Complex Health Care System Research Articles

Evaluation of an interactive education workshop on hospital pharmacists’ ethical reasoning: an observational study

BackgroundPharmacists are often faced with scenarios in practice that require application of ethical reasoning and decision-making skills. There is limited research on the ethical decision-making processes of hospital pharmacists. Pharmacists who are compassionate and put the interests of their patients first are thought to positively impact on patient care, but there are often complex health-care system pressures in the hospital setting that cause pharmacists to behave in ways that may conflict with professional values and behaviours. This multisite study aimed to evaluate an interactive education workshop on hospital pharmacists’ ethical reasoning skills and explore the need for ongoing training and support.MethodsThis mixed-methods study was carried out across two health services including three hospitals. It incorporated a pre-workshop survey, a feedback survey immediately post-workshop and a third survey four weeks after the workshop. Semi-structured interviews were conducted with hospital pharmacists at least four weeks after the ethics workshop.ResultsIn total, 32 participants completed the pre-workshop survey, nominating peers/colleagues as the most common source of support they would consult to inform ethical decision-making (17/118 sources of support). Almost all (n = 31/33; 94%) strongly agreed/agreed that the education session provided them with ethical reasoning skills and a process/framework which they could use when faced with an ethical issue. Pre- and post-survey responses showed increased self-confidence in identifying the regulatory frameworks applicable to pharmacy privacy requirements (p = 0.011) and ethical issues applicable to pharmacy privacy requirements (p = 0.002), as well as applying ethical reasoning to scenarios that involve pharmacy privacy dilemmas/issues (p = 0.004). Participants’ self confidence in knowing where to find support when faced with clinical and non-clinical ethics questions was improved (p = 0.002 and p = 0.003 respectively). Participants supported the introduction of quarterly ethics cafes after the workshop, compared to before the workshop (p = 0.001).ConclusionHospital pharmacists rely on discussions with colleagues to brainstorm how to address ethical issues. This study showed that a targeted interactive education workshop facilitated familiarity with ethics resources and decision-making processes. It also demonstrated that this approach could be used to enhance hospital pharmacists’ readiness, confidence, and capabilities to recognise and respond to challenging ethical issues.

Self-Management Using eHealth Technologies for Liver Transplant Recipients: Scoping Review.

Liver transplantation has become increasingly common as a last-resort treatment for end-stage liver diseases and liver cancer, with continually improving success rates and long-term survival rates. Nevertheless, liver transplant recipients face lifelong challenges in self-management, including immunosuppressant therapy, lifestyle adjustments, and navigating complex health care systems. eHealth technologies hold the potential to aid and optimize self-management outcomes, but their adoption has been slow in this population due to the complexity of post-liver transplant management. This study aims to examine the use of eHealth technologies in supporting self-management for liver transplant recipients and identify their benefits and challenges to suggest areas for further research. Following the Arksey and O'Malley methodology for scoping reviews, we conducted a systematic search of 5 electronic databases: PubMed, CINAHL, Embase, PsycINFO, and Web of Science. We included studies that (1) examined or implemented eHealth-based self-management, (2) included liver transplant recipients aged ≥18 years, and (3) were published in a peer-reviewed journal. We excluded studies that (1) were case reports, conference abstracts, editorials, or letters; (2) did not focus on the posttransplantation phase; (3) did not focus on self-management; and (4) did not incorporate the concept of eHealth or used technology solely for data collection. The quality of the selected eHealth interventions was evaluated using (1) the Template for Intervention Description and Replication guidelines and checklist and (2) the 5 core self-management skills identified by Lorig and Holman. Of 1461 articles, 15 (1.03%) studies were included in the final analysis. Our findings indicate that eHealth-based self-management strategies for adult liver transplant recipients primarily address lifestyle management, medication adherence, and remote monitoring, highlighting a notable gap in alcohol relapse interventions. The studies used diverse technologies, including mobile apps, videoconferencing, and telehealth platforms, but showed limited integration of decision-making or resource use skills essential for comprehensive self-management. The reviewed studies highlighted the potential of eHealth in enhancing individualized health care, but only a few included collaborative features such as 2-way communication or tailored goal setting. While adherence and feasibility were generally high in many interventions, their effectiveness varied due to diverse methodologies and outcome measures. This scoping review maps the current literature on eHealth-based self-management support for liver transplant recipients, assessing its potential and challenges. Future studies should focus on developing predictive models and personalized eHealth interventions rooted in patient-generated data, incorporating digital human-to-human interactions to effectively address the complex needs of liver transplant recipients. This review emphasizes the need for future eHealth self-management research to address the digital divide, especially with the aging liver transplant recipient population, and ensure more inclusive studies across diverse ethnicities and regions.

