Leading Health Systems Research Articles

Current and anticipated future state of cachexia care in patients with cancer.

Aims: We assessed care in cancer patients with cachexia across leading health systems (LHSs).Patients & methods: Qualitative interviews and quantitative surveys were conducted with LHSs executives and frontline health care personnel, representing 46 total respondents and 42 unique LHSs and including oncology service line leaders, supportive care services, dietitians and surgical oncologists.Results: Cachexia was not considered a top priority, and formal diagnoses were rare. Participants highlighted the importance of addressing barriers to increase clinical trial enrollment and support frontline health care personnel and patients in early detection of cachexia.Conclusion: Cachexia prioritization needs to be elevated across LHSs executives to obtain capital and strategic imperatives to advance related care.

The Application of Health Leadership Competencies Around the World to the Canadian Midwifery Profession: A Scoping Review

Objectives: To review and map the key leadership competencies and frameworks created by health care professionals and health leaders across the globe. To use the themes that emerge to create a new leadership framework for Canadian midwifery. Background: Effective leadership has a significant impact on health care outcomes. In an effort to describe effective leadership, many health professions and organizations are creating lists of competencies within leadership frameworks. Midwifery is a relatively young profession in Canada. To date there has been no published Canadian work on leadership or leadership frameworks. Midwifery has a vital role to play within health care but needs to grow in leadership knowledge and capacity. Methods: A scoping review was conducted using both a published literature search and a grey literature search. The published literature search was conducted using CINAHL and OVID, while the grey literature search included an online review of the websites of major health professions in Canada, the UK, the US, Ireland, Australia, and New Zealand. Results: Twenty-three articles met the inclusion criteria. Within the articles were 582 key competencies, organized into 133 separate themes. Thematic analysis of the competencies results in competencies falling into five major themes of leadership: self, patient/client care, team, organization, and health systems. Conclusion: A new framework was created using the emerging themes found in the scoping review: Leading Self, Leading the Team, Leading Client Care, Leading the Organization, and Leading Health Systems. This new framework was applied to the Canadian midwifery profession, using core midwifery documents. This scoping review can be used by Canadian midwifery organizations looking to create a leadership framework and by university midwifery programs as they look to incorporate leadership competencies into their curriculum. This article has been peer reviewed.

Usability and Feasibility Evaluation of a Web-Based and Offline Cybersecurity Resource for Health Care Organizations (The Essentials of Cybersecurity in Health Care Organizations Framework Resource): Mixed Methods Study.

Cybersecurity is a growing challenge for health systems worldwide as the rapid adoption of digital technologies has led to increased cyber vulnerabilities with implications for patients and health providers. It is critical to develop workforce awareness and training as part of a safety culture and continuous improvement within health care organizations. However, there are limited open-access, health care-specific resources to help organizations at different levels of maturity develop their cybersecurity practices. This study aims to assess the usability and feasibility of the Essentials of Cybersecurity in Health Care Organizations (ECHO) framework resource and evaluate the strengths, weaknesses, opportunities, and threats associated with implementing the resource at the organizational level. A mixed methods, cross-sectional study of the acceptability and usability of the ECHO framework resource was undertaken. The research model was developed based on the technology acceptance model. Members of the Imperial College Leading Health Systems Network and other health care organizations identified through the research teams' networks were invited to participate. Study data were collected through web-based surveys 1 month and 3 months from the date the ECHO framework resource was received by the participants. Quantitative data were analyzed using R software (version 4.2.1). Descriptive statistics were calculated using the mean and 95% CIs. To determine significant differences between the distribution of answers by comparing results from the 2 survey time points, 2-tailed t tests were used. Qualitative data were analyzed using Microsoft Excel. Thematic analysis used deductive and inductive approaches to capture themes and concepts. A total of 16 health care organizations participated in the study. The ECHO framework resource was well accepted and useful for health care organizations, improving their understanding of cybersecurity as a priority area, reducing threats, and enabling organizational planning. Although not all participants were able to implement the resource as part of information computing technology (ICT) cybersecurity activities, those who did were positive about the process of change. Learnings from the implementation process included the usefulness of the resource for raising awareness and ease of use based on familiarity with other standards, guidelines, and tools. Participants noted that several sections of the framework were difficult to operationalize due to costs or budget constraints, human resource limitations, leadership support, stakeholder engagement, and limited time. The research identified the acceptability and usability of the ECHO framework resource as a health-focused cybersecurity resource for health care organizations. As cybersecurity in health care organizations is everyone's responsibility, there is potential for the framework resource to be used by staff with varied job roles. Future research needs to explore how it can be updated for ICT staff and implemented in practice and how educational materials on different aspects of the framework could be developed.

