Health System Leaders Research Articles

The Role of Nurse Implementation Scientists in Leading Health System Transformation in Atlantic Canada and Beyond: A Discussion Paper.

To discuss and provide examples of how nurse implementation scientists can support health system transformation. Discussion paper. Using Prince Edward Island's health system strategic plan as a case exemplar, selected key priorities in the strategic plan were mapped with examples and discussion of how nurse implementation scientists can support health system transformation on Prince Edward Island and beyond. Accelerating the development and delivery of evidence-informed services that support health system transformation is needed. Nurse implementation scientists are ideally positioned to lead these efforts. Appropriate resourcing and compensation are essential to fully embrace nurse implementation scientist roles, collaboration, and buy-in from health system leaders. Practical examples of how nurse implementation scientists can lead health system transformation in a rigorous, evidence-informed way are identified. Literature providing examples of how nurse implementation scientists can make meaningful impacts within health systems, particularly in rural contexts, is limited. Nurse implementation scientists are ideally positioned to collaborate with and lead health system transformation by virtue of their knowledge, skills, qualifications and experience. Implications of this work extend beyond nursing to other health disciplines, health organisations, government leaders, researchers and populations. The discussion and examples provided may be applicable to similar contexts. No patient or public contribution.

Capturing and Categorizing the Burden of Musculoskeletal Injuries in U.S. Active Duty Service Members: A Comprehensive Methodology.

Musculoskeletal injuries (MSKIs) represent the most common, costly, and impactful medical conditions affecting active duty service members (ADSMs) of the United States Armed Forces. Inconsistent, variable MSKI surveillance methods and often incompletely described criteria for cohort selection, injuries, incidence, and prevalence have limited efforts to observe longitudinal trends, identify gaps in care, or highlight specific military branches or sites that could benefit from enhanced MSKI intervention protocols. The purpose of this manuscript is to present a comprehensive, well-documented, and reproducible framework for capturing and categorizing MSKI burden, healthcare utilization, and private sector costs for ADSMs across a 12-year period spanning the International Classification of Diseases, 10th Revision, Clinical Modification transition. This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Upper Extremity, Lower Extremity, Spine, and Head/Neck MSKIs, associated health care utilization, and private sector costs were obtained by querying electronic health records from military treatment facilities, private sector care (PC) claims, and theater medical data from October 1, 2010 to September 30, 2021 (Fiscal Years 10-21), using the Military Health System Data Repository. Utilization associated with MSKIs per body region in the direct care and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs were captured per year and categorized by service, body region, and setting. MSKI surveillance research in ADSMs has been impacted by variable, often incompletely described methods. While our approach is not without limitations, our aim was to present a well-documented, reproducible methodology for MSKI investigation in military personnel. By presenting a comprehensive blueprint for capturing and categorizing MSKI care in U.S. service members, our goal is for this methodology to enhance the efforts of researchers, public health officials, and Military Health System leaders to combat MSKIs, the primary medical threat to military readiness.

Engaging family caregivers with structured communication for safe care transitions: A making healthcare safer rapid review

Objectives To summarize and assess the effectiveness of patient safety practices (PSPs) for engaging family caregivers with structured communication to improve care transitions safety. This review provides information for clinicians, health system leaders, and policymakers to better inform approaches to improve patient safety during care transitions. Methods We searched PubMed, Embase, and the Cochrane Library for eligible studies published in 2010 through 30 June 2023, and reviewed gray literature searches and reference lists of relevant systematic reviews. We used prespecified inclusion and exclusion criteria to assess relevant studies. Findings We identified 323 unique records and assessed 86 full-text articles for possible inclusion. We included nine studies (two randomized controlled trials, six pre-post studies, and one single-arm study) which assessed PSPs focused on hospital discharge to home, transfers from intensive care units, and transitions from residential care to home. We found that PSPs for engaging family caregivers with structured communication improved caregiver satisfaction (low strength of evidence) in residential care transitions. For other outcomes, we rated the evidence as insufficient to permit conclusions. None of the studies reported rates of unintended harms. Conclusions There is little evidence on the effectiveness of PSPs using structured communication with family-caregivers to improve care transitions safety. One study showed improvement in caregiver satisfaction. More high-quality research is needed to assess the effectiveness of these PSPs and unintended harms.

