Complex Health Care System Research Articles

Current state of reflective learning in anaesthesiology residents: a call for 'reflection-on-action' training in Singapore.

Reflective learning is the cognitive process whereby information from new experiences is integrated into existing knowledge structures and mental models. In our complex healthcare system, reflective learning (specifically 'reflection on action') is important for postgraduate learners. We observed that our anaesthesiology residents were not building on their competence through deliberate experiential and reflective practice. This qualitative study explored the current state and challenges of reflective learning in anaesthesia training in Singapore. This study was conducted at KK Women's and Children's Hospital, Singapore, from 1 January 2018 to 31 October 2018. A semi-structured interview format was used in focus groups. Information collection continued until data saturation was reached. The interviews were coded and analysed, and themes were identified. Seven focus group interviews involving 19 participants were conducted. Reflective learning was found to be poor. It was of concern that the stimuli for reflection and reflective learning emerged from medical errors, critical incidents and poor patient outcomes. Challenges identified were: (a) lack of an experiential learning framework; (b) need for reflective training; (c) quality of experiential triggers; (d) clinical pressures; and (e) poor learner articulation and feedback. We described some strategies to frame, teach and stimulate reflective learning. This study described the state and challenges of reflective learning in anaesthesia training. We advocate the implementation of reflective training strategies in postgraduate training programmes in Singapore. Research is warranted to integrate patient feedback and outcomes into reflective practice.

Is Attachment Theory the Answer to a Complex Healthcare System?

AimsThis article proposes the need for a theoretical framework that can be applied to underpin the varied idiosyncratic mental health systems.MethodsBowlby's Attachment Theory defines a set of values that are required for a developing child to acquire a stable base which allow for healthy psychological development into adulthood. These values and behaviours may serve as a caring and holistic framework for people using mental health services.ResultsThe outcomes in mental health remain unsatisfactory and services are overall fragmented and increasingly specialised. Ongoing recognition of the inter-related relationship between a person's immediate and social environment and their mental health are frequently overlooked as services become ever stretched in terms of finances, capacity and limited resources including support for staff. The emphasis of treatment is on illness instead of the multifactorial humanity of the individuals using the services. A key outcome of mental health provision is recovery but instead, recovery is compromised by a reductive approach to care that may paradoxically compromise rights, autonomy, confidence and self-belief when people are at their most vulnerable. This creates feelings of mistrust, uncertainty and a limited sense of safety toward services.Attachment theory takes into account the individual, their experiences, their social world and the significant people in their lives. The principles required for the developing child to develop a secure attachment from a stable base are similar to those required for people experiencing mental illness to facilitate recovery and develop resilience to help manage and reduce episodes of relapse.Systems that work well, frequently exhibit values underlying models of care that include continuity, consistency, respect, safety, autonomy, human rights, freedom, supportive, trusting relationships and collaboration. The opposite of that seen in what presents as autocratic and risk-averse approaches of many mental health services.The principles required to enable a child to develop into a psychologically well-adjusted adult are similar to those required when a person is at their most vulnerable. Episodes of mental illness can be a time for reflection and growth, with the right care and therapeutic intervention, illness can also be a time to learn and develop skills for greater resilience in future.ConclusionThis paper outlines the implications and cultural changes that are required so that the principles of attachment theory can serve as a theoretical framework across mental health services to provide a stable base for people using the services and staff providing the care.

Formulary management guiding principles for automated systems.

Structural and financial changes in US healthcare are the driving forces reshaping care delivery and the technologies that clinicians use in their practice. Structural-level changes in healthcare organizations bringing facilities varying in size, systems, and complexity under the new integrated care delivery networks create unprecedented challenges. This paper develops guiding principles for formulary management in automated systems that facilitate medication management and alignment of medication information technology (IT) solutions in healthcare organizations ranging in size from a single facility to very large enterprise/multifacility networks. This paper describes formulary management best practices for healthcare organizations as they follow crucial medication management processes: formulary item builds, urgent and nonformulary medication requests, and formulary item build testing and maintenance. As medication management practices are embedded in automated technologies that are similar yet nuanced, we pay special attention to practices and change control processes that maximize coordination among systems while preserving medication data integrity and reducing medication errors. For increasingly complex healthcare systems with multiple medication management system demands, formulary drug database builds and maintenance are challenging and time-consuming. Formulary item build, testing, and maintenance processes involve multifunctional teams collaborating to ensure the integrity of data, prevent unexpected system incompatibilities, and improve patient safety by reducing medication errors. Ideally, formulary item build, testing, and maintenance processes produce consistent final drug records in IT systems meeting user needs.