Newborn screening in Mexico and Latin America: present and future

The first newborn screening (NBS) program to be implemented in Latin America was in Mexico in 1974, eleven years after the initial NBS programs in other parts of the world. In the last 50 years, progress has been made in implementing and expanding NBS in Mexico and across Latin America, yet children across the region do not fully benefit from this effective public health strategy. Here, we review the progress in the implementation of expanded NBS in Latin America with a focus on Mexico and the challenges faced by its complex healthcare system. In light of new technologies such as genomic sequencing and their potential utilization for NBS, we discuss what the future of NBS may be for Mexico and countries in Latin America and the Caribbean region, given economic and technological constraints.

Increasing Provider Utilization of a Seizure Action Plan in the Outpatient Setting.

A seizure action plan (SAP) is a powerful tool that provides actionable information for caregivers during seizures. Guidelines have expressed the need for individualized SAPs. Our quality improvement team aimed to increase implementation of an SAP within a pediatric tertiary center, initially among epilepsy providers and expanded to all neurology providers. Process changes were implemented using Plan-Do-Study-Act cycles and data were evaluated monthly using control charts. The team focused on tracking patients who received SAPs and identified opportunities for improvement, including reminders within the electronic medical record, and standardizing clinic processes. A secondary analysis was performed to trend emergency department (ED) use among our patient population. The SAP utilization rate among epilepsy providers increased from a baseline of 39% to 78% by December 2019 and reached the goal of 85% by June 2020, with a further increase to 92% by February 2022 and maintained. The SAP utilization rate among general neurology providers increased from 43% in 2018 to 85% by July 2020, and further increased to 93% by February 2022 and maintained. ED visits of established patients with epilepsy decreased from a baseline of 10.2 per 1000 to 7.5 per 1000. Quality improvement methodologies increased the utilization of a standardized SAP within neurology outpatient care centers. The SAP is a simplified tool that allows patients and providers to navigate a complex health care system. The utility of an SAP may potentially extend to minimizing unnecessary ED visits.

"Nobody does checkups back there": A qualitative study of refugees' healthcare needs in the United States from stakeholders' perspectives.

The number of refugees globally grew to 35.3 million in 2022, and many refugees are exposed to various health risks along their migration journey. As a result, they may arrive in host communities with numerous health issues, including communicable diseases and chronic and mental health conditions. Navigating the healthcare system in a host country proves to be a significant challenge for them, leading to delayed care. This qualitative study explored the convolute healthcare needs of refugees in the United States by soliciting insights from stakeholders involved in refugee resettlement and healthcare. In-depth interviews were conducted with fifteen stakeholders who work closely with refugees, including healthcare providers, cultural/clinical health navigators supporting refugees, staff from refugee resettlement agencies and governmental entities, and researchers studying refugee health. Following informed consent, interviews were audio-recorded, transcribed verbatim, and imported into MAXQDA 2022 (VERBI Software) for thematic analysis. The results revealed key themes, including the heterogeneity of refugee populations, limited awareness of preventive healthcare, high prevalence and suboptimal management of chronic conditions, complexity of the healthcare system, lack of follow-up, and language barriers. Further research is warranted concerning the long-term health of refugee populations in the United States. Additionally, more tailored programs involving peer educators are recommended to support refugee communities in navigating the complex healthcare system in the host country.

Leadership in children and young people's nursing: an evolving journey.