Progress with the Learning Health System 2.0: a rapid review of Learning Health Systems’ responses to pandemics and climate change

BackgroundPandemics and climate change each challenge health systems through increasing numbers and new types of patients. To adapt to these challenges, leading health systems have embraced a Learning Health System (LHS) approach, aiming to increase the efficiency with which data is translated into actionable knowledge. This rapid review sought to determine how these health systems have used LHS frameworks to both address the challenges posed by the COVID-19 pandemic and climate change, and to prepare for future disturbances, and thus transition towards the LHS2.0.MethodsThree databases (Embase, Scopus, and PubMed) were searched for peer-reviewed literature published in English in the five years to March 2023. Publications were included if they described a real-world LHS’s response to one or more of the following: the COVID-19 pandemic, future pandemics, current climate events, future climate change events. Data were extracted and thematically analyzed using the five dimensions of the Institute of Medicine/Zurynski-Braithwaite’s LHS framework: Science and Informatics, Patient-Clinician Partnerships, Continuous Learning Culture, Incentives, and Structure and Governance.ResultsThe search yielded 182 unique publications, four of which reported on LHSs and climate change. Backward citation tracking yielded 13 additional pandemic-related publications. None of the climate change-related papers met the inclusion criteria. Thirty-two publications were included after full-text review. Most were case studies (n = 12, 38%), narrative descriptions (n = 9, 28%) or empirical studies (n = 9, 28%). Science and Informatics (n = 31, 97%), Continuous Learning Culture (n = 26, 81%), Structure and Governance (n = 23, 72%) were the most frequently discussed LHS dimensions. Incentives (n = 21, 66%) and Patient-Clinician Partnerships (n = 18, 56%) received less attention. Twenty-nine papers (91%) discussed benefits or opportunities created by pandemics to furthering the development of an LHS, compared to 22 papers (69%) that discussed challenges.ConclusionsAn LHS 2.0 approach appears well-suited to responding to the rapidly changing and uncertain conditions of a pandemic, and, by extension, to preparing health systems for the effects of climate change. LHSs that embrace a continuous learning culture can inform patient care, public policy, and public messaging, and those that wisely use IT systems for decision-making can more readily enact surveillance systems for future pandemics and climate change-related events.Trial registrationPROSPERO pre-registration: CRD42023408896.

A mixed-methods landscape assessment of supportive care for heart failure.

Aim: Understanding factors that shape leading health systems' (LHS) perspectives around heart failure (HF) treatment. Patients & methods: First of its kind study using a cross-sectional, descriptive, mixed-method design (from executives and frontline healthcare providers) with quantitative survey (n=35) and qualitative interview (n=12) data from 47 participants (41 different LHS). Results: 97% of LHS had dedicated HF programs, but variations in maturity highlights opportunities for care standardization. Treatment innovations continue, though practitioners may struggle to keep pace amid provider/patient barriers. HF programs strive to co-locate supportive care services to optimize treatment, but access can prove challenging. Conclusion: Opportunities exist, with external partner support, for LHS to become more comprehensive HF care providers, increasing standardization of care across LHS and improved HF treatment.

Bridging cultures for better healthcare: how the Ktunaxa Nation is leading health systems transformation

Bridging cultures for better healthcare: how the Ktunaxa Nation is leading health systems transformation

Assessment of complementary and alternative medicine methods in the management of ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome.

A wide variety of musculoskeletal, arthritic, connective tissue, and vasculitic diseases fall under the umbrella of "rheumatic diseases". Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the three members of this disease group with relatively high prevalence. Pharmacological options are at the center of therapeutic algorithms in treating rheumatic diseases, particularly in reducing inflammation. Despite significant advances in pharmacological treatment in recent years, achieving complete treatment success in a group of patients is impossible. Therefore, patients with rheumatic diseases frequently utilize alternative treatment options, such as complementary and alternative medicine. Complementary and alternative medicine is a broad category of health practices not part of the leading health system. Patients with rheumatic diseases turn to complementary and alternative medicine for various reasons, including restricted access to some treatments due to high prices and rigorous regulations, worries about drug side effects, and symptoms that continue despite pharmacological treatment. In addition, because complementary and alternative medicine options are considered natural, they are frequently accepted as well tolerated and have few harmful effects. Ankylosing spondylitis, rheumatoid arthritis, and fibromyalgia syndrome are the primary foci of this comprehensive review. First, we attempted to summarize the non-traditional physical medicine and complementary and alternative medicine options that can be utilized to manage these diseases. Second, we addressed the link between exercise and inflammation in rheumatic diseases. We briefly discussed the possible benefits of exercise-based approaches. In addition, we highlighted the benefits of cooperation between rheumatology and physical medicine-rehabilitation clinics.