Artificial intelligence integration in healthcare: perspectives and trends in a survey of U.S. health system leaders

BackgroundThe healthcare sector is rapidly integrating artificial intelligence-derived predictive models (AIDPM) to enhance clinical decision support, operational efficiency, and patient experiences. However, research on management strategies for AIDPM acquisition, deployment, and governance remains limited. This study examines changes in AIDPM integration and governance since 2021, with a particular focus on large language models and health equity considerations.ResultsOur survey of health system leaders achieved a 49% response rate (32/65). While 84% of institutions reported using AIDPM in clinical practice, only 53% had established dedicated teams for these models. Compared to 2021, there was a significant increase in representation from experts in clinical informatics, operations, and quality improvement on AIDPM teams. Most organizations (41%) primarily purchased AIDPM from external vendors. Support for integrating large language models into healthcare practices was unanimous among respondents. The principal obstacles to AIDPM adoption included regulatory concerns, data security, workflow integration, and clinician acceptance. A large majority (72%) of respondents supported government regulation of AI in healthcare. While 76% of organizations reported having a team member dedicated to health equity, ethicists and diversity leaders were underrepresented on AIDPM teams (18%). Organizations reported various efforts to promote health equity, but involvement of frontline clinicians in AIDPM development and its impact on health equity was significantly less common.ConclusionsClinical adoption of AIDPM faces challenges due to the absence of established best practices. Health system leaders strongly support federal regulations for AI in healthcare. These regulations could provide quality and safety standards. The study highlights the need for developing evaluation guidelines, especially for large language models. It also reveals a lack of uniform involvement of frontline clinicians and equity experts in AIDPM governance. Their involvement could increase adoption and trust of these new AI tools. Future research should assess healthcare systems' adherence to emerging regulations and best practice frameworks. This research should emphasize patient safety and health equity. These findings underscore the urgent need for a comprehensive roadmap. This roadmap would guide the responsible implementation of AIDPM in healthcare settings.

Transitional Care Support for Medicaid-Insured Patients With Serious Mental Illness: Protocol for a Type I Hybrid Effectiveness-Implementation Stepped-Wedge Cluster Randomized Controlled Trial.

People diagnosed with a co-occurring serious mental illness (SMI; ie, major depressive disorder, bipolar disorder, or schizophrenia) but hospitalized for a nonpsychiatric condition experience higher rates of readmissions and other adverse outcomes, in part due to poorly coordinated care transitions. Current hospital-to-home transitional care programs lack a focus on the integrated social, medical, and mental health needs of these patients. The Thrive clinical pathway provides transitional care support for patients insured by Medicaid with multiple chronic conditions by focusing on posthospitalization medical concerns and the social determinants of health. This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric hospitalization. This study aimed to (1) engage staff and community advisors in participatory implementation processes to adapt the Thrive clinical pathway for all Medicaid-insured patients, including those with SMI; (2) examine utilization outcomes (ie, Thrive referral, readmission, emergency department [ED], primary, and specialty care visits) for Medicaid-insured individuals with and without SMI who receive Thrive compared with usual care; and (3) evaluate the acceptability, appropriateness, feasibility, and cost-benefit of an adapted Thrive clinical pathway that is tailored for Medicaid-insured patients with co-occurring SMI. This study will use a prospective, type I hybrid effectiveness-implementation, stepped-wedge, cluster randomized controlled trial design. We will randomize the initiation of Thrive referrals at the unit level. Data collection will occur over 24 months. Inclusion criteria for Thrive referral include individuals who (1) are Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) reside in Philadelphia; (3) are admitted for a medical diagnosis for over 24 hours at the study hospital; (4) are planned for discharge to home; (5) agree to receive home care services; and (6) are aged ≥18 years. Primary analyses will use a mixed-effects negative binomial regression model to evaluate readmission and ED utilization, comparing those with and without SMI who receive Thrive to those with and without SMI who receive usual care. Using a convergent parallel mixed methods design, analyses will be conducted simultaneously for the survey and interview data of patients, clinicians, and health care system leaders. The cost of Thrive will be calculated from budget monitoring data for the research budget, the cost of staff time, and average Medicaid facility fee payments. This research project was funded in October 2023. Data collection will occur from April 2024 through December 2025. Results are anticipated to be published in 2025-2027. We anticipate that patients with and without co-occurring SMI will benefit from the adapted Thrive clinical pathway. We also anticipate the adapted version of Thrive to be deemed feasible, acceptable, and appropriate by patients, clinicians, and health system leaders. ClinicalTrials.gov NCT06203509; https://clinicaltrials.gov/ct2/show/NCT06203509. DERR1-10.2196/64575.

