Health System Leaders Research Articles

Research and Career Outcomes for Pediatric Hospital Medicine Fellowship Graduates.

Pediatric hospital medicine (PHM) fellowships have rapidly developed to meet established needs. The purpose of this research was to describe the research and career outcomes of PHM fellowship graduates. We hypothesized that graduates would report significant research and academic productivity. This was an institutional review board-approved, cross-sectional survey of PHM fellowship graduates in 2018. The 88-item survey was modified from an existing survey, developed by experts to address study objectives and pilot tested, and it included quantitative and qualitative items to assess characteristics of fellowship training and research and career outcomes. A total of 63% of PHM fellowship graduates (143 of 228) completed the survey (graduation dates, 2000-2018). In total, 89% graduated from dedicated PHM fellowship programs, with 59% completing a 2-year fellowship and 78% now practicing primarily at a university or children's hospital. Fellows conducted research in clinical research (53%), quality improvement (41%), health services (24%), and medical education (19%). A total of 77% of graduates continued to do research after graduation, with 63% publishing and 25% obtaining grant funding. Graduates of 2- and 3-year fellowships and those with a master's degree were significantly more productive. Graduates now hold important roles in academic and health systems leadership. Graduates are highly satisfied with their decision to do PHM fellowship and identified 5 themes regarding how fellowship impacted their career outcomes. In this study, we document robust research activity and leadership positions among PHM fellowship graduates and can serve as a benchmark for metrics that PHM educational leaders can use to assess outcomes and improve training regarding research and career development.

Nurses’ experiences of working while pregnant: A qualitative descriptive study

BackgroundHealthcare work environments are fraught with occupational hazards that can impact nurse health as well as patient care. However, little is known about how these hazards impact nurse health during pregnancy, and the experiences of nurses in the work environment during pregnancy and upon their return postpartum. ObjectiveTo describe registered nurses’ (RNs’) experiences of working while pregnant and returning to work postpartum. Specifically, their experiences related to the work environment and work-related hazards. DesignA qualitative descriptive design was utilized to describe nurse experiences at work, occupational hazards during pregnancy, and experiences of returning to work after pregnancy. Participants and SettingA convenience sample of twenty nurses working in direct patient care roles across the United States were recruited for virtual semi-structured interviews. MethodParticipants were interviewed using a semi-structured question guide to explore nurse experiences, specifically occupational hazards at work during pregnancy and upon returning to work. Interview transcripts were analyzed using deductive and inductive content analysis. ResultsDeductive findings for occupational hazards and risks during pregnancy and postpartum included exposure to infectious diseases, imaging, physical tasks (e.g., lifting and performing CPR), cleaning products, patient violence, and medication administration. Inductive thematic findings included: support needed avoid occupational hazards and make necessary modifications; desire to be ‘supernurses’ and put the patient first even when it meant taking risks for our health and that of their child; and fear of the consequences of occupational hazards and exposures. ConclusionsOccupational hazards experienced by nurses during pregnancy that may impact their health and that of their baby were broader than previously studied. Pregnant nurses should receive education from their healthcare providers early in their pregnancies about the occupational hazards themselves and the potential modifications they should seek. Managers, occupational health and other health system leaders, and policymakers should be aware of occupational hazards for nurses, including pregnant nurses, and support workplace modifications. Future research should focus on assessing the prevalence of these hazards, the longitudinal impact of exposures that can lead to negative consequences for nurse and fetal health, and reducing the risk of exposure to these hazards for pregnant nurses. Tweetable abstractRNs described a variety of occupational hazards of working while pregnant and postpartum. Inconsistent ability to modify work to protect self and baby leads to completing work demands known to be hazardous.

Gerontological nursing competencies: A crosswalk with the 4Ms framework of the age-friendly initiative

ABSTRACT The Age-friendly Health Systems Initiative is a current multidisciplinary movement driving quality improvement across all health care settings. The 4Ms framework (What Matters, Medication, Mobility, and Mentation) provides a common evidence-based language and system of care that can be utilized by all health care providers. Faculty of one nursing program were interested in knowing whether the principles and language of the 4Ms framework align well with the current competencies used to guide undergraduate and beginning level practice for nurses. To answer this question, a crosswalk of curricular and competency guidelines for gerontological nursing was completed to identify how well the competencies aligned with the key concepts of the evidence-based 4Ms framework. Key findings of this crosswalk are being shared with educators for the purpose of describing a systematic way to ensure that the 4Ms are integrated into gerontological curricula and course design. The steps taken to complete the crosswalk are described to guide educators across all disciplines interested in creating curricula that will adequately prepare students to be collaborative partners and leaders in Age-friendly Health Systems.

