Improvements In Health Service Delivery Research Articles

Abstract P3-10-10: Planning and implementation of two regional one-stop breast health centres within a large geographic health authority: Outcomes and quality improvements in health service delivery

Abstract Interrogative examination of wait times for the pathway steps leading to diagnosis, surgical treatment, and oncology consultation for breast cancer within a geographically dispersed publically funded health authority led to advocacy for and establishment of two large one-stop Breast Health Centres (BHCs) within the largest urban cities. One year after publication of the 2000 EUSOMA guidelines for breast cancer diagnosis and treatment, regional breast cancer pathways and wait times did not meet guidelines. Population median wait time from date of first investigation to tissue diagnosis was 2.7 or 5.9 weeks (for clinical presentation or screen presentation respectively), 6.0/7.0 weeks to definitive surgical intervention, and 14.3/11.7 weeks to oncology consultation. Only 39 % of patients were diagnosed initially via core needle biopsy. 5 % of patients underwent immediate reconstructive surgery. Due to wait times for initial imaging (mammogram, ultrasound) at hospital facilities, baseline imaging was often performed at private imaging labs without needle diagnostic capability, and repeated again with a series of wait times at the hospitals - as the initial community images were not accessible to the hospital interventional radiologists. Smaller communities and their hospitals maintained shorter wait times in comparison to the large urban centres. Repeat population based measurement in 2009 indicated wait times were unchanged, and MRI guided biopsy was still not available within the region. Nursing support and patient education re breast cancer prognosis and treatment was not available until the time of oncology consultation. BHCs were planned, funded by the Ministry of Health, established in physical conjunction with the breast screening programs, and became operational as of early 2012. During the first year of BHC operation, population median wait time from date of first investigation was 2.0 weeks for tissue diagnosis, 6.4 weeks for final definitive surgical intervention, and 9.4 weeks for oncology consultation. 90 % of patients were initially diagnosed via initial core needle biopsy with IHC staining for ER, PR, and HER2. Patients served by the BHCs had nurse navigator support and education from time of presentation. The surgical team overcame regional surgical wait time barriers such as available admission beds by establishing the first comprehensive population-based outpatient mastectomy and reconstruction program in Canada with over 1200 performed to date. These wait times have been maintained in spite of increase in the HA population from 1.2 million to 1.6 million during the project timeline. Citation Format: Martin LA, Janzen R, Wong F, Doris P. Planning and implementation of two regional one-stop breast health centres within a large geographic health authority: Outcomes and quality improvements in health service delivery [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-10.

Adolescent Mental Health Case Management: Consumer Perspectives

This qualitative study describes case management practices and suggestions for mental health service delivery improvement from the perspective of parents and guardians of adolescent service recipients, as well as youth service recipients over the age of 18. Data were collected during a series of 10 personal semistructured interviews. Parent/guardian interview participants discussed case management and what they perceived as barriers to effective case management services, as well as those aspects found within quality services. Interview participants also discussed their ideas on how to improve mental health case management service at both the micro and macro level. Interview results indicate mental health case management is not meeting its full capacity as a service that can positively impact adolescent outcomes.

Implementation of electronic medical records requires more than new software: Lessons on integrating and managing health technologies from Mbarara, Uganda

Implementation lessons•Technology alone does not necessarily lead to improvement in health service delivery, in contrast to the common assumption that advanced technology goes hand in hand with progress.•Implementation of electronic medical record (EMR) systems is a complex, resource-intensive process that, in addition to software, hardware, and human resource investments, requires careful planning, change management skills, adaptability, and continuous engagement of stakeholders.•Research requirements and goals must be balanced with service delivery needs when determining how much information is essential to collect and who should be interfacing with the EMR system.•EMR systems require ongoing monitoring and regular updates to ensure they are responsive to evolving clinical use cases and research questions.•High-quality data and analyses are essential for EMRs to deliver value to providers, researchers, and patients.

Development of the Health Literacy of Caregivers Scale - Cancer (HLCS-C): item generation and content validity testing.

BackgroundHealth literacy refers to an individual’s ability to engage with health information and services. Cancer caregivers play a vital role in the care of people with cancer, and their capacity to find, understand, appraise and use health information and services influences how effectively they are able to undertake this role. The aim of this study was to develop an instrument to measure health literacy of cancer caregivers.MethodContent areas for the new instrument were identified from a conceptual model of cancer caregiver health literacy. Item content was guided by statements provided by key stakeholders during consultation activities and selected to be representative across the range of cancer caregiver experiences. Content validity of items was assessed through expert review (n = 7) and cognitive interviews with caregivers (n = 16).ResultsAn initial pool of 82 items was generated across 10 domains. Two categories of response options were developed for these items: agreement with statements, and difficulty undertaking presented tasks. Expert review revealed that the majority of items were relevant and clear (Content Validity Index > 0.78). Cognitive interviews with caregivers suggested that all except three items were well understood.ConclusionA resultant 88 item questionnaire was developed to assess cancer caregiver health literacy. Further work is required to assess the construct validity and reliability of the new measure, and to remove poorly performing and redundant items, which will result in a shorter, final measure. The new measure has the potential to inform the development and evaluation of interventions and the improvement of health service delivery to cancer caregivers.