NHS action on social and economic development in England: Vague national policy expectations

Under recent reforms to the National Health Service (NHS) in England, NHS organizations have been given new objectives to contribute to social and economic development. Health systems in other high-income countries are pursuing related approaches. This paper analyses national policy documents to understand the framing of the NHS's new policy priorities on social and economic development. We focus on the role of NHS integrated care systems—area-based planning bodies responsible for managing NHS resources and coordinating local services. National policy is vague about what social and economic development means in practice. There is limited guidance on which approaches local organizations should prioritize, and which organisations are responsible for implementation. Greater clarity from national policymakers and an overarching framework to guide local action is needed to reduce the risk of inaction, poorly targeted interventions, and missed opportunities for learning and evaluation. Policymakers and health system leaders also need to be realistic about the limits of local action given the importance of national public policy choices in shaping the social determinants of health. Coordinated policy action and investment across government is needed to address underlying social and economic conditions.

Integrating community health workers into HIV care clinics: a qualitative study with health system leaders and clinicians in the Southern United States

BackgroundCommunity health workers (CHWs) can support patient engagement in care for a variety of health conditions, including HIV. This paper reports on the experiences of HIV clinics and health departments that integrated CHWs into their health systems as part of a capacity-building initiative to address HIV-related disparities in the United States.MethodsSemi-structured interviews were conducted with key informants (n = 14) in two Ryan White HIV/AIDS program jurisdictions: Mississippi (jurisdiction covers the entire state) and the city of New Orleans, Louisiana. This work was part of a larger evaluation of an initiative that used a Learning Collaborative model to facilitate the implementation of evidence-informed interventions to address HIV care continuum gaps in four jurisdictions. The two jurisdictions that focused on integrating CHWs into HIV care clinics and support service agencies were selected for this sub-analysis. Interview participants included HIV clinic leaders and staff, health department leaders, and other Learning Collaborative leaders. Interview transcripts were coded and analyzed for themes related to the acceptability, feasibility, and perceived impact of CHW integration.ResultsOverall, participants expressed interest in having support from CHWs at HIV clinics and service agencies to assist with patient retention and engagement efforts. However, there were challenges integrating CHWs into existing systems (e.g., gaining access to electronic health records, changing policies to conduct home visits, and clarifying roles and scope of work). Negotiating contracts and accessing funding for CHW positions presented major challenges that often contributed to turnover and conflicts around scope of practice. When health departments leveraged existing funding streams to support CHW positions, the clinics and agencies where the CHWs worked had limited flexibility over the hiring process.ConclusionsOur findings reinforce the value and acceptability of CHWs as part of the workforce in HIV clinical and support service settings; however, integrating CHWs into clinics and service agencies required effort. Training the CHWs was not sufficient; other staff and clinicians had to understand the role of CHWs to facilitate their integration into health systems. Resources are needed to support organizations in incorporating CHWs effectively, and long-term, flexible sources of funding are necessary for these positions.

Co-producing evidence to inform universal health coverage implementation in Ireland: 2019-2024