ASHP Statement on the Pharmacist’s Role in Clinical Pharmacogenomics

The American Society of Health-System Pharmacists (ASHP) believes pharmacogenomic testing can improve medication-related outcomes across the continuum of care in all health-system practice settings. These improvements include improved clinical outcomes, decreased side effects, lower cost of treatment, increased medication adherence, more appropriate selection of therapeutic agents, decreased length of treatment, and enhanced patient safety.1-4 Because of their distinct knowledge, skills, and abilities, pharmacists are uniquely positioned to lead interprofessional efforts to develop processes for ordering pharmacogenomic tests and for reporting and interpreting test results. Pharmacists are also singularly qualified to lead efforts to guide optimal drug selection and drug dosing and provide patient as well as provider education based on those results. Pharmacists therefore have a fundamental responsibility to ensure that pharmacogenomic testing is performed when needed and the results are utilized to optimize medication therapy.1 Pursuant to this leadership role, pharmacists share accountability with other health-system leaders,...

Radiology at the Helm of Value-Based Care Transformation: From Stewardship to Leadership.

In the past decade, the need to temper the rising cost of care in the United States has become a national priority. Most concerning is that more than $900 billion of the nearly $4 trillion spent each year is not effectively improving patients’ health [1]. Additionally, a large portion of this “wasted expenditure” reflects deficiencies at the provider-patient level: use of low-value services, failure of care delivery, and failure of care coordination [1]. Strategies to improve value (higher-quality care at a lower cost) are being designed at the population level, institutional level, and provider level and may be driven by multiple stakeholders, including policymakers, payers, health system leaders, or frontline clinicians.

Ontario's COVID-19 Modelling Consensus Table: mobilizing scientific expertise to support pandemic response.

SettingCOVID-19 has highlighted the need for credible epidemiological models to inform pandemic policy. Traditional mechanisms of commissioning research are ill-suited to guide policy during a rapidly evolving pandemic. At the same time, contracting with a single centre of expertise has been criticized for failing to reflect challenges inherent in specific modelling approaches.InterventionThis report describes an alternative approach to mobilizing scientific expertise. Ontario’s COVID-19 Modelling Consensus Table (MCT) was created in March 2020 to enable rapid communication of credible estimates of the impact of COVID-19 and to accelerate learning on how the disease is spreading and what could slow its transmission. The MCT is a partnership between the province and academic modellers and consists of multiple groups of experts, health system leaders, and senior decision-makers. Armed with Ministry of Health data, the MCT meets once per week to share results from modelling exercises, generate consensus judgements of the likely future impact of COVID-19, and discuss decision-makers’ priorities.OutcomesThe MCT has enabled swift access to data for participants, a structure for developing consensus estimates and communicating these to decision-makers, credible models to inform health system planning, and increased transparency in public reporting of COVID-19 data. It has also facilitated the rapid publication of research findings and its incorporation into government policy.ImplicationsThe MCT approach is one way to quickly draw on scientific advice outside of government and public health agencies. Beyond speed, this approach allows for nimbleness as experts from different organizations can be added as needed. It also shows how universities and research institutes have a role to play in crisis situations, and how this expertise can be marshalled to inform policy while respecting academic freedom and confidentiality.

Components of contributing conditions to strengthen health system management and leadership capacity building: a systematic review and decision making framework.

The purpose of this study is to identify components of contributing conditions to strengthen leadership and management capacity in the health system. A systematic search was undertaken in databases including PubMed, Scopus, Web of Science and local resources of Scientific Information Database and Magiran in January 2020. Two independent researchers checked the research process, screening of articles and quality assessment. The quality of the studies was assessed by JBI critical appraisal tools for qualitative studies. The components of the dimensions of health system management and leadership capacity were categorized according to the WHO conceptual framework using a content analysis approach. A total of 17 articles were included in this study. In total, 16 categories of components include human resource information system (n = 5); criteria, plans and procedures for selection and appointment (n = 5); development of education system (n = 11); skills (n = 39); knowledge (n = 8); attitudes (n = 6); behaviors (n = 10); resource and critical management system (n = 7); performance and processes management (n = 3); operational planning for critical systems (n = 4); establish control systems (n = 2); inputs and outputs of organizations (n = 2); accountability and responsibility to customers and stakeholders (n = 4); legal authority and requirements to play the role of managers (n = 9); external and internal environment management (n = 7); establish a system of appreciation and encouragement (n = 6). Each of these categories also contains subcategories. Identifying prerequisite conditions are necessary for building leadership and management capacity in health systems. Therefore, extracted components provide a simple but coherent framework that can be adapted or modified for use in local situations. The components have a variety of uses, including mapping current activities, needs assessment, planning leadership and management development strategies and monitoring and evaluation.