Self-Perception of Transition Readiness Amongst Pediatric Patients with Childhood Heart Disease.

This study assesses self-report of transition readiness among adolescents and young adults (ages 12-25years) with childhood and congenital heart disease (CHD), receiving care at Hasbro Children's Hospital, whose CHD diagnosis warranted transfer to adult cardiology care. Patients were mailed the American Academy of Pediatrics/American College of Physicians Transition Readiness for Youth Assessment survey. Confidence scores ranged between 0 (not) and 10 (very). Mann-Whitney U test was used to assess differences in scores between younger (12-17years) and older (18-25years) groups. 396 patients met inclusion criteria; 88 surveys were returned. Half of respondents were in the older group. While most respondents felt empowered to take charge of their own health and equally confident about moving to adult care, this did not always translate to actual knowledge. Younger patients had statistically significant lower knowledge scores in these metrics. Aspects of care with low scores include medication refills, communication with primary care team, and the lifelong need for cardiology follow up and health insurance. This discrepancy between self-report and actual knowledge highlights the need for more varied and age appropriate interventions to help patients navigate a complex healthcare system. A concrete approach to acquire the knowledge necessary to ensure successful transfer to adult cardiology care should be a focus.

How digital health documentation transforms professional practices in primary healthcare in Denmark: A WPR document analysis.

Historically, recordkeeping has been an essential task for health professionals. Today, this mandatory task increasingly takes place as digital documentation. This study critically examines problem constructions in practical documents on digital documentation strategies in Danish municipal healthcare and how these problem constructions imply particular solutions. A document analysis based on the approach presented in Bacchi's "What's the problem represented to be?" was applied. Forty practical documents in the form of guidelines, strategies, and quality control documents were included. The analysis uncovered three problem representations: lack of coherence between health services in a complex healthcare system, lack of assessable data for management and political prioritization, and inefficiency in the healthcare system. The proposed solution is a digitalized and standardized practice that transforms recordkeeping in the municipalities. However, municipal healthcare is at risk of being fragmented due to digital documentation's focus on the organizational management of health with task-oriented practices supplied by an anonymous health professional. We find that digital documentation functions as an organizational micromanagement approach that assigns the health professional a subject position as an employee acting according to the organization's framework rather than the profession's normative framework.

Simulation of Supply Chain Resilience Model of the Pharmaceutical Industry in the Country in the Supply of Remdesivir Using System Dynamics Approach

Background: In the event of a crisis and epidemic of infectious disease, ensuring the proper and timely supply of necessary medicine is one of the main priorities of the health care system in any country. Therefore, the present study investigates the resilience of the Iranian medicine supply chain using the system dynamics simulation method in increasing the level of access to Remdesivir.
 Methods: This is a development-applied study to provide a model using the system dynamics approach, which first presents a rich image that is based on the model, and then cause-effect models appropriate to the observations made. It was structured on the behavior of the system and also inspired by valid theories. The effect of key factors affecting the supply chain resilience of the country’s pharmaceutical industry was designed and analyzed using a system dynamics approach using decision support system (DSS) Vensim software. The time horizon considered for this research was 5 years, from 2019 to 2023. To predict and simulate the system dynamics model, the data collected from the questionnaires and the interviews with experts in this field were used.
 Results: Based on the result of this study, it can be expected that by reducing the schedule pressure by 1 and 3 % during the time of the study, the resilience of the supply chain of remedesvir in the country upgraded to about 32% and 47%.
 Conclusions: According to the complexity of health care systems, it is difficult to recognize the interaction of different variables, therefore, the effect of interventions is not immediately recognizable and requires the passage of time. In addition, the majority of the factors influencing health care outcomes are nonlinear. Therefore, the use of simulation models can help to clarify the indirect behavior of complex health care problems.

The Concept of Pharmacy Ethics and the Examples of Ethical Dilemmas Encountered by Pharmacists in the Asir Region, Saudi Arabia: A Qualitative Study.

IntroductionPharmacists’ involvement in patient care is expanding. The inclusion of this function within a complex healthcare system populated by demanding patients may create ethical challenges. In Saudi Arabia, few studies have been conducted on pharmacy ethics, and the available data are quantitative in nature. Thus, there remains a need for a qualitative assessment of the ethical dilemmas facing pharmacists.MethodsThis exploratory study utilized a qualitative methodology that included open-ended, in-depth, semi-structured interviews, followed by content analysis. The study recruited credentialed pharmacists from community and hospital pharmacies. Themes and codes were created and classified.ResultsEighteen pharmacists were interviewed, and their responses were categorized into eight areas of ethical dilemma: beneficence and non-maleficence, autonomy, justice, confidentiality, veracity, communication skills, sincerity and religion, and law. Taken together, it appears that most of the ethical challenges to the practice of pharmacy center on the theme of beneficence and non-maleficence. Additionally, it was found that some social and religious practices and beliefs contribute to the formation of participants’ ethical backgrounds.ConclusionThese findings may aid in the development of national pharmacy ethics guidelines in Saudi Arabia. Additional quantitative research is necessary to confirm the study’s findings.