Abstract Background In 2017, Ireland’s parliamentary health committee published a ten-year health reform plan, entitled Sláintecare, with the aim of delivering universal healthcare. Endorsed by government in 2018, progressing Sláintecare remains government policy in 2024. In 2019, Prof Burke was awarded public funding to co-produce knowledge for the design and implementation of the regions, a key aspect of Sláintecare. In 2020, with the arrival of COVID-19, regional reform was paused and the research pivoted to capture the learning from the COVID-19 health system response to inform Sláintecare. In 2022/3, the research returned to focus on the regions. Methods Foundations’ research resulted in 14 peer-reviewed publications between 2019 and 2023. These were mixed-methods using qualitative and quantitative data and analysis. Coproduction with health system leaders that were devising and implementing the regions and the COVID-19 health system response underpinned the research. Results There are 14 academic publications from the Foundations Research (2019-2023). At the core of co-production is trust and good working relationships. Co-producing research with senior policy makers and implementers has benefits and drawbacks. The benefits include access to resources and data and that the data and knowledge generated are more likely to be adopted. Drawbacks include control over areas researched, denial of access to data and lack of openness to research findings. Producing controversial findings, unpopular with government, minister or health system leaders can also lead to difficulties for the research team. Discussion/conclusions Details of the coproduction process with senior health system and policy leaders will be presented. It will detail specific examples of the research which were initiated by the health system and those that came from the academic research team. It will give examples of how the research influenced the policy making and implementation processes. Key messages • Co-producing research between academics and health system and policy leaders leads to better use of evidence. • Trust and good workign relationships are key to co-producing research that is used in policy making and implementation processes.

Co-producing research on universal health system reform in the context of COVID-19

Abstract Issue How to co-produce and embed research into universal health system reform implementation in the context of COVID-19. In many respects the pandemic revolutionised the use of data and research, with near real-time data informing key health policy and system decisions. This was evident in the production of publicly available data sets tracking COVID-19 infection as well as health system dashboard tracking activity in real-time and influencing day-to-day decisions made. How can this use of data and research evidence become the norm for all health system reform and policy decisions? Results The Foundations’ research project is a partnership project in place since Autumn 2019. Initially focused on producing evidence to inform the design and implementation of new regional areas with the Department of Health Sláintecare Reform Office and the Irish national Health Service Executive as partners. When COVID-19 occurred all work on the regions was paused the research pivoted to harness the learnings form the COVID-19 response to inform universal health system reform. The partnership applied research nature of the programme allowed research to be coproduced and co-designed with health system leaders, meant the researchers understood if and when it was possible to engage with partners and how to feed result into the health system at the earliest opportunity. Lessons Trust and pre-existing working relationships with partners allowed the research to pivot and to continue during the pandemic. The applied partnership nature of the research meant that at times the health system was very engaged in the research and at other times (eg during COVID waves and surges or the cyber-attack) there was limited engagement. The co-production nature of the research allowed a dynamic, ongoing, two-way learning between the health system and the research team. It is extremely difficult to measure impact of research on health system and reform decisions.

How to not revert to type: learnings from the pandemic response for universal health system reform

Abstract Background Understanding of the opportunities and learnings for health system change that have arisen during the pandemic is still emerging. Situated in the Irish health reform context of Sláintecare, the programme which aims to deliver universal, integrated healthcare, this study set out to generate evidence on the processes that impacted access to universal, integrated care during COVID-19, with a view to informing universal health system reform and implementation. Methods The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with 16 health system professionals (including managers and frontline workers) from a range of responses to explore their experiences during the pandemic. Following thematic analysis, a complexity-informed approach guided the interpretation of the findings. Results A range of factors facilitated better access to integrated care during the crisis, falling under three key themes (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a human-centred health system. Conclusions Alongside establishing health system structures, we must also incorporate alternative approaches to reform that recognise the value of shared sense-making in an interdependent system, while also allowing for innovation, exploration and learning; and acknowledging the role of social dynamics in driving change.

Medical silos, social identity, and duty of care: A call for health leaders to improve transitions of care.

This article explores the concept of medical silos, particularly within hospital systems, and examines their deeper roots in social identity and the fiduciary duty of care of healthcare providers. While traditional perspectives focus on informational and communication barriers, this analysis highlights how professional identity and moral obligations contribute to the persistence of silos. Social identity theory reveals that strong in-group affiliations, formed during medical training and specialization, fosters collaboration within groups but also create divisions between them. Similarly, the fiduciary duty of care, central to ethical medical practice, may inadvertently reinforce silo boundaries in resource-limited environments. By emphasizing the role of centralized leadership, the article proposes that health system managers and leaders, with the broadest possible duty of care, must take action to dismantle these barriers. Recommendations include re-evaluating policies for patient transitions and fostering integrated care pathways to improve overall system flow, rather than simply balancing the agendas of stakeholders within their silos.

The number of patient scheduled hours resulting in a 40-hour work week by physician specialty and setting: a cross-sectional study using electronic health record event log data.