Engaging Stakeholders to Optimize Sleep Disorders' Management in the U.S. Military: A Qualitative Analysis.

Sleep disorders' are highly prevalent among U.S. active duty service members (ADSMs) and present well-documented challenges to military health, safety, and performance. In addition to increased need for sleep medicine services, a major barrier to effective sleep management has been a lack of alignment among patients, health providers, and economic-decision-makers. To address this gap in knowledge, the purpose of the present study was to engage diverse stakeholders vested in improving sleep disorders' management in the military. We elicited feedback from ADSMs with sleep disorders (five focus group discussion, n = 26) and primary care managers (PCMs) (11 individual semi-structured interview) in two military treatment facilities (MTFs) in the National Capitol Region, in addition to national level military and civilian administrative stakeholders (11 individual semi-structured interview) about their experiences with sleep disorders' management in U.S. MTFs, including facilitators and barriers for reaching a definitive sleep diagnosis, convenience and effectiveness of sleep treatments, and key desired outcomes from interventions designed to address effectively sleep disorders in the U.S. military health care system (MHS). Recordings from focus groups and semi-structured interviews were transcribed verbatim and analyzed using QSR International's NVivo 12 software using inductive thematic analysis. The study was approved by Walter Reed National Military Medical Center Department of Research Programs. Active duty service members with sleep disorders often fail to recognize their need for professional sleep management. Whereas PCMs identified themselves as first-line providers for sleep disorders in the military, patients lacked confidence that PCMs can make accurate diagnoses and deliver effective sleep treatments. Active duty service members cited needs for expeditious treatment, educational support and care coordination, and support for obtaining sleep treatments during deployment. Challenges that PCMs identified for effective management include insufficient time during routine care visits, delays in scheduling testing procedures, and limited number of sleep specialists. Primary care managers suggested offering evidence-based telehealth tools and enhanced care coordination between PCMs and specialists; standardized medical education, materials, and tools; patient preparation before appointments; self-administered patient education; and including behavioral sleep specialists as part of the sleep management team. For administrative stakeholders, key outcomes of enhanced sleep management included (1) improved resource allocation and cost savings, and (2) improved ADSM safety, productivity, and combat effectiveness. Current military sleep management practices are neither satisfactory nor maximally effective. Our findings suggest that solving the military sleep problem will require sustained effort and ongoing collaboration from ADSM patients, providers, and health systems leaders. Important potential roles for telehealth and technology were identified. Future research should seek to enhance implementation of sleep management best practices to improve outcomes for patients, providers, MHS, and the military as a whole.

Trauma-Informed Care in Child Health Systems.

Trauma-Informed Care in Child Health Systems.

