Health Care Movement Research Articles

Quality and Safety in Health Care, Part I: Five Pioneers in Quality.

Five pioneers had a huge impact on the quality movement in health care in the United States. Ernest Codman contributed in many ways, including his focus on outcome analysis. Avidis Donabedian is known for his focus on the 3 domains of structure, process, and outcome in health care. Walter Shewhart is known especially for the control chart and early work on what W. Edwards Deming made into the PDSA cycle. Deming is also known for other contributions, including his 14 points of management, correcting system problems rather than blaming the workers, and his System of Profound Knowledge. Juran is known for the Pareto principle and his emphasis on customer satisfaction and addressing the human, not just statistical side, of quality improvement.

Practice and Power: Community Health Workers and the Promise of Moving Health Care Upstream.

Against the backdrop of historic upheavals in American health care, a resurgent interest in the role of community health workers (CHWs) presents important strategic and technical questions. The ability to successfully navigate these issues and expand the health care role and impact of CHWs will depend on how stakeholders reimagine elements of practice and structures of power in American medicine. Practice redesign and redefined power dynamics can help health care settings successfully integrate CHWs, address social determinants of health for patients and communities, and achieve the Triple Aim of improved outcomes, higher quality of care, and lower costs.

Board Acts on Strategic Plan, Certification, Other Issues

New strategic initiatives, part of a comprehensive strategic planning document, reflect member concerns about a changing health care environment and movement toward integrated care.

Review and Synthesize Completed Research Through Systematic Review.

The evidence-based health care movement has generated new opportunity for scholars to generate synthesized sources of evidence. Systematic reviews are rigorous forms of synthesized evidence that scholars can conduct if they have requisite skills, time, and access to excellent library resources. Systematic reviews play an important role in synthesizing what is known and unknown about a particular health issue. Thus, they have a synergistic relationship with primary research. They can both inform clinical decisions when the evidence is adequate and identify gaps in knowledge to inform research priorities. Systematic reviews can be conducted of quantitative and qualitative evidence to answer many types of questions. They all share characteristics of rigor that arise from a priori protocol development, transparency, exhaustive searching, dual independent reviewers who critically appraise studies using standardized tools, rigor in synthesis, and peer review at multiple stages in the conduct and reporting of the systematic review.

Corporate Takeover of U.S. Catholic Education and the Effect on Catholic Identity: Models from the Church’s 19th-Century Schools and 21st-Century Hospitals

There is a movement toward “corporatization” evident in Catholic hospitals, Catholic schools, and Catholic social service agencies taking up management structures and other features and behaviors employed by corporations. Many see these practices as threatening the identity and influence of religion as the profit concerns begin to take center stage. This development is assessed from two perspectives. The 19th-century shift in Catholic education was equally radical and raised no less conflicting values in religious identity. The story of Catholic healthcare's movement over the past 30 years from direct control and administration primarily by religious orders of women to mega health systems provides a parallel experience adjusting this Catholic ministry to the demands of the corporate world and re-expressing Catholic identity.

To Move Health Care to Health Caring: A Conversation With Julie Kennedy Oehlert, DNP, RN.

The complex nature of health care requires a culture of interprofessionality that supports high-functioning interprofessional teams. Wolf and Prince (2014) wrote, "Culture is the foundation on which any healthcare encounter is delivered" (p. 3). It is therefore important for nursing to elevate thought leaders who can address the culture of health care organizations and how culture can be transformed. Julie Kennedy Oehlert is one of these leaders.

The Role of the Fitness Professional in the Clinical Setting.

While fitness professionals have not historically been considered an extension of the health care team, there is a growing movement in health care to provide more complete and effective team-based care and to better integrate clinical and community resources. One way to do this is through physician referrals to community-based fitness professionals who can help patients translate clinician-advised exercise recommendations into individualized and effective exercise programs. Fitness professionals are uniquely qualified to fulfill this role given their training and practical expertise in exercise physiology, exercise program design and implementation, and health behavior change principles.

THE NEOLIBERAL TURN IN AMERICAN HEALTH CARE.

Leaving millions both uninsured and underinsured, the Affordable Care Act does not create a system of universal health care in the United States. To understand its shortcomings, we have to understand it as part of a historic shift in the political economy of