Children and young people's (CYP) nursing leaders have experienced considerable challenges in the context of a complex health and social care system with rapidly changing organisational structures, including the establishment of integrated care systems in England on 1 July 2022. The CYP nursing lead at NHS England commissioned a review of CYP organisational structures in emerging integrated care systems across England. The review encompassed a vision for CYP services, leadership, governance structures and opportunities for progression. A proforma was used to collate data from CYP trusts, CYP standalone hospitals and children's wards in district general hospitals. Qualitative interviews were also undertaken with senior children's nurses. At the same time, the first author of this article interviewed senior children's nurses as part of a Florence Nightingale Foundation leadership scholarship. The aim was to explore how they navigated their leadership journey and understand what advice they may give to future leaders in CYP nursing. The findings in this article identify 'what good looks like' in terms of CYP nursing leadership. Six recommendations for future development and enhancement of CYP nursing leadership are outlined.

Clinical Validation of Digital Healthcare Solutions: State of the Art, Challenges and Opportunities.

Digital health technologies (DHTs) at the intersection of health, medical informatics, and business aim to enhance patient care through personalised digital approaches. Ensuring the efficacy and reliability of these innovations demands rigorous clinical validation. A PubMed literature review (January 2006 to July 2023) identified 1250 papers, highlighting growing academic interest. A focused narrative review (January 2018 to July 2023) delved into challenges, highlighting issues such as diverse regulatory landscapes, adoption issues in complex healthcare systems, and a plethora of evaluation frameworks lacking pragmatic guidance. Existing frameworks often omit crucial criteria, neglect empirical evidence, and clinical effectiveness is rarely included as a criterion for DHT quality. The paper underscores the urgency of addressing challenges in accreditation, adoption, business models, and integration to safeguard the quality, efficacy, and safety of DHTs. A pivotal illustration of collaborative efforts to address these challenges is exemplified by the Digital Health Validation Center, dedicated to generating clinical evidence of innovative healthcare technologies and facilitating seamless technology transfer. In conclusion, it is necessary to harmonise evaluation approaches and frameworks, improve regulatory clarity, and commit to collaboration to integrate rigorous clinical validation and empirical evidence throughout the DHT life cycle.

Co-creating a continuous leadership development program in rural municipal healthcare - an action research study.

An increasingly complex healthcare system entails an urgent need for competent and resilient leadership. However, there is a lack of extensive research on leadership development within healthcare. The knowledge gaps extend to various frameworks and contexts, particularly concerning municipal healthcare, knowledge leadership, and the application of knowledge in the field of practice. This study is the first in a larger action research project that aims to co-create a knowledge-based continuous leadership development program for healthcare in a rural Arctic municipality. This present study aims to explore the knowledge and experiences of the participating healthcare leaders to develop a common basis for co-creating the program. This hermeneutical study presents the first cycle of the larger action research project. An appreciative approach facilitated the project. Twenty-three healthcare leaders from three different leadership levels attended and evaluated two leadership development workshops and participated in four focus groups. The data were analyzed using Braun and Clarke's reflexive thematic analysis. Two main themes were identified: (1) changing from striving solo players to team players, and (2) learning to handle a conflicting and complex context. These results influenced how the leadership development program based on the participants' co-creation was organized as a collective and relational process rather than an individual competence replenishment. The knowledge and experiences of healthcare leaders led to the co-creation of a knowledge-based continuous leadership development program based on the facilitated interaction of four essential elements: (1) competence development, (2) structures for interaction, (3) interpersonal safety, and (4) collective values and goals. The interaction was generated through trusted reflection facilitated by appreciative inquiry. The four elements and core played a crucial role in fostering relationships and facilitating learning, driving transformative change in this leadership development program. The study's results provide a solid foundation for further co-creating the program. However, more research is needed to fully explore the practical application and overall significance.

Realist synthesis of a rapid response system in managing mental state deterioration in acute hospital settings.