Constructive debate: A task for all pharmacy leaders

While the future is always uncertain, today’s pharmacy leaders are faced with a particularly wide range of challenges. Therefore, if hospital pharmacy departments are to create well-informed strategic plans, forecasting future events is as important an exercise as ever. To this end, the Society of Hospital Pharmacists of Australia (SHPA) has recently published the inaugural Pharmacy Forecast Australia 2021.1 The impetus for developing this document arose from the success of the American Society of Hospital Pharmacists’ (ASHP) Pharmacy Forecast which, over the past decade, has grown to become a key feature of the Society’s educational landscape.2 It has become a much-anticipated annual publication used by multiple pharmacy practice sectors as a tool to anticipate and plan for future demand, service provision and leadership. Pharmacy Forecast Australia 2021 is a new strategic thought leadership piece on emerging trends and phenomena forecasted to impact pharmacy practice and the health of Australian patients to 2026 developed by SHPA utilising ‘wisdom of crowds’ methodology. It is anticipated that Pharmacy Forecast Australia 2021 will help equip hospital pharmacy departments to proactively position themselves and their teams for potential future events and trends with contextualised recommendations by the report’s authors. The Forecast, then, is a stimulant to prompt discussion that assists health system leaders in their strategic planning efforts, in their mission to provide optimal care for patients and advancing the profession of pharmacy. As a process and an output, the Forecast sits adjacent to SHPA’s advocacy activities and membership frameworks. This important distinction befits the unique methodology with the themes’ questions, analysis and recommendations distilled directly from leading hospital pharmacists and their colleagues based on their experiences in a range of roles, covering all Australian jurisdictions and unrestrained by organisational limitations. It is anticipated the value of the report will be found through its use by pharmacy practitioners and pharmacy leaders to inform strategic planning. The unique methodology is by no means intended to either qualitatively or quantitatively predict future events. Rather, the report should be used as a prompt to stimulate discussion, informed by the themed analysis provided by Australian subject matter experts and including associated recommendations. Pharmacy Forecast Australia 2021 presents current and future challenges to hospital pharmacy care provision, identified by a broad cross-section of the Australian landscape. The report is divided into six themes: ‘Workforce of the future’, ‘Workforce resourcing’, ‘Reliability of supply’, ‘Medication complexity and access’, ‘Medication safety’ and ‘Electronic revolution’. While many of the identified themes will not be surprising to the reader, it is anticipated the recommendations will provide sound advice and guidance on how to approach issues common to many, such as: addressing barriers to new clinical initiatives; investing and developing the pharmacy technical workforce; unifying efforts to fortify procurement; centralising medication safety in workforce planning; and maximising the benefits offered through electronic systems and telehealth. It may be that not all will agree with the opinions and recommendations of the Forecast Panellists and theme authors. This is to be expected and, indeed, hoped for, as it will generate constructive debate, one of the objectives in creating the report. The author has no conflicts of interest to declare.

ASHP Foundation's forecast report feels more relevant than ever this year

ASHP Foundation's forecast report feels more relevant than ever this year

Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England using a realist approach.

People in disadvantaged areas are more likely to have an avoidable emergency hospital admission. Socio-economic inequality in avoidable emergency hospital admissions is monitored in England. Our aim was to inform local health care purchasing and planning by identifying recent health care system changes (or other factors), as reported by local health system leaders, that might explain narrowing or widening trends. Case studies were undertaken in one pilot and at five geographically distinct local health care systems (Clinical Commissioning Groups, CCGs), identified as having consistently increasing or decreasing inequality. Local settings were explored through discussions with CCG officials and stakeholders to identify potential local determinants. Data were analysed using a realist evaluation approach to generate context-mechanism-outcome (CMO) configurations. Of the five geographically distinct CCGs, two had narrowing inequality, two widening, and one narrowing inequality, which widened during the project. None of the CCGs had designed a large-scale package of service changes with the explicit aim of reducing socio-economic inequality in avoidable emergency admissions, and local decision makers were unfamiliar with their own trends. Potential primary and community care determinants included: workforce, case finding and exclusion, proactive care co-ordination for patients with complex needs, and access and quality. Potential commissioning determinants included: data use and incentives, and targeting of services. Other potential determinants included changes in care home services, national A&E targets, and wider issues - such as public services financial constraints, residential gentrification, and health care expectations. We did not find any bespoke initiatives that explained the inequality trends. The trends were more likely due to an interplay of multiple health care and wider system factors. Local decision makers need greater awareness, understanding and support to interpret, use and act upon inequality indicators. They are unlikely to find simple, cheap interventions to reduce inequalities in avoidable emergency admissions. Rather, long-term multifaceted interventions are required that embed inequality considerations into mainstream decision making.

What can a learning healthcare system teach us about improving outcomes?

This review describes the learning healthcare system paradigm, recent examples, and future directions. Patients, clinicians, and health systems frequently encounter decisions between available treatments, technologies, and healthcare delivery methods with little or no evidence about the comparative effectiveness and safety of the available options. Learning healthcare systems endeavor to recognize such knowledge gaps, integrate comparative effectiveness research - including clinical trials - into clinical care to address the knowledge gaps, and seamlessly implement the results into practice to improve care and patient outcomes. Recent studies comparing the effectiveness of diagnostic tests and treatments, using information technology to identify patients likely to experience an outcome or benefit from an intervention, and evaluating models of healthcare delivery have demonstrated how a learning healthcare system approach can reduce arbitrary variation in care, decrease cost, and improve patient outcomes. Learning healthcare systems have the potential to answer questions of importance to patients, clinicians, and health system leaders, improve efficiency of healthcare delivery, and improve patient outcomes. Achieving this goal will require realignment of the culture around clinical care, institutional and federal investment, expanded stakeholder engagement, tailored ethical and regulatory guidance, and methodologic advances in information technology and biostatistics.