Healthcare Quality Improvement: The Need for a Macro-Systems Approach.

While the structure of healthcare systems evolved out of the need to address acute conditions, the function of healthcare systems evolved to primarily address chronic conditions. The healthcare delivery system organically developed to respond to "one-off" acute illness or injury. Subsequently, healthcare delivery systems grew into legacy systems that evolved into complex systems over time. Healthcare delivery for acute conditions tends to utilize a specific part or form of the healthcare delivery system. In contrast, healthcare delivery for chronic conditions forces patients to seek care over time between different places or healthcare entities. Because of the self-contained structural organization of these healthcare delivery systems, they were not designed to provide coordinated, integrated, and longitudinal care over time and place. Consequently, today's complex legacy healthcare delivery system requires significant improvement in the quality of care delivered to patients, especially those with chronic conditions. As a complex and legacy system, the most appropriate approach to improve the quality of delivered care is through a re-design quality improvement process, rather than a new system design process. In this paper, we describe the conceptual framework for quality improvement (QI) and the current micro and macro level approaches to quality improvement. We applied the current quality improvement approaches to the QI conceptual framework. We identified the limitations in current quality improvement processes in complex healthcare systems at the macro-level, pointing to the need for macro-systems approaches to healthcare quality improvement.

Improving outcomes through patient-generated evidence—the next step in patient advocacy

Patient advocacy—a term that is broad in scope but that essentially describes a range of services for patients, survivors, and caregivers who are living with, or have lived with a disease. The paramount goal of patient advocacy is to truly represent the voice of patients to ensure their needs and preferences are met within an often complex and labyrinthine health-care system, which is rarely built to recognise—let alone accommodate—the needs of those who must attempt its navigation.

Understanding "Work as Done": Using a Structured Video-Based Observational Method to Understand and Model the Role of the Physical Environment in Complex Clinical Work Systems.

To describe the planning, development, and implementation of a structured video-based observational method that can be used to systematically examine and model the role of the physical environment within healthcare systems. Direct observation methods are often used in healthcare to study complex healthcare systems. However, these observations often occur in real time, which predisposes the collected data to shortcomings such as time lags in recording of activities, overlooking events, or limiting the scope of information than can be collected. Video observation approaches eliminate many of these challenges and provide opportunities for researchers to understand and model the role of the physical environment. An approach to developing and implementing a structured video-based observational method to study and model complex health systems is presented. A structured observational approach can be highly effective for collecting multiple layers of data necessary for understanding interactions between the physical environment and other systems components in healthcare settings. The proposed video-based observation method is effective in settings that have clearly defined environmental boundaries, limited number of people, are complex and fast-paced such as the OR, ED trauma rooms, and ICU rooms. Video-based observation is an effective complement to the traditional observational method for in-depth study of the built environment in health systems, enabling researchers to employ quantitative approaches to data collection and analysis, in addition to qualitative interpretations.

Towards integrated care in the complex healthcare system of Belgium: an implementation strategy based on vicinity networks and a mixed financing model

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Implementation strategies for the patient safety reporting system using Consolidated Framework for Implementation Research: a retrospective mixed-method analysis

BackgroundHealthcare-related adverse events occur because of complex healthcare systems. The patient safety reporting system is a core component of patient safety initiatives in hospitals. However, hospital management often encounters a cultural barrier with its implementation and struggles to overcome the same. Implementation science would be useful for analysing implementation strategies. This study determines the effects of the implemented strategy on an increase in the number of patient safety reports and the determinants of successful implementation, using the implementation framework.MethodsMixed method analysis was performed in Fujita Health University Hospital (FHUH), a large volume hospital in Japan. We identified strategies to implement the patient safety reporting system by scrutinising internal documents using the Consolidated Framework for Implementation Research (CFIR). The electronic reporting systems developed in 2004 in the FHUH and the number of reports were analysed using the staff data and hospital volumes.ResultsReports (n = 110,058) issued between April 2004 and March 2020 were analysed. The number of reports increased from 2004 to 2008 and from 2013 to 2019, reaching 14,037 reports per year. Between 2009 and 2012, the FHUH experienced a stagnation period where the number of reports were not increasing. From the qualitative materials, we identified 74 strategies which contributed to the implementation of the patient safety reporting system. Among these, the domain of ‘intervention characteristics’ in the CFIR contained 12 strategies, ‘outer settings’ contained 20, ‘inner settings’ contained 21, ‘characteristics of individuals’ contained 8, and ‘process’ contained 13. There were two concentrated periods of the implemented strategies, the number was 17 in 2007 and 10 in 2016. These concentrated periods preceded a remarkable increase in the number of patient safety reports.ConclusionsA safety culture had been fostered in FHUH in the study period. A relationship between number of strategies and development of a reporting culture was observed. The intensity of adequate strategies was needed for implementation of patient safety reporting system. Therefore, the implementation framework is useful for analysing patient safety initiatives for safety culture.