Mental state deterioration in patients poses significant challenges in healthcare, potentially resulting in adverse outcomes for patients and continued reliance on restrictive interventions. Implementing evidence-based approaches such as a rapid response system that prioritises early identification and intervention can effectively manage adverse outcomes. However, little is known regarding the effectiveness of these interventions. The objective of this synthesis was to test and refine initial programme theories by synthesising evidence to understand what works, for whom and under what circumstances. Based on the realist synthesis methodology, we searched EMBASE, CINAHL, MEDLINE, the Cochrane Library and grey literature for evidence to inform contexts, mechanisms and outcomes on the functioning of a rapid response model. We identified 28 relevant sources encompassing peer-reviewed journal articles and grey literature. This synthesis identified three important elements that contribute to the effectiveness of a rapid response system for managing mental state deterioration: care processes, therapeutic practices and organisational support. Essential elements include improving confidence and clinical skills through training, timely assessment and intervention, teamwork, communication and the creation of governance structures for monitoring and evaluation. To ensure the effectiveness, an organisation must adopt a comprehensive approach that incorporates organisational support, resource allocation, training, clear communication channels and commitment to continuous quality improvement. However, implementing interventions within a complex healthcare system requires thoughtful consideration of the organisational culture and governance structures. By taking a comprehensive and holistic approach to improvement initiatives, organisations can strive to achieve optimal outcomes in managing mental state deterioration and improving patient care.

Patterns of Service Utilization across the Full Continuum of Care: Using Patient Journeys to Assess Disparities in Access to Health Services

Healthcare organizations have a contractual obligation to the public to address population-level inequities to health services access and shed light on them. Various studies have focused on achieving equitable access to healthcare services for vulnerable patients. However, these studies do not provide a nuanced perspective based on the local reality across the full continuum of care. In previous work, graph topology was used to provide visual depictions of the dynamics of patients’ movement across a complex healthcare system. Using patients’ encounters data represented as a graph, this study expands on previous work and proposes a methodology to identify and quantify cohort-specific disparities in accessing healthcare services across the continuum of care. The result has demonstrated that a more nuanced approach to assessing access-to-care disparity is doable using patients’ patterns of service utilization from a longitudinal cross-continuum healthcare dataset. The proposed method can be used as part of a toolkit to support healthcare organizations that wish to structure their services to provide better care to their vulnerable populations based on the local realities. This provides a first step in addressing inequities for vulnerable patients in accessing healthcare services. However, additional steps need to be considered to fully address these inequities.

Abstract PO2-10-10: Developing a Continuum of Care Model to Address Healthcare Disparities in Breast and Cervical Cancer: The Promise Fund's Approach

Abstract The Promise Fund is creating a systemic change in healthcare service delivery through its Continuum of Care model in which patients are provided health education, navigation for breast and cervical health, affordable early detection screenings, diagnostics, treatment, and/or support services through an established network of providers, reducing healthcare costs, alleviating the burden of our complex healthcare system, and improving patient outcomes. This model, established in Palm Beach County, has potential to be scaled across Florida and beyond. The Promise Fund's primary focus is to eliminate preventable deaths and stop the progression of breast and cervical cancer among women in South Florida. The region faces significant healthcare disparities, with over 80,000 uninsured women in Palm Beach County alone. Disproportionately affecting minority groups, these women often experience delayed diagnoses and higher mortality rates compared to White women. Barriers such as transportation, translation, education, and childcare further contribute to suboptimal survival rates, despite high cure rates exceeding 95% for breast and cervical cancer. Through public and private partnerships, the Promise Fund established a Women's Health Center co-located at a Palm Beach County Federally Qualified Health Center (FQHC). FHQCs are community-based facilities that provide comprehensive primary care services to uninsured or low-income individuals in areas of high need. At this strategically selected FQHC, the Promise Fund supplies state-of-the-art equipment for breast and cervical cancer screenings, such as a 3D Genius Mammography Machine, donated by Hologic, Inc., ultrasounds, LEEP, and colposcopy. To facilitate access, the Promise Fund employs over 20 patient navigators positioned in FQHCs, free clinics, and community-based organizations across South Florida. These navigators connect women to resources, engage in outreach, and enroll at-risk individuals into the program. The impact of the navigators is significant, with over 20,000 women engaged, over 80 cancers treated, more than 5,000 women finding medical homes, and over 19,000 women receiving education and outreach. Additionally, the program has facilitated over 4,000 mammograms and 2,000 pap tests, all provided at little to no cost to the patients. Promise Fund Patient Navigators are well-trained, culturally competent, and bilingual. They help patients overcome barriers to care, arranging transportation, childcare, and translation services. Our navigators are carefully selected from the community and undergo rigorous training in breast and cervical health, navigation, and reporting. Moreover, the Promise Fund supports patients throughout their cancer journey by brokering low-cost or free treatment from private hospitals. Despite the prevailing healthcare disparities, the Promise Fund's patient-centered approach has yielded positive outcomes. Over 98% of women navigated by the organization comply with receiving their screening mammogram, drastically surpassing the national average. Research has consistently demonstrated that patient navigators significantly improve patient outcomes by facilitating early screening and timely access to treatment, thus reducing disease progression and healthcare costs. Additionally, the Promise Fund’s expansive Continuum of Care model effectively decreases the time patients have to wait between diagnosis and starting treatment, as well as decreases the overall treatment time for patients. The success of the Promise Fund's inaugural Women's Health Center has led to the replication of this model in three additional FQHCs in Palm Beach and Broward County, ensuring that no woman in these areas should go without essential breast and cervical cancer resources. Citation Format: Nancy Brinker, Donna Shalala, Edith Mitchell, Haywood Brown, Wayne Frederick, Jane Mendez, Deeptee Jain, David Dodson, David Brodsky, Lillie Shockney. Developing a Continuum of Care Model to Address Healthcare Disparities in Breast and Cervical Cancer: The Promise Fund's Approach [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-10-10.