To quantify how many patient scheduled hours would result in a 40-h work week (PSH40) for ambulatory physicians and to determine how PSH40 varies by specialty and practice type. We calculated PSH40 for 186188 ambulatory physicians across 395 organizations from November 2021 through April 2022 stratified by specialty. Median PSH40 for the sample was 33.2 h (IQR: 28.7-36.5). PSH40 was lowest in infectious disease (26.2, IQR: 21.6-31.1), geriatrics (27.2, IQR: 21.5-32.0) and hematology (28.6, IQR: 23.6-32.6) and highest in plastic surgery (35.7, IQR: 32.8-37.7), pain medicine (35.8, IQR: 32.6-37.9) and sports medicine (36.0, IQR: 33.3-38.1). Health system leaders and physicians will benefit from data driven and transparent discussions about work hour expectations. The PSH40 measure can also be used to quantify the impact of variations in the clinical care environment on the in-person ambulatory patient care time available to physicians. PSH40 is a novel measure that can be generated from vendor-derived metrics and used by operational leaders to inform work expectations. It can also support research into the impact of changes in the care environment on physicians' workload and capacity.

Engaging primary care patients at risk for suicide in mental health treatment: user insights to inform implementation strategy design

BackgroundGiven that the majority of suicide decedents visit primary care in the year preceding death, primary care has been identified as a key setting in which to engage patients at risk for suicide in mental health services. The objective of this research was to identify barriers and facilitators to engagement in mental health services among primary care patients at risk for suicide to inform the development of strategies to increase engagement.MethodsSeventy-four semi-structured qualitative interviews were conducted with primary care patients (n = 20), primary care (n = 18) and behavioral health (n = 12) clinicians, mental health intake coordinators (n = 4), and health system and clinic leaders (n = 20). Patients who had been referred for mental health services from primary care and reported an elevated score (≥ 1) on item 9 on the Patient Health Questionnaire at the time of referral were eligible to participate. Eligible clinicians and leaders were employed in a primary care or behavioral health setting in a single large health system with an integrated mental health program. Interviews typically lasted 30–60 min, were completed over video conference or phone, and were coded by members of the research team using a rapid qualitative analysis procedure.ResultsParticipants were primarily female (64.9%), white (70.3%) and non-Hispanic/Latine (91.9%). The most identified barriers to mental health care engagement were waitlists, capacity limits, insurance, patient characteristics, communication, collaboration, and/or difficulties surrounding travel. The most commonly cited facilitators of engagement included telehealth, integrated care models, reminders, case management support, psychoeducation, motivational enhancement, and scheduling flexibility. Concrete suggestions for improving engagement in mental health services included increasing communication between providers, streamlining referral and intake processes, providing reminders and follow ups, and advocacy for increased reimbursement for suicide risk assessment.ConclusionsResults underscore the myriad barriers patients at risk for suicide encounter when attempting to engage in mental health care in a primary care setting. Facilitators of engagement and suggestions for improving connections to care were also identified, which can inform the design of implementation strategies to improve engagement in mental health services among primary care patients at risk for suicide.Trial registrationClinicalTrials.gov Identifier: NCT05021224 (Registered August 19, 2021).

Investigating Leadership: Reflections on the methodological choices used to research how allied health clinicians are enabled to step into health systems leadership roles

This article examines the methodological choices made for a research study into Health Systems Leadership. Reflections on key learnings are provided as a way of offering insight for researchers navigating these decisions for the first time. Embarking on qualitative research to effect change is purposeful but challenging; choosing the most appropriate methodology and methods can often be confounding and stressful for new researchers. This article explores the decision to use Interpretive Descriptive methodology with an Appreciative Inquiry lens and makes visible decision junctures in the development of this research. Literature provides a wealth of expert guidance and excellent insights into research methodology and methods. However, very little expounds on the learnings of those who have gone before and what their insights and learnings may be. Research into allied health clinicians and their journey into health systems leadership roles provides an opportunity to reflect on an applied research journey.

A new patient navigation model of care to support older adults in transitions of care: Key considerations for implementation for policy-makers and health system leaders.

