Complex Health Care System Research Articles

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.

Stroke and COVID-19: The Value of Narrative Medicine

Stroke and COVID-19 are both traumatic and life-altering experiences that are marked by uncertainty, fear, and medical intervention. The devastation that stroke and COVID-19 oppress on an individual and a population is well established, and these traumas are potently magnified in the troughs of the COVID-19 pandemic. Furthermore, stroke has been shown to be a potential complication of COVID-19 infection, and while there is global controversy regarding this finding, it is undeniable that there are patients across the world presenting with both conditions concurrently. Thus, the topic of isolated stroke and the co-occurrence of stroke and COVID-19 amidst the pandemic both warrant considerable investigation on both a basic science level and a humanistic level. This opinion article advocates for a narrative medicine approach to better explicate the intertwining of stroke and COVID-19. Interviewing patients who presented with both stroke and COVID-19 as well as patients who present with stroke during the pandemic will provide the opportunity to gather and juxtapose individual illness experiences, including encounters with the health care system, relationship with care teams and care takers, recovery, and insights into the future. Creating, analyzing, and comparing such an anthology of illness narratives of the 2 patient populations will offer a unique understanding into the experience of different, yet over-lapping, medical traumas in an unprecedented time. With this deeper appreciation of patient accounts, the health care system can better recognize how to provide for future patients who present specifically with stroke or stroke and COVID-19. However, more broadly, this study can also afford insight into how the health care system can better provide for and support patients who present with complex diagnoses in the context of a complex healthcare system, which most probably will operate under the effects of the pandemic for time to come as well as other, future complicating factors.

Leading across complex healthcare systems: Learning from an action inquiry project

To focus solely on organisational management is no longer enough to be effective. Instead, healthcare managers and leaders must also pay attention to the behaviours required to shape organising within complex systems. The author, together with his collaborator, Dr Mark Gatenby, undertook research within a large UK rehabilitation unit over the course of a year. This work combined consulting with action inquiry and explored the challenges faced by healthcare managers and professionals as they grappled with the complex dynamics within their own complex hospital organisation and the wider region. A notable finding was that quite different behaviours are needed to positively impact on a complex system when compared with the behaviours that are often modelled by organisational managers and still taught in management development programmes. Ten relevant behavioural practices are shared, including purposing, empathising, conversing, leading for learning, influencing, role shaping, culturing, storying, languaging and reflecting. The ideas underlying these practices are described and the implications outlined. Suggestions are offered for action along with a few questions for individual reflection. The paper concludes that a refocussing of leadership development is required to stimulate individual interest in system behaviour. When combined with fresh approaches to commissioning management development, this is more likely to produce a new generation of healthcare system leaders.

Problem-Based Learning in Phytochemistry Courses: Its’ Effectiveness in Improving Medical Students’ Critical Thinking Ability Viewed from Cognitive Style

The implementation of the Problem-Based Learning (PBL) model for medical students has long been initiated to be integrated into the learning system and curriculum, however, empirical support for the application of the PBL model to medical students is still weak, becoming an obstacle. On the one hand, the need for critical thinking development among medical students is increasingly urgent, this is related to their future assignments in a more complex health care system that requires critical thinking ability. Our current study aims to evaluate the effectiveness of the problem-based learning (PBL) model on improving the critical thinking ability of medical students in terms of cognitive style. This study is an experimental study (one group pretest-posttest design) involving 21 medical students (medical students') in phytochemistry courses at one of the universities providing medical and nursing science programs in Indonesia. The study started by giving a cognitive style test using the GEFT (Group Embedded Figure Test) instrument to classify students into FD and FI cognitive styles, pretest, learning implementation using the PBL model (carried out for five meetings), and posttest. The pretest and posttest used a critical thinking ability test instrument in the form of an essay test. Descriptive and statistical analyzes were performed to evaluate the effectiveness of the PBL model. The results of the study show that the PBL model has been convincingly effective in improving students' critical thinking ability in phytochemistry courses for both FD/FI cognitive style modes. Based on these findings, we recommend the use of the PBL model in extensive and intensive learning to develop the critical thinking ability of medical students

The Role of General Practice in Complex Health Care Systems.

According to the WHO, in a complex system, “there are so many interacting parts that it is difficult (…), to predict the behavior of the system based on knowledge of its component parts. “In countries without general practitioner (GP)-gatekeeping, the number of possible interactions and therefore the complexity increases. Patients may consult any doctor without contacting their GP. Family medicine core values, e.g., comprehensive care, and core tasks, e.g., care coordination, might be harder to implement and maintain. How are GPs perceived and how do they perceive themselves if no GP-gatekeeping exists? Does the absence of any GP-gatekeeping influence family medicine core values? A PubMed and Cochrane search was performed. The results are summarized in form of a narrative review. Four perspectives regarding the GP's role were identified. The GPs' self-perception regarding family medicine core values and tasks is independent of their function as gatekeepers, but they appreciate this role. Patient satisfaction is also independent of the health care system. Depending on the acquisition of income, specialists have different opinions of GP-gatekeeping. Policymakers want GPs to play a central role within the health care system, but do not commit to full gatekeeping. The GPs and policymakers emphasize the importance of family medicine specialty training. Further international studies are needed to determine if family medicine core values and tasks can be better accomplished by GP-gatekeeping. Specialty training should be mandatory in all countries to enable GPs to fulfill these values and tasks and to act as coordinators and/or gatekeepers.

COVID-19 case fatality rate in the context of healthcare system organization and EHCI performance: Focus on the Visegrad (V4) countries

Abstract This article tries to explain the differences in COVID-19 case fatality rate (CFR) in 22 European countries by their type of organization and performance level of their healthcare systems. The CFR is taken here as the most important indicator since it measures the ratio between COVID deaths and COVID cases. In our view, this indicator reflects the true performance of the healthcare system, as this indicator is freed form public health interventions, like testing, lockdowns or social distancing. Our research is also unique, because it sees the healthcare system in a holistic way and tries to explain the CFR not by individual risk factors, socioeconomic indicators, or partial system parameters, but by using a complex healthcare system classification method adopted from Isabelle Joumard and an overall healthcare system performance index adopted from European Health Consumer Index (EHCI). The main results are twofold. First, higher EHCI score is related to lower CFR. So, the countries are cumulated basically in two quadrants: High EHCI performers (score 790 and higher) with low CFR (below 1.93%) and low EHCI performers with high COVID CFR. Second, apart from Czech Republic, the V4 countries are not doing very well in fighting COVID. Hungary is the worst, not only from the V4 group, but the worst from the whole list of 22 European countries included in this research. Poland is doing better, but still is high above the median CFR. Slovakia was the second worst from the V4 group. Czech Republic is the best V4 performer and the only country with EHCI score lower than median and CFR also lower than the median.

Institutional ethnography - a primer.

This review introduces a qualitative methodology called institutional ethnography (IE) to healthcare professionals interested in studying complex social healthcare systems. We provide the historical context in which IE was developed, and explain the principles and terminology in IE for the novice researcher. Through the use of worked examples, the reader will be able to appreciate how IE can be used to approach research questions in the healthcare system that other methods would be unable to answer. We show how IE and qualitative research methods maintain quality and rigour in research findings. We hope to demonstrate to healthcare professionals and researchers that healthcare systems can be analysed as social organisations, and IE may be used to identify and understand how higher-level processes and policies affect day-to-day clinical work. This understanding may allow the formulation and implementation of actionable improvements to solve problems on the ground.