Preliminary adaptation of the systems thinking for everyday work cue card set in a US healthcare system: a pragmatic and participatory co-design approach

IntroductionHealthcare is a highly complex adaptive system, requiring a systems approach to understand its behaviour better. We adapt the Systems Thinking for Everyday Work (STEW) cue cards, initially introduced as...

Effect of interventions to improve safety culture on healthcare workers in hospital settings: a systematic review of the international literature

BackgroundIn an era of safety systems, hospital interventions to build a culture of safety deliver organisational learning methodologies for staff. Their benefits to hospital staff are unknown. We examined the...

Exploring the influence of health system factors on adaptive capacity in diverse hospital teams in Norway: a multiple case study approach

ObjectivesUnderstanding flexibility and adaptive capacities in complex healthcare systems is a cornerstone of resilient healthcare. Health systems provide structures in the form of standards, rules and regulation to healthcare providers...

Empowering Healthcare through Comprehensive Informatics Education: The Status and Future of Biomedical and Health Informatics Education.

Education in biomedical and health informatics is essential for managing complex healthcare systems, bridging the gap between healthcare and information technology, and adapting to the digital requirements of the healthcare industry. This review presents the current status of biomedical and health informatics education domestically and internationally and proposes recommendations for future development. We analyzed evidence from reports and papers to explore global trends and international and domestic examples of education. The challenges and future strategies in Korea were also discussed based on the experts' opinions. This review presents international recommendations for establishing education in biomedical and health informatics, as well as global examples at the undergraduate and graduate levels in medical and nursing education. It provides a thorough examination of the best practices, strategies, and competencies in informatics education. The review also assesses the current state of medical informatics and nursing informatics education in Korea. We highlight the challenges faced by academic institutions and conclude with a call to action for educators to enhance the preparation of professionals to effectively utilize technology in any healthcare setting. To adapt to the digitalization of healthcare, systematic and continuous workforce development is essential. Future education should prioritize curriculum innovations and the establishment of integrated education programs, focusing not only on students but also on educators and all healthcare personnel in the field. Addressing these challenges requires collaboration among educational institutions, academic societies, government agencies, and international bodies dedicated to systematic and continuous workforce development.

Navigating the Patient with Heart Failure through the Health-care System – The Perspective of Hospital Nurses

Navigating the Patient with Heart Failure through the Health-care System – The Perspective of Hospital Nurses

Analyzing Patterns of Service Utilization Using Graph Topology to Understand the Dynamic of the Engagement of Patients with Complex Problems with Health Services

Background: Providing care to persons with complex problems is inherently difficult due to several factors, including the impacts of proximal determinants of health, treatment response, the natural emergence of comorbidities, and service system capacity to provide timely required services. Providing visibility into the dynamics of patients’ engagement can help to optimize care for patients with complex problems. Method: In a previous work, graph machine learning and NLP methods were used to model the products of service system dynamics as atemporal entities, using a data model that collapsed patient encounter events across time. In this paper, the order of events is put back into the data model to provide topological depictions of the dynamics that are embodied in patients’ movement across a complex healthcare system. Result: The results show that directed graphs are well suited to the task of depicting the way that the diverse components of the system are functionally coupled—or remain disconnected—by patient journeys. Conclusion: By setting the resolution on the graph topology visualization, important characteristics can be highlighted, including highly prevalent repeating sequences of service events readily interpretable by clinical subject matter experts. Moreover, this methodology provides a first step in addressing the challenge of locating potential operational problems for patients with complex issues engaging with a complex healthcare service system.