Developing junior doctors as leaders of service improvement

Purpose – This paper aims to provide an overview of the design and initial outcomes of a leadership and service improvement program for junior medical staff. Design/methodology/approach – This paper describes the rationale, initial set-up, structure, program outcomes and future directions of the Medical Service Improvement Program for junior doctors. This program is a recent initiative of the Western Australian public healthcare system. Findings – The Medical Service Improvement Program illustrates a successful approach to developing junior doctors to lead improvements in health service delivery. The program has resulted in tangible personal outcomes for participants, in addition to important organisational outcomes. Practical implications – This paper provides an evidence-based structured approach to developing the leadership abilities of junior medical staff. It provides practical information on the design of the leadership program that aligns the participant learning outcomes to postgraduate medical competencies. The program has demonstrated clear service outcomes, confirming that junior medical staff is both capable and committed to leading service improvement and reform. Originality/value – This paper provides clear evidence for the benefits of providing dedicated non-clinical time for junior medical staff to lead quality and improvement initiatives. This case study will assist hospital administrators, postgraduate education units and those involved in designing and administering clinical leadership development programs.

When Opportunity Beckons: The Impact of the Public Service Accountability Monitor's Work on Improving Health Budgets in South Africa

The Eastern Cape Province of South Africa struggles with high poverty, poor public infrastructure, and dysfunctional administrative systems. One result is that the Eastern Cape has the worst health outcomes in the country. This case study illustrates how a South African civil society organization has used its budgetary analysis to advocate for improvements in health service delivery. This case study is part of the Learning Program of the International Budget Partnership’s Partnership Initiative. The PI Learning Program seeks to assess and document the impact of civil society engagement in public budgeting.

Assessing the use of an essential health package in a sector wide approach in Malawi

BackgroundThe sector wide approach (SWAp) used in many developing countries is difficult to assess. One way is to consider the essential health package (EHP) which is commonly the vehicle for a SWAp's policies and plans. It is not possible to measure the impact of an EHP by measuring health outcomes in countries such as Malawi. But it is possible to assess the choice of interventions and their delivery in terms of coverage. This paper describes an attempt to assess the Malawi SWAp through its EHP using these available measures of technical efficiency.MethodsA burden of disease model was used to identify the priority diseases and their estimated incidence. Data from the health management information system (HMIS) were used to measure the coverage of these interventions. A review of the cost-effectiveness of the chosen and potential interventions was undertaken to assess the appropriateness of each intervention used in the EHP. Expenditure data were used to assess the level of funding of the EHP.Results33 of the 55 EHP interventions were found to be potentially cost-effective (<$150/DALY), 12 were not so cost-effective (>$150/DALY) and cost-effective estimates were not available for ten. 15 potential interventions, which were cost-effective and tackling one of the top 20 ranked diseases, were identified.Provision had increased in nearly all EHP services over the period of the SWAp. The rates of out patient attendances and inpatient days per 1000 population had both increased from 929 attendances in 2002/3 to 1135 in 2007/08 and from 124 inpatient days in 2002/03 to 179 in 2007/08.However, by 2007/08 the mean gap between what was required and what was provided was 0.68 of the estimated need. Two services involving the treatment of malaria were overprovided, but the majority were underprovided, with some such as maternity care providing less than half of what was required.The EHP was under-funded throughout the period covering on average 57% of necessary costs. By 2007/08 the funding paid by SWAp partners including the government of Malawi to fund the EHP was at US$13.5 per capita per annum, which was almost half of the revised EHP estimated required expenditure per capita per annum.DiscussionThe SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two thirds of the services required. This was despite serious under-funding of the EHP, an increase in the population and shortage of staff.ConclusionsThe identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.

Culturally and linguistically diverse peoples' knowledge of accessibility and utilisation of health services: exploring the need for improvement in health service delivery

With 28% of Australia's population having a culturally and linguistically diverse (CALD) background, the health system faces an increasing challenge to provide accessible and culturally competent health care. The view that all CALD communities are homogenous and solutions can be developed for the entire nation is detrimental. Despite available health services, CALD communities are reluctant to use them due to cultural differences, perceived racism and misunderstandings leading to the existing health disparities. Therefore, gathering data from four prominent CALD communities, such as the Sudanese, Afghani, Pacific Islander and Burmese communities in Logan, Queensland, about how they perceive and use health services can provide insightful information towards development of a service model that will better suit these CALD communities. The objective of the study was to examine the extent to which four prominent CALD communities (Sudanese, Afghani, Pacific Islander and Burmese) access and use health services in Logan, Queensland. Six focus group interviews using interpreters were conducted in English with Sudanese, Afghani, Pacific Islander and Burmese people. The results indicated that even long-standing CALD communities, such as the Pacific Islander people, were unfamiliar with health services and experienced difficulties accessing appropriate health care. Most wanted doctors to use traditional healing methods alongside orthodox medicine, but did not feel respected for their beliefs. Language difficulties impeded communication with health professionals who were hindered by ineffective use of interpreters. In conclusion, a clear role for bilingual community-based navigators was identified by CALD participants to address concerns about the health system, and to improve accessibility and health service usage.