Merit-based incentive payment system participation and after-hours documentation among US office-based physicians: Findings from the 2021 National Electronic Health Records Survey.

After-hours documentation burden among USclinicians is often uncompensated work and has been associated with burnout, leading health systems to identify root causes and seek interventions to reduce this. A few studies have suggested quality programmeparticipation (e.g., Merit-Based Incentive Payment System [MIPS]) was associated with a higher administrative burden. However, the association between MIPS participation and after-hours documentation has not been fully explored. Thus, this study aims to assess whether participation in the MIPS programme was independently associated with after-hours documentation burden. We used 2021 data from the National Electronic Health Records Survey. We used a multivariable ordinal logistic regression model to assess whether MIPS participation was associated with the amount of after-hours documentation burden when controlling for other factors. We controlled for physician age, specialty, sex, number of practice locations, number of physicians, practice ownership, whether team support (e.g., scribes) is used for documentation tasks, and whether the practice accepts Medicaid patients. We included 1801 office-based US physician respondents with complete data for variables of interest. After controlling for other factors, MIPS participation was associated with greater odds of spending a greater number of hours on after-hours documentation (odds ratio = 1.44, 95% confidence interval 1.06-1.95). MIPS participation may increase after-hours documentation burden among USoffice-based physicians, suggesting that physicians may require additional resources to more efficiently report data.

Exit, voice or neglect: Understanding the choices faced by doctors experiencing barriers to leading health system change through the case of Sierra Leone

This paper presents a study from Sierra Leone that explored the experiences of doctors as they endeavored to improve the health care systems in which they worked. Twenty-eight interviews were conducted with doctors in Sierra Leone, complemented by long-standing experience of national health provision and research by the authors. Drawing on Hirschman's theory of ‘exit, voice and loyalty’, the paper's framework analysis elaborates the doctor's career decisions and choices under systematic political and economic constraints, and in particular, the specter of retribution, including posting to undesirable jobs and withholding of salaries. This retribution was considered a driver of exit by doctors from the system, and few examples were given of doctors successfully advocating for change through advocacy (‘voice’). We suggest that the relevance of Hirschman's theory to this setting is in drawing attention to the critical themes of retribution, opportunity, loyalties, and partial exits, ones often neglected in efforts to reduce emigration of doctors and strengthen their leadership. Ultimately, this paper critiques the overemphasis of mechanistic ‘capacity building’ in global health and recommends that health system strengthening must be viewed as a jointly political as well as technical exercise.

ASHP Statement on the Roles and Responsibilities of the Pharmacy Executive.

Leading hospitals and health systems must have a strategic and innovative pharmacy executive who plans and oversees the design and operation of the entire and complex medication-use process throughout the system. It is essential that this leader report to an executive who can help the leader execute the practice models of tomorrow that include business outside normal hospital practice. As the most knowledgeable leader of the medication-use process, this leader (may be referred to as the “chief pharmacy officer” but hereafter “the pharmacy executive”) proactively aligns pharmacy goals with strategic organizational initiatives to advocate for pharmacy practice advancement and improved patient care. The intrinsic value a pharmacy executive brings to the organization’s enterprise and executive leadership includes the following: ... Significant changes in pharmacy practice, healthcare, and health-system management over the past 20 years have dramatically transformed the traditional role of the pharmacy director.1 More widespread use of the title “chief pharmacy officer” was first proposed in 2000 in an attempt to meet these new transformations and to enhance the contribution pharmacy makes to patient care by creating organizational parity between the pharmacy executive and other executive officers (e.g., chief nursing, medical, and information officers).2

16.F. Workshop: Expanding coverage and improving quality: health reforms and policy learning across North America