Characteristics of the ideal hospitalist inpatient care program: perceptions of Canadian health system leaders

BackgroundDespite the growing prevalence of hospitalist programs in Canada, it is not clear what program features are deemed desirable by administrative and medical leaders who oversee them. We aimed to understand perceptions of a wide range of healthcare administrators and frontline providers about the implementation and necessary characteristics of a hospitalist service.MethodsWe conducted semi-structured interviews with a range of administrators, medical leaders and frontline providers across three hospital sites operated by an integrated health system in British Columbia, Canada.ResultsMost interviewees identified the hospitalist model as the ideal inpatient care service line, but identified a number of challenges. Interviewees identified the necessary features of an ideal hospitalist service to include considerations for program design, care and non-clinical processes, and alignment between workload and physician staffing. They also identified continuity of care as an important challenge, and underlined the importance of communication as an important enabler of implementation of a new hospitalist service.ConclusionsMost hospital administrators and frontline providers in our study believed the hospitalist model resulted in improvements in clinical processes and work environment.

Developing a Mobile App for Concussion to aid Patient Empowerment and Symptom Management.

Despite the high prevalence of concussions each year in Canada, access to consistent and science-based information on how to self-manage these injuries remains a significant hurdle for many patients. Currently, available mobile applications (apps) focus mainly on supporting patients with sports-related concussions, although falls account for more traumatic brain injuries (TBI) than sports-related TBI’s in Alberta. Patients from a broader demographic may be limited from accessing information on how to correctly manage and track their symptoms as they feel that currently available resources are not applicable to them. Through collaboration between health system leaders, expert consultations, patients, and university students, a mobile app was designed as a platform to help patients manage and track symptoms at home, as well as to clarify misleading information and misconceptions surrounding injury. The team engaged numerous physicians, patient advisors, and health system leaders to improve upon the features of currently-existing concussion apps such as symptom tracking, insight into concussion, and strategies for returning to work/school that are more inclusive to adult, non-sports related injuries. We believe that these features will advance recovery by alleviating the burden of uncertainty and confusion for patients and their family members.

The Telemedicine Takeover: Lessons Learned During an Emerging Pandemic.

Introduction: Health care systems rose to the challenges of COVID-19 by creating or expanding telehealth programs to ensure that patients could access care without an in-person appointment. Traditionally, physicians receive limited formal telemedicine training, making preparedness for this transition uneven. To describe challenges to and attitudes toward providing virtual patient care, we distributed a survey to physicians within our system who largely had no formal prior training/experience with telemedicine, but transitioned to routine telemedicine use. Data collected are then used to offer actionable recommendations for health system leaders and medical educators. Materials and Methods: Surveys were distributed to all faculty outpatient general internal medicine physicians working at any New York University Langone Health, New York City Health + Hospitals/Bellevue and Gouverneur, and the VA NY Harbor Health System (n = 378) in mid-2020. Survey items consisted of Likert and open-ended questions related to experience with televisits (13 items) and attitudes toward care (24 items). Results: Telehealth-related challenges varied by site and modality. Primary challenges included establishing a connection from the patient's (98%) or physician's end (84%) and difficulty in the following domains: working with team members (39%), physical examinations (95%), establishing new patient relationships (70%), and taking history (40%), among others. In thematic analysis, significant themes with illustrative qualitative commentary emerged related to technological challenges, new systems issues, and new patient/physician communication experiences. Discussion: Experience differences were rooted in the type of technology employed. Safety-net practices conducted mostly telephonic visits, whereas private outpatient sites utilized video, despite both using identical electronic medical records. As we consider a "new normal" and prolonged community transmission of COVID-19 infection, it is essential to establish telemedicine training, tools, and protocols that meet the needs of both patients and physicians.