A Patient Navigation (PN) model of care was introduced in a large metropolitan hospital in Ontario (Canada) to support transitions in care for older adults in 2019. The patient navigator is a community social worker or "community transitional lead" embedded in the hospital's in care teams to assist with discharge planning and provide follow-up care to older adults, their families, and/or care partners for up to 90 days. Initially, the PN program supported acute care patients and has since expanded in the Emergency Department and Reactivation Care Centre. In this cohort retrospective observational study, we described the new PN model of care by analyzing the clinical notes collected by the patient navigator. This article provides preliminary insights for health leaders who are interested in implementing this novel PN model to improve transitions of care in a hospital setting. Funding was provided by the SLAIGHT Family Foundation.

An Organizational Case Study of Mental Models among Health System Leaders during Early-Stage Implementation of a Population Health Approach.

As the COVID-19 pandemic recedes, the importance of population health has come into sharp focus, prompting many health systems to explore leveraging population health data (PHD) for operational planning. This approach requires that healthcare leaders embrace the dual priorities of maintaining excellence in patient care while promoting the overall health of populations. However, many leaders are new to population-based thinking, posing a threat to successful operationalization if mental models are not aligned. This qualitative case study explored the alignment of mental models among 13 senior leaders at Trillium Health Partners (THP), one of Canada's largest community hospitals, as they embark on embedding PHD within operational workflows. All leaders recognized the necessity of adopting a population health approach amid resource constraints and growing pressures. When discussing the operationalization of PHD, two distinct mental models emerged among leaders: one focused on patient care and the other on population health. While executive leaders demonstrated a fluidity in their thinking between the two, programmatic leaders favoured one over the other. For example, some viewed the organization's focus on PHD as competing with their patient care responsibilities, while others saw the use of PHD as a solution to the organization's operational pressures. Despite these divergences, leaders unanimously stressed the importance of increasing the organization's risk tolerance and devolving decision-making as a necessary precursor to realizing the transformation to a PHD-driven approach. These divergent mental models highlight a need to clarify the shared vision for the use of PHD along with its impact on leadership roles and accountabilities. These findings illustrate the current state from which THP aims to evolve and underscore the importance of aligning leaders' mental models as a critical step to facilitating successful integration of PHD and advancing a collective vision for healthcare transformation.

The Experience of Hospitalisation for People Living With Dementia: A Qualitative Exploration of How Context Shapes Experiences.

Dementia has become an increasingly pressing issue in healthcare systems, and acute care settings such as hospitals have been shown to be particularly problematic for people living with dementia. People living with dementia are hospitalised at higher rates than those without and often have poor experiences and outcomes of hospitalisation. To support the evolution of hospital systems to better meet the needs of people living with dementia, it is important to consider the relationship between the context of the hospital and the experiences of people living with dementia and their caregivers. The term context refers to the environment and conditions that shape experiences and includes elements such as policies, procedures, design and social norms. A greater understanding of the relationship between the hospital context and the experiences of people living with dementia will support the future development of interventions to modify contextual elements to improve the experiences of people living with dementia. Our aim was to explore the relationship between the experiences of people living with dementia and their caregivers in hospital, and the contextual elements of the hospital. In this interpretive descriptive study, we conducted interviews with people living with dementia and caregivers of people living with dementia about their experiences in hospital. Interviews were conducted with people living with dementia (n = 3), caregivers of people living with dementia (n = 8) and one dyad of a person living with dementia and their caregiver (n = 1) about the hospitalisation of the person living with dementia. Using inductive and deductive methods of analysis, we describe contextual factors that shape their experiences. Our findings demonstrate how the hospital context shaped the experiences of people living with dementia and their caregivers while the person living with dementia was hospitalised. The themes reflect elements of the hospital context: communication systems, the value of caregivers, the focus on acute physical needs, staff capacity, the physical environment and normalised practices. The findings suggest that there are aspects of the hospital context that can be modified to influence the experiences of people living with dementia and their caregivers. This study demonstrates how the context of hospital shapes the experiences of people living with dementia and their caregivers and points to aspects of the context that health system leaders could explore to begin to improve the capacity of hospitals to support people living with dementia. The study provides evidence of the need for health system leaders and practitioner to explore how the hospital context shapes the experiences of people wtih dementia and their caregivers, and begins to explore ways that contextual changes can improve their experiences.

“We do these audits, but in the end, it’s useless.” How can facility-based maternal death reviews improve the quality of care in Benin?