Bleeding Disorders in Women and Girls: State of the Science and CDC Collaborative Programs.

Women and girls with bleeding disorders experience abnormal and excessive bleeding that can negatively impact their overall health and quality of life. In this report, we provide an overview of the biology, types, clinical care, and state of the science related to bleeding disorders in girls and women and describe Centers for Disease Control and Prevention (CDC) activities related to (1) surveillance of bleeding disorders in women; (2) scientific review, research, and collaboration to inform health care gaps in identifying and caring for women with bleeding disorders; and (3) development of health promotion and education programs to bring awareness about bleeding disorders to both women and girls in the population at large and various health care providers who care for women. Findings generated from surveillance and research activities inform the development of new public health programs aimed at improving diagnostic and health care services and empowering women with bleeding disorders with the knowledge they need to navigate a complex health care system with the need for specialty care services. Additional work is needed to improve provider awareness and understanding of the unique needs of women and girls with bleeding disorders to achieve appropriate care and treatment and ensure optimal outcomes and quality of life.

Measuring the Impact of an Educational Intervention on Evidence-Based Practice.

Background With an increasingly complex health care system, there are greater demands for nurses to have a strong foundation in evidence-based practice (EBP) competencies because of their relationship to improved patient and organizational outcomes. Attributes such as knowledge, skills, and attitudes contribute to the development of EBP competencies. Method A quasi-experimental study with a pretest/posttest design was conducted to evaluate the outcomes for 30 RNs in an acute care setting who attended a 3-hour EBP educational intervention using the Healthcare EBP Assessment Tool questionnaire. Results The nurses demonstrated a significant improvement in their perceived understanding of EBP after the intervention (p = .005). Statistically significant improvements were also noted on the subscales of frequency, ability, desire, and barriers. Conclusion Advances in the perception of EBP competencies made by the participants of this intervention may enhance their feeling of contributing to the organization and result in improved patient outcomes and work environment. Further research is needed to investigate the effectiveness of other interventions, including opportunities to be involved in quality improvement projects and research studies. [J Contin Educ Nurs. 2022;53(3):109-114.].

Effectively utilizing wellness and engagement surveys

Wellness and engagement in busy and complex healthcare systems are challenging. Much has been written about how individual healthcare workers can prevent their own burnout and improve wellness as well as the role of institutional and organizational goals to promote engagement and wellness. However, while there is clearly not one explanation or one solution for this problem, there is also not one standard approach to assessing these important issues, though surveys are most commonly used to assess the characteristics of the workplace. We suggest a framework of strategies for effective use of surveys to improve employee wellness and engagement based on practical experience that involve operational next steps organizations and programs can take after surveys as well as contextualizing the information they provide. These steps include adapting and leveraging quality improvement (QI) tools customarily used for patient safety for the purpose of wellness and engagement.

A discrete event simulation-based methodology for building a digital twin of patient pathways in the hospital for near real-time monitoring and predictive simulation

Background: Discrete Event Simulation (DES) is one of the many tools and methods used in the analysis and improvement of healthcare services. Indeed, DES provides perhaps the most powerful and intuitive method for analyzing, evaluating, and improving complex healthcare systems. This paper highlights the process of developing a Digital Twin (DT) framework based on online DES to run the DES model in parallel with the real world in real-time. Methods: This paper suggests a new methodology that uses DES connected to the Internet of Things (IoT) devices to build a DT platform of patient pathways in a hospital for near real-time monitoring and predictive simulation. An experimental platform that mimics the behavior of a hospital has been used to validate this methodology. Results: The application of the proposed methodology allowed us to test the monitoring functionality in the DT. Therefore, we noticed that the DT behaves exactly as the emulator does in near real-time, we also tested the prediction functionality and we noticed that the DT provides us with a proactive overview for the near future of the patient pathways. The predictive functionality of this DT must be improved depending on the various reasons mentioned in this article. Conclusions: This paper presents a new methodology called HospiT'Win that uses DES and IoT devices to develop a DT of patient pathways in hospitals. This DT consists of two real-time models, a DT for Monitoring (DTM) and a DT for Predicting (DTP). An experimental platform with an emulator of a real hospital was used to validate this methodology before connecting to the real hospital. In the DTP, "dynamic" empirical distributions were used to perform a predictive simulation for the near future. In future research, some additional features and machine learning algorithms will be used to improve the proposed DT models.