A qualitative analysis of patient and caregiver experiences with myelomeningocele through online discussion boards.

Patients and caregivers impacted by myelomeningocele (MMC) use online discussion board forums to create community and share information and concerns about this complex medical condition. We aim to identify the primary concerns expressed on these forums with the goal of understanding gaps in care that may merit investment of resources to improve care received by this population. Anonymous posts from online MMC discussion boards were compiled using internet search engines. Posts were then analyzed using an adaptation of the Grounded Theory Method, a three-step system involving open, axial, and selective coding of the data by two independent researchers to identify common themes. Analysis of 400 posts written primarily by parents (n = 342, 85.5%) and patients (n = 45, 11.25%) yielded three overarching themes: questions surrounding quality of life, a lack of support for mothers of children with MMC, and confusion with a complex healthcare system. Many posts revealed concerns about management and well-being with MMC, including posts discussing symptoms and related conditions (n = 299, 75.75%), treatments (n = 259, 65.75%), and emotional aspects of MMC (n = 146, 36.5%). Additionally, families, especially mothers, felt a lack of support in their roles as caregivers. Finally, in 118 posts (29.5%), patients and families expressed frustration with navigating a complex healthcare system and finding specialists whose opinions they trusted. MMC is a complex medical condition that impacts patients and families in unique ways. Analysis of online discussion board posts identified key themes to be addressed in order to improve the healthcare experiences of those impacted by MMC.

Understanding responsibility for health inequalities in children’s hospitals in England: a qualitative study with hospital staff

ObjectivesThis study aimed to understand how staff in children’s hospitals view their responsibility to reduce health inequalities for the children and young people who access their services.DesignWe conducted an exploratory...

PHARMACY PRACTICE STANDARDS AND CHALLENGES IN NIGERIA: A COMPREHENSIVE ANALYSIS

Pharmacy practice standards and challenges in Nigeria constitute a critical area of concern due to their profound impact on healthcare delivery and patient outcomes. This comprehensive analysis delves into the multifaceted landscape of pharmacy practice in Nigeria, highlighting prevailing standards and the array of challenges faced by pharmacists in their professional endeavors. Nigeria, like many other developing countries, grapples with a complex healthcare system marked by resource constraints, regulatory ambiguities, and evolving patient needs. Within this context, pharmacists play a pivotal role as frontline healthcare providers, responsible for ensuring safe and effective medication use. However, the absence of robust regulatory frameworks and standardized practices poses significant hurdles to the delivery of quality pharmaceutical care. This analysis examines the existing pharmacy practice standards in Nigeria, emphasizing the role of regulatory bodies such as the Pharmacists Council of Nigeria (PCN) in setting guidelines and enforcing compliance. It also scrutinizes the challenges encountered by pharmacists, including inadequate infrastructure, limited access to essential medicines, counterfeit drugs, and insufficient professional development opportunities. Furthermore, the analysis explores the impact of socio-economic factors, cultural beliefs, and healthcare disparities on pharmacy practice in Nigeria. It underscores the need for collaborative efforts among stakeholders, including government agencies, healthcare institutions, pharmaceutical industry players, and professional associations, to address these challenges comprehensively. In conclusion, this study underscores the importance of enhancing pharmacy practice standards in Nigeria to promote patient safety, optimize medication therapy outcomes, and advance public health objectives. By addressing the identified challenges and fostering a supportive environment for pharmacists, Nigeria can harness the full potential of its pharmacy workforce to meet the healthcare needs of its population effectively.
 Keywords: Pharmacy, Standards, Nigeria, Practices, Review.