Benin scaled up facility-based Maternal Death Reviewss (MDRs) in 2013 to address its high maternal mortality rate. This study aims to assess the extent to which facilitybased MDR captured the complex causes of maternal deaths in 2022. In this mixedmethod study, we first conducted a quantitative analysis of dysfunctions, root causes,and recommendations extracted from all facility-based MDR reports that occurred in Benin's health facilities in 2022. We calculated frequency distributions based on the systemic maternal care quality assessment framework's components and the iceberg model for system thinking's layers. Second, we conducted in-depth and informal interviews and (non)participant observations and reviewed facility-based MDR policyrelated documents. Content analysis was applied to qualitative data. facility-based MDR teams identified 1295 dysfunctions, 1216 root causes, and 1082 recommendations in facility-based MDR reports of 540 maternal deaths. One-fifth of reports were uninformative, lacking dysfunctions, root causes, or recommendations.Within the health system components, leadership and governance received the least attention regarding dysfunctions (1 %) and root causes (12 %).Most dysfunctions (87 %) and root causes (73 %) focused on the iceberg's tip, leading to reactive recommendations rather than addressing deeper systemic issues. Two main factors emerged: non-compliance with facility-based MDR requirements (time constraints, unreliable data, fear of strained provider relationships) and limitations in facility-based MDR processes (data collection and analysis tool constraints),

Quality Indicators for Transition from Pediatric to Adult Care for Youth With Chronic Conditions: Proposal for an Online Modified Delphi Study.

The transition from pediatric to adult care poses a significant health system-level challenge impeding the delivery of quality health services for youth with chronic health conditions. In Canada and globally, the transition to adult care is regarded as a top priority in adolescent health in need of readily applicable, adaptable, and relevant national metrics to evaluate and benchmark transition success across disease populations and clinical care settings. Unfortunately, existing literature fails to account for the lack of engagement from youth and caregivers in developing indicators, and its applicability across chronic conditions, primary care involvement, and health equity considerations. Our proposed study aims to establish a consensus-driven set of quality indicators for the transition to adult care that are universally applicable across physical, developmental, and mental health conditions, clinical care settings, and health jurisdictions. Using an integrated knowledge translation (iKT) approach, a panel comprising youth, caregivers, interdisciplinary health care providers, and health system leaders will be established to collaborate with our research team to ensure that the study methodology, materials, and knowledge dissemination are suitable and reflect the perspectives of youth and their families. We will then conduct an iterative 3-round Online Modified Delphi (OMD) study (n=160) to (1) compare and contrast the perspectives of youth, caregivers, health care providers, and health system leaders on quality indicators for transition; and (2) prioritize a key set of quality indicators for transition applicable across disease populations that are the most important, useful, and feasible in the Canadian context. Using the RAND/UCLA Appropriateness Method (RAM) multistage analytic approach, data from each panel and stakeholder group will be examined separately and compared to establish a key set of indicators endorsed by both panels. The study is funded by the Canadian Institutes of Health Research and Physicians Services Incorporated. This study will produce quality indicators to evaluate and inform action equitably to improve transition from pediatric to adult care for youth and their families in Canada. PRR1-10.2196/60860.

Empowering youth as agents of change: Gaps and opportunities for meaningful youth engagement (MAYE) for sustainable nutrition, climate and public health programmes.

Addressing the intersection of food insecurity, malnutrition and climate change in Sub-Saharan Africa requires meaningful adolescent and youth engagement to drive sustainable change. Drawing on empirical evidence and collective experiences from youth-led initiatives and coalitions, four gaps and opportunities to better involve youth in programmes are discussed, including, the need to: (1) standardise the definition of youth to improve programme design and data harmonisation, (2) provide capacity building and mentorship for youth leadership in health service delivery, (3) foster youth leadership and multisectoral collaboration in food and health systems and (4) enhance capacity development for non-youth actors to support genuine youth participation. This viewpoint underscores the importance of involving African youth in public health nutrition, climate change and food security programmes design and implementation-as drivers of change to addressing hunger and climate crises. By centering youth voices and experiences, programmes and policies can better address African communities' complex challenges, fostering inclusivity, sustainability and resilience in achieving better nutrition and public health programmes and outcomes.