COVID-19 infection prevention and control procedures and institutional trust: Perceptions of Canadian intensive care and emergency department nurses

PurposeHealthcare workers must ensure effective infection prevention and control (IPC) to prevent nosocomial spread of SARS-CoV-2, the virus that causes COVID-19. This questionnaire study aims to evaluate Canadian critical care and emergency department nurses’ readiness to follow IPC guidelines in their workplace, and to understand their perceptions of trust in organizational preparedness, communication, and infection risk.MethodsWe adapted an internationally distributed survey for the Canadian context. This cross-sectional questionnaire, incorporating validated scales for items including institutional trust, was distributed by email to nurses via the Canadian Association of Critical Care Nurses and the Canadian Association of Emergency Physicians networks between 16 March and 25 May 2020. We evaluated intensive care unit and emergency department nurses’ adherence to IPC protocols, barriers and facilitators to IPC guideline adherence, and their level of institutitonal trust.ResultsThree hundred and nineteen nurses responded to the survey. There was higher trust in organizational preparedness among nurses who were older (B = 0.31, P < 0.001) and more experienced (F = 18.09, P < 0.001), and particularly among those with previous experience working in outbreak settings (F = 7.87, P = 0.005). Compared with those without experience working in outbreak settings, respondents with this experience reported higher levels of fear of becoming ill and fear of providing care for COVID-19 patients (χ2 = 21.48, P = 0.002 and χ2 = 12.61, P = 0.05, respectively). Older and more experienced nurses reported greater comfort with IPC skills and easier access to personal protective equipment. While the vast majority (96%) of respondents reported using masks and gloves, only 83% had access to isolation facilities for suspected or confirmed COVID-19 cases.ConclusionCanadian nurses had strong self-reported adherence to IPC measures and personal protective equipment use. There were high levels of trust in health system leadership to ensure protective measures are present and reliable. Trust was particularly high among older and more experienced nurses despite these populations reporting higher levels of fear of personal illness.

Deliberative Stakeholder Engagement in Person-centered Health Research

ABSTRACT Robust stakeholder engagement in health research requires broad communicative integration, not only of patients but also other stakeholders such as health system leaders, clinicians, and researchers. As patients’ personal narratives tend to focus on their own health care experiences, it can be challenging to incorporate these perspectives at the health system level, where discussions often address technical issues such as strategies for aggregating and interpreting population-level data. The PaTH Health System Leaders Demonstration Project provides a case study to explore the potential usefulness of deliberative techniques for facilitating heterogeneous stakeholder engagement in what some sociologists of science call ‘hybid forums.’ Close textual analysis of the event transcript yields insight on how social learning motivates group opinion shifts in deliberative processes. Reconstruction of the event’s narrative arc marks a path of ‘dynamic updating’ that manifests in group opinion change. Analysis of episodes where participants perform ‘deliberative openness’ lends qualitative nuance to previously reported process measure outcomes reflecting high participant satisfaction. Such inquiry helps address a gap in literature on stakeholder engagement in comparative effectiveness health research, sheds light on the understudied genre of ‘empowered deliberation’, and illustrates design principles and practices useful for upstream integration of stakeholder engagement in the research process.

Synergies and fragmentation in country level policy and program agenda setting, formulation and implementation for Global Health agendas: a case study of health security, universal health coverage, and health promotion in Ghana and Sierra Leone

BackgroundGlobal health agendas have in common the goal of contributing to population health outcome improvement. In theory therefore, whenever possible, country level policy and program agenda setting, formulation and implementation towards their attainment should be synergistic such that efforts towards one agenda promote efforts towards the other agendas. Observation suggests that this is not what happens in practice. Potential synergies are often unrealized and fragmentation is not uncommon. In this paper we present findings from an exploration of how and why synergies and fragmentation occur in country level policy and program agenda setting, formulation and implementation for the global health agendas of Universal Health Coverage (UHC), Health Security (HS) and Health Promotion (HP) in Ghana and Sierra Leone. Our study design was a two country case study. Data collection involved document reviews and Key Informant interviews with national and sub-national level decision makers in both countries between July and December 2019. Additionally, in Ghana a stakeholder workshop in December 2019 was used to validate the draft analysis and conclusions.ResultsNational and global context, country health systems leadership and structure including resources were drivers of synergies and fragmentation. How global as well as country level actors mobilized power and exercised agency in policy and program agenda setting and implementation processes within country were also important drivers.ConclusionsThere is potential in both countries to pull towards synergies and push against fragmentation in agenda setting, formulation and implementation of global health agendas despite the resource and other structural constraints. It however requires political and bureaucratic prioritization of synergies, as well as skilled leadership. It also requires considerable mobilization of country level actor exercise of agency to counter sometimes daunting contextual, systems and structural constraints.

Clinical Faceoff: How Will Recent Price Transparency Policies Impact Orthopaedic Surgery and its Patients?

Clinical Faceoff: How Will Recent Price Transparency Policies Impact Orthopaedic Surgery and its Patients?