Are hard-to-reach populations being reached with immunization services? Findings from the 2005 Papua New Guinea national immunization coverage survey

Objective To measure immunization coverage among children aged 12–23 months in Papua New Guinea (PNG) and to assess if and why there are differences between hard-to-reach and more accessible communities. Methods WHO cluster sampling methodology was employed to measure immunization coverage in PNG's four regions. Survey data were re-analyzed according to a local assessment of geographical accessibility indicated by census unit type: urban, rural and hard-to-reach. Census units were designated as hard-to-reach if they were five or more kilometres from a health centre. Findings Nationwide coverage for most antigens falls below the national target of 80% although there are regional differences with Islands performing the best. Late doses are a major concern: just 4% were fully immunized with valid (“on time”) doses by 1 year of age. Coverage was lower in both rural and remote communities: at 6 months 48% of children from urban units had received three valid doses of DTP-3 but only 16% in rural areas and 13% in hard-to-reach communities. Reasons for failure to immunize varied: 21% of mothers said their child was not immunized because distance, travel conditions or cost of transportation prevented access to local health centres; 27% cited a lack of knowledge or misconceptions about immunization; while 29% believed it was because of an issue with the health system. Conclusions Throughout PNG there is an urgent need to increase immunization coverage and to ensure that children are immunized on time according to the schedule. Both coverage and timeliness of doses are worse for children living in hard-to-reach and rural areas. Achieving national immunization targets requires improvements in health service delivery, including outreach, especially for remote and rural communities, as well as greater community education and social mobilisation in support of immunization services.

Failure to complete adjuvant chemotherapy is associated with adverse survival in stage III colon cancer patients

Two recent North American studies have shown that completion of 5-fluorouracil (5FU)-based adjuvant chemotherapy is a major prognostic factor for the survival of elderly stage III colon cancer patients. The aim of the present study was to confirm this finding in a population-based series from Australia. The study cohort comprised 851 stage III colon cancer patients treated by surgery alone and 461 who initiated the Mayo chemotherapy regime. One-third of patients who initiated chemotherapy failed to complete more than three cycles of treatment. Independent predictors for failure to complete were treatment in district or rural hospitals, low socioeconomic index and treatment by a low-volume surgeon. Patients who failed to complete chemotherapy showed worse cancer-specific survival compared not only to those who completed treatment (HR=2.24; 95% confidence interval (CI) (1.66–3.03), P<0.001) but also to those treated by surgery alone (HR=1.37; 95% CI (1.09–1.72), P=0.008). The current and previous studies demonstrate the importance of completing adjuvant 5-FU-based chemotherapy for colon cancer. Further prospective studies are required to identify better the physiological and socioeconomic factors responsible for failure to complete chemotherapy so that appropriate improvements in health service delivery can be made.

How quality improvement in health care can help to achieve the Millennium Development Goals

A recent article in The Lancet analysed the barriers to reaching the Millennium Development Goals (MDGs) concerning maternal health, child health, tuberculosis, malaria and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). (1) Inappropriate provider behaviour, insufficient case management, limited management capacity, and referral and communication failures were identified at the service delivery level; at the policy and strategic management level, insufficient coordination between actors, weak links between programmes, and inappropriate use of information were mentioned. Looking at this evidence from a quality improvement angle is particularly interesting. The majority of the barriers described by the authors relate to the classic quality dimensions that define a quality service (in both delivery and management): to be effective, efficient, accessible, timely, acceptable, evidence-based, equitable, safe and client centred. For example, inappropriate provider behaviour often results from a lack of patient orientation, unacceptable and ineffective communication, and the non-application of evidence-based standards. If the majority of barriers to health-related MDGs can be seen as quality-related, quality improvement approaches may be able to tear down some of them. Quality improvement means any process or tool aimed at reducing the quality gap in systemic and organizational functions according to the dimensions of quality. The basic principles of quality improvement are common sense: customer focus, strong leadership, involvement of people, process approach, system approach to management, continual improvement, factual approach to decision-making, and mutually beneficial supplier relationships. (2) There is evidence that these basic principles can contribute to the improvement of health service delivery in developing countries: an article in this issue of the Bulletin describes how some of them have been used to improve the emergency care of children in several countries. (3) If we accept that quality improvement can make a difference in service delivery and management, we should look at how we can make this happen on a large scale and what the determinants are for the successful introduction of quality improvement approaches. Although quality improvement is already an aim of the vast majority of health sectors, there are still numerous problems linked to the introduction of approaches in developing countries. In many countries the choice of quality approaches is driven by the attraction of brands and by small lobby groups rather than by a rational decision-making process--consequently, they are often not adapted to the country's reality. As an example, the introduction of sophisticated hospital accreditation brands from competition-driven rich countries to poor district health systems rarely leads to the desired outcome, as rural inhabitants often have no alternative to district hospitals and market forces are limited. …