A brief overview of thoracic surgery in the United States.

The 331 million people of the United States are served by a complex and expensive healthcare system that accounts for nearly 18% of the country’s gross domestic product. Over 90% of patients are insured by private or government-funded plans, but despite high coverage and unusually high healthcare spending, vast disparities exist within the United States population based on demographics in terms of diagnosis, treatment, and outcomes of disease. Thoracic surgeons in the United States are trained to treat patients with diseases of the chest in the operative and perioperative settings, and can accomplish this training through multiple highly competitive pathways. Thoracic surgeons perform an average of 135 operations each per year which address diseases of the lungs, trachea, esophagus, chest wall, mediastinum, and diaphragm. Video assisted thoracoscopic surgeries are the most commonly performed procedures, which are primarily completed to treat lung cancer. Lung cancer is the deadliest and second most prevalent malignancy in the United States, with over 200,000 new cases expected this year. In addition to encouragement of smoking cessation and more attention to air pollutants, increased access to lung cancer screening has significantly expedited diagnosis and reduced mortality from lung cancer in the last several years. Thoracic surgeons in the United States are tasked with treating common yet highly morbid diseases of the chest in a patient population that is diverse in terms of race, socioeconomic status, and healthcare insurance coverage. As the population ages and a shortage of thoracic surgeons looms, the importance of early diagnosis, skillful surgical management, and attention to the disparities that exist in our system cannot be overstated.

Experts in Medical Training Call for Curricula to Address Social Determinants of MH

Experts in Medical Training Call for Curricula to Address Social Determinants of MH

Integrating Physicians Into Lean Quality Improvement Through a Structured Educational Program: The ECLIPSE Program.

In the increasingly complex health care system, physicians require skills and knowledge to participate with multidisciplinary team members in quality improvement (QI) that adds value to health care organizations. The Educational and Clinical Leaders Improving Performance with Structured E3L training (ECLIPSE) program was developed to address this challenge. Clinically relevant components of lean management were leveraged to create an online, flipped-classroom curriculum, and this was paired with Kaizen adapted specifically for physicians and multidisciplinary clinicians to promote experiential skills utilization. The focus of each adapted Kaizen was a topic of institutional QI priority, such as improving patient throughput or reducing readmission rates. Participants were awarded certification in the E3 Leadership management system-a patient-centered, equity-focused system based on lean principles. After 4 years, 50 E3 Leadership certificates were awarded to multidisciplinary clinicians, including 30 to physicians; participants scored an average 85% on module quizzes. The ECLIPSE program has improved physician participation in multidisciplinary QI projects with institutional alignment.

Workforce Development to Improve Access to Pain Care for Veterans: A Qualitative Analysis of VA-ECHO Participant Experiences.

Background/ObjectiveThe prevalence of chronic pain and its links to the opioid epidemic have given way to widespread aims to improve pain management care and reduce opioid use, especially in rural areas. Pain Management Specialty Care Access Network-Extension for Community Health Outcomes (VA-ECHO) promotes increased pain care access to rural Veterans through knowledge sharing from specialists to primary care providers (PCPs). We explored PCP participants’ experiences in VA-ECHO and pain management care.MethodsThis qualitative study is based on a descriptive secondary analysis of semi-structured interviews (n = 10) and 3 focus groups with PCPs participating in VA-ECHO from 2017–2019. A rapid matrix analysis approach was used to analyze participants’ responses.ResultsVA-ECHO was an effective workforce development strategy for meeting PCPs’ training needs by providing pain management knowledge and skills training (eg alternative care approaches and communicating treatment options). Having protected time to participate in VA-ECHO was a challenge for many PCPs, mitigated by leadership and administrative support. Participants who volunteer to participate had more positive experiences than those required to attend.ConclusionsVA-ECHO could be used for meeting the workforce development needs of PCPs. Respondents were satisfied with the program citing improvement in their practice and increased confidence in providing pain management care to Veterans despite some challenges to participation. These findings offer insight into using VA-ECHO to meet the VHA’s workforce development to improve Veterans’ access to pain management care. The ECHO model presents opportunities for workforce development in large complex healthcare systems and garnering ongoing support for this training model is necessary for promoting workforce development for PCPs.