Abstract Health systems globally share challenges with expanding coverage while increasing quality. This workshop organized by the North American Observatory on Health Systems and Policies (NAO) will draw on the results of major health system studies of Canada, the United States (US) and Mexico. The NAO is a partnership of researchers, governments, and health organizations in the three countries, promoting evidence-informed health system policy decision-making. It works with the European Observatory on Health Systems and Policies and other global affiliates. One of the NAO's activities is co-publishing, with the European Observatory and the University of Toronto Press, full-length books about the health care systems in each of the three countries, modeled after the European Observatory's Health System in Transition (HiT) book series that includes full-length treatments of the systems in 70 countries. In 2020 new books will be jointly released in all three countries (Canada's third edition, the US's second, and Mexico's first). This workshop has two overarching Objectives first, to describe the recent health policy developments to provide insights into the successes and challenges of the three North American countries' health systems; second, to explore the potential for policy learning across the three countries with shared challenges but quite different institutional, political and economic contexts. Lead authors of each of these studies will deliver a short presentation describing the major public health and health system challenges faced in their country, and providing an analysis of recent health sector reforms. A panel discussion will follow, facilitated by the chairperson, that will start with a speaker that brings an international perspective to comment on the areas of convergence and divergence in health sector reforms in North America with those taking place across the European region. Each of the lead authors will then respond to the questions and comments raised, and will take questions and comments from the participants. This workshop brings together leading health system and public health scholars from Canada, the US, and Mexico for the first time at this international conference, which will provide participants with an opportunity to learn about these complex and ever-changing health systems and to engage in rich and lively discussion. Key messages In-depth health system studies provide the opportunity to identify lessons that may be transferable across national boundaries. Comparing recent health reforms in the three largest North American countries provide insight into policy learning across high- and middle- income contexts.

Defining and classifying public health systems: a critical interpretive synthesis

BackgroundThe introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks.MethodsA critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme – health systems arrangements (governance, financial and delivery arrangements).ResultsA total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented.ConclusionsPublic health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Systems leadership doctor of nursing practice: global relevance.

This article considers the systems leadership doctor of nursing practice degree as an option to increase nursing leadership roles and heighten presence at policy tables globally, particularly in low- and middle-income countries. Recent global reports emphasize core competencies needed for nursing leadership, particularly systems leadership and health policy, to successfully move the global health agenda forward. Using the Yale University School of Nursing programme as an exemplar, this paper is focused on the elements directly linked to leadership competencies and relevance of a systems leadership doctor of nursing practice programme globally. The dramatic growth and wide variability of doctor of nursing practice programmes offered in all 50 US States have generated questions and debate. According to the American Association of Colleges of Nursing as of May 2018, there are 121 schools that reported having a leadership focus in postmaster's doctor of nursing practice degree offering. Yet there has not been the same enthusiasm for development and implementation for a practice doctorate in nursing across the globe. A narrative literature review was conducted aimed at addressing the relevance of a practice doctorate globally. This analysis of the literature included a search of peer-reviewed and grey literature. Nursing school websites were visited, and opinions of nurse leaders and students were sought. In addition, global reports that supported nursing leadership and their role in policy development were reviewed. Globally, nurses have a critical role in leading health systems. Developing a cadre of nurse leaders educated at the doctoral level who can communicate with policymakers and develop strategies to meet health systems' goals is necessary. In recent global health reports and campaigns, strengthening nursing leadership and presence at policymaking tables are recurring themes. Offering a systems leadership doctor of nursing practice degree is one viable option to increase doctorally prepared nurse leaders for nursing policy and practice engagement. This calls for work with country and regional governments, regulatory bodies and nursing associations to empower nursing to contribute fully.

Could implementation of mifepristone address Canada’s urban–rural abortion access disparity: a mixed-methods implementation study protocol

IntroductionIn January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada,...

Sharon Pappas, PhD, RN, NEA-BC, FAAN

Sharon Pappas, PhD, RN, NEA-BC, FAAN (seated, center), is chief of the Nurse Executive Team for Emory Healthcare in Atlanta, Georgia.

LADDERS: A dynamic paradigm for planning, implementing, and evaluating sustainable change in learning health systems.

The science of learning health systems borrows and adapts models from many fields. One in particular is implementation science which has been experiencing a flourishing of new theories, models, and frameworks, some of which are generating sufficient evidence as to their effectiveness and applicability to emerge as candidates for wide adoption as useful tools for the field. In reviewing these, a common paradigm can be described which is a synthesis of those elements regularly cited by health systems implementing successful transformational change activities. As a paradigm, it offers a practical bridge to these models, concepts, and frameworks that are often hard to operationalize and are used with varying degrees of completeness. These elements can be arranged in a memorable acronym—LADDERS—Leadership, Alignment, Data, Demonstration, Evaluation, Replication, and Sustainability. LADDERS identifies the multiple elements and dimensions recognized by persons involved in leading health system change activities. It provides a simple, useful way to assess progress by health systems in planning, implementing, evaluating, and sustaining change. There is ample organizational and systems change literature to fully describe the actual LADDERS elements individually; therefore, this article describes characteristics and functions of each element and the dynamics represented in a DNA image to reflect that in learning health systems change is recursive, constant, and happens in complex environments that are always readjusting to new stimuli and directions, and this is often not accounted for in a framework, model, or theory. It concludes with several examples of application of the LADDERS paradigm and suggests how it is a complementary approach to accomplishing Institute of Medicine Learning Health Systems goals.

