.

Filling the gaps in the COVID-19 pandemic response: medical personnel in the US military health system

BackgroundThe COVID-19 pandemic was an unprecedented public health emergency that heavily affected the healthcare workforce. Although the Military Health System (MHS) has robust capabilities and was able to deploy medical staff to support civilian hospitals during the crisis, it too was adversely impacted by personnel issues. We aimed to identify and address gaps in understanding the impact of the COVID-19 pandemic on healthcare personnel in the MHS.MethodsWe conducted semi-structured key informant interviews with 28 MHS stakeholders, including policymakers, program managers, and healthcare providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo.ResultsBurnout and mental health concerns across the workforce increased during the pandemic, although some felt military culture facilitated resilience. Reduction in personnel was noted and slow hiring processes and noncompetitive wages hindered hiring, contributing to staffing shortages. Initial disruptions occurred in training and skills readiness, although these issues were reduced over time. Concerns remain about newer trainees’ preparedness and teaching staff’s availability in the MHS.ConclusionThis study uniquely assessed the impact of the COVID-19 pandemic response on the MHS healthcare workforce through in-depth key informant interviews. Multi-pronged strategies are needed to promote personnel well-being in complex healthcare systems like the MHS.

When Things Go Right: Safety II in an Academic Emergency Department.

Objectives Historically, "safety" has been defined as an absence of error. Practice variability of any kind has been viewed as a threat. This is termed Safety I. Meanwhile, Safety II posits that clinician practice variability is a necessary adaptation required to meet patient needs in a complex healthcare system. We hypothesize that clinicians in the emergency department (ED) make proactive adaptations and utilize practice variability to enhance safety. Methods This is a cross-sectional survey-based study of clinical team members at a tertiary care academic ED with an annual census of 76,000. Qualitative data on instances of proactive safety were collected and analyzed via inductive response analysis. Ratings of support for practice adjustments and experiences of negative emotions during practice variability were collected using 5-point Likert scales. Results There were 84 respondents, of which 33 (39%) were nurses, 28 (33%) were physicians, and 23 (27%) held other clinical roles. Qualitative data included 128 instances of harm prevention, with some respondents describing more than one. Instances include proactive safety via collaboration (n = 47; 36.72%), time-based interventions (n = 46; 35.94%), physical harm prevention (n = 27; 21.10%), and patient/visitor interactions (n = 8; 6.25%). Of respondents, 73.17% (n = 30) felt that policies matched daily work most of the time, and 92.68% (n = 38) felt enabled to adapt to the needs of a patient most of the time. Experiences of self-doubt, fear of repercussion, or anxiety occurred most when adhering to a policy despite patient needs (n = 20; 48.78%). Conclusions Clinical team members report keeping patients safe through various forms of behavior adaptations, most frequently reporting collaboration beyond usual expected practice. Respondents report policies to match daily work most of the time and feel enabled to adapt to the needs of patients. Feelings of self-doubt, fear of repercussion, or anxiety were reported most frequently when clinicians adhered to a policy despite the needs of a patient.

Needs Assessment for a Leadership Course in Saudi Medical Schools: The Student Perspective.

Leaders in healthcare no longer need to hold formal management positions; instead, leadership is perceived to be the responsibility of all healthcare professionals. Despite changes in curricula and teaching design, however, this review of the content taught in medical colleges in Saudi Arabia reveals a lack of leadership and a failure to equip young graduates to compete on the global stage. Medical students need leadership skills for patient care, cooperation, and navigating the complex healthcare system. Clinical management skills in hospitals require these talents also. The complexity of healthcare and the impact healthcare executives have on people's lives highlight the importance of these skills. Thus, healthcare practitioners must develop non-technical skills like proactivity, motivation, and change management to lead across professional boundaries and negotiate the increasingly complex healthcare landscape. This cross-sectional study combines a quantitative approach with a self-administered questionnaire-based survey. The sampling procedure is a non-probability convenience technique, adapted for 700 male and female undergraduate medical students from four medical colleges. Of the students, 75.46% had minimal leadership experience and 22.69% had some leadership experience; 3.02% of 464 students considered themselves highly experienced in leadership. As the needs assessment and other relevant factors show, leadership should be introduced as a skilled subject. There will always be a growing demand for competent medical graduates, who are capable of becoming future leaders. Although elementary leadership concepts remain fundamentally the same, curricular development must focus on the needs of society and stakeholders.

Healthcare quality improvement: It's time to update the Donabedian approach with a complex systems perspective.

There is broad consensus that healthcare systems are complex systems, which as a result, face complex problems. From this perspective, quality of care can be conceptualised as an emergent outcome of the healthcare system, that is more than the sum of individual components of care (in terms of inputs and processes), and quality improvement as a complex systems problem. However, traditional approaches, such as Donabedian's structure/process/outcome framework, are rooted in a linear, reductionist perspective, that fails to recognise that quality of care is created in the context of complex healthcare systems, and the many interactions and uncertainties at play that shape quality of care and health outcomes. A paradigm shift is needed from a reductionist to a systems thinking approach if we are to better understand and improve quality of care. Such a shift begins with asking different research questions, situated within the system context, that focus on identifying how interventions may contribute to system improvement, as opposed to seeking to directly link interventions with quality of care outcomes. In contrast to traditional healthcare quality measures focusing on single components of the system in isolation, research needs to explicitly consider quality of care as an emergent system outcome and identify new indicators and methods of assessment that provide insight into how the healthcare system functions as an interconnected whole. It is an opportune moment to harness the energy of the international healthcare quality movement to drive the innovation needed in research and practice to adopt a systems thinking approach.