The role of real-world evidence in clinical care: A survey of oncology leaders.

e18515 Background: Many health systems seek the ability to share and learn from real-world evidence, or aggregated cancer patient data, to improve patient outcomes. Although precision medicine initiatives are becoming more commonplace at large health systems, there is limited data defining the attitudes of health system leaders on their views of precision medicine. To this end, the Health Management Academy conducted a survey of oncology leaders to explore their views on the application of real-world evidence in clinical oncology. Methods: In August 2017, the Health Management Academy surveyed leaders from 43 leading health systems regarding their awareness, integration, and operationalization of precision medicine. The survey included 48 questions that assessed the state of precision medicine, challenges with clinical decision making, and reimbursement policies. Four questions addressed data sharing and impact of real-world evidence on clinical decision making. Health system leaders were contacted via email. Results: We obtained a response rate of 49% (21/43). Respondents included Chief Medical Officers (CMOs) and oncology leaders representing 21 health systems, 296 hospitals, and approximately 2.9 million admissions annually. 80% of respondents expect real-world outcomes from aggregated, de-identified data to be “extremely important” in guiding physician decision making in complex cases. 63% of respondents considered providing oncologists with clinical guidance for molecular diagnostics and targeted therapies “extremely important”. 60% of responding health systems are involved in a cancer data sharing collaboration, most commonly the Oncology Precision Network (44%). Most (73%) respondents would find a tool that compared real-world outcomes across treatment regimens for patients with any combination of clinical and molecular characteristics “extremely valuable”. Conclusions: Real-world evidence to improve patient care remains a critical priority among health system leaders. Furthermore, these leaders recognize that decision support tools will be required to make this data actionable for clinicians at their individual points of care.

Value-Based Healthcare in Residency Training: a Perspective from Singapore

Value-based health care aims to achieve the best outcomes at the lowest cost. Many leading health systems worldwide have already begun to restructure care delivery guided by value-based concepts. Residency training programs will play a key role in the transition to value-based healthcare. However, incorporating value-based healthcare into residency programs has received little attention. This commentary introduces an approach developed in Singapore which encompasses structured teaching, clinical teaching, and evaluations. We elaborate on how educators can use avenues such as quality improvement initiatives and journal clubs to introduce concepts of value-based healthcare to residents. The curriculum is then reinforced by allowing residents to apply value-based concepts in their clinical rounds and multidisciplinary meetings. Lastly, we give examples of how residents can be assessed with a value-based healthcare component in their in-training examinations and posting evaluations. This approach contributes to a well-planned and smoothly executed educational program in value-based healthcare for residents, which will be a keystone in the long-term success of the value-based healthcare model.

Activities and Attributes of Nurse Practitioner Leaders: Lessons from a Primary Care System Change

Nurse practitioners (NPs) are being encouraged to practice to the full extent of their skills, and they have a critical role to play in leading health system reform. The evidence in support of NP-led initiatives is growing; however, in spite of the positive outcomes associated with these initiatives, considerable opposition to and debate about the potential for NPs to lead health system change and interprofessional teams continues. To date, we know very little about NP leadership activities, particularly those activities that contribute to primary care system change, and there are very few examples of this type of leadership. The qualitative descriptive study here was part of a larger case study that examined stakeholder participation in a system change led by NPs. The change involved the introduction of a new NP-led model of team-based primary care delivery in Ontario, Canada. Data from participant interviews and public documents were analyzed to describe the activities and attributes (perseverance, risk-taking and effective communication) of two NP leaders who were the drivers of this change. Knowledge of these activities and attributes has the potential to inform NP leadership roles in health system policy planning and implementation. However, to be able to provide effective leadership in system change, NPs need access to educational content about public policy and opportunities to develop and practice the skills required to work with multiple stakeholders, including those who oppose change.

Navigating Primary Care

Navigating Primary Care