The Impact of Health Policy on Access to Healthcare: Utilizing Geographic Information Systems (GIS) for Detailed Access and Equity Mapping

Health policies are significant in relation to health equity and accessibility. Achieving equity in health care must understand the geographic distribution of health care and the impact of policy decisions on access Planners can use Geographic Information Systems (GIS) as an aid powerful to visualize and scrutinize these differences. The current study addresses some of the challenges of integrating multiple data sources, definitions of access and equity and the dynamic nature of health care processes. Furthermore, sophisticated analytical methods are needed to truly map all complex health care systems. Therefore this paper, describe a cross-sectional mental health treatment (C-SMHT) that uses a fuzzy inference system to assess justice and access to health care. Using ambiguous GIS data to address uncertainty and environmental variability, this approach provides a comprehensive picture of how policy change has shaped health disparities to improve. C-SMHT has many applications for policy makers as well as public health practitioners. This paper will provide a snapshot of mental health provider availability and utilization. Simulation studies to examine how the effectiveness of the C-SMHT approach can help to better identify underserved areas, better allocate resources, and deliver treatment were found to be good. A number of initiatives will be developed as part of this project to assess their impact on the availability of mental health services in defined areas or countries. In addition to providing recommendations to policy makers based on research findings, the simulation will also provide insights into how policies affect equity and access.

Management of BRCA-associated breast cancer patients in low and middle-income countries: a review.

Breast cancer poses a significant global health challenge, with higher incidence rates in developed countries. However, low- and middle-income countries (LMICs) suffer from higher mortality rates due to various factors, including limited screening programs, delayed diagnosis and inadequate access to healthcare and advanced treatments. Approximately 5%-10% of breast cancer cases stem from germline mutations in BRCA-1/2 genes. A positive BRCA1/2 status obtained through genetic testing significantly influences surgical and medical treatment decisions. Therefore, genetic counseling, proper surveillance and customized interventions for BRCA1/2 carriers are essential to maximizing the benefits of monitoring, chemoprevention and risk-reducing surgeries for breast and ovarian cancers. Identification of BRCA mutations also impacts treatment strategies, leading to the integration of chemotherapeutic agents like platinum-based chemotherapy and PARP inhibitors. However, implementing these advanced treatment guidelines in LMICs with complex, fragmented and underfunded healthcare systems presents numerous challenges. In this review, we explore the current status and obstacles associated with managing BRCA1/2-associated breast cancer in LMICs.

A network frame offers a promising transdisciplinary tool for understanding complex health and health care system problems like suicide

As health and health care systems continue to face massive challenges from local to global well-being, understanding the processes that lead to improvement or deterioration in human health has embraced a broad range of forces from genes to national cultures. Despite the many efforts to deploy a common framework that captures diverse drivers at scale, the common missing element is the absence of a flexible mechanism that can guide research within and across levels. This hinders both the cumulation of knowledge and the development of a scientific foundation for multiplex interventions. However, studies across disciplines using a wide variety of methods and measures have converged on "connectedness" as crucial to understanding how factors operate in the health space. More formally, a focus on the critical role of the network structure and content of key elements and how they interact, rather than just on the elements themselves, offers both a generalized theory of active factors within levels and the potential to theorize interactions across levels. One critical contemporary health crisis, suicide, is deployed to illustrate the Network Embedded Symbiome Framework. The wide range of health and health care research where networks have been implicated supports its potential but also cautions against inevitable limits that will require creative theorizing and data harmonization to move forward.

Institutional ethnography: A methodology for exploring complex problems in healthcare systems.

Healthcare professionals experiencing barriers in the delivery of care are often unaware of factors within complex institutions that create and perpetuate those problems. Institutional ethnography in healthcare is a research methodology that starts from the perspective of a problem that clinicians or people receiving care experience and seeks to identify how those negative experiences are coordinated by institutional structures. This paper describes and advocates for the use of institutional ethnography as a powerful tool to investigate problems experienced by individuals or groups in the complex systems of healthcare design and delivery. It is a research methodology that has been adopted across settings in North America, although it has the potential to be utilized more broadly across other settings by clinicians and researchers. This echoes calls from other authors for its use across a wider range of healthcare disciplines and settings. Institutional ethnography is an underutilized research methodology that has potential to address a wide range of challenges experienced in contemporary healthcare. It offers healthcare clinicians the opportunity to better understand and resolve issues affecting their practice within complex healthcare systems.

Consilience of healthcare legislation, complexity science & computational analysis

Our US Health Care System (HCS) has evolved from simple to complex and needs reform. Thus far, all legislative initiatives have failed to result in establishing a friendly, cost-effective, quality healthcare system. The question becomes, can Complexity Science (CS) and computational analytic platform modeling be used to help create better Health Care Policies (HCP) and reform our all too complex HCS? Modeling has been used in many diverse disciplines but has yet to be utilized in preemptive evaluation of major US legislative HCPs. Review of US Health Care Policy History (HCPH) viewed in the context of a Complex Adaptive System(CAS) reveals how, unanticipated historical events, politics, social, and personal leadership have tangentially shaped our US HCPs. Future construction of HCPs with the help of CS, and preemptive computational modeling (CM) techniques, will hopefully yield stronger conclusions in legislative HCP construction and advance our US HCS into one with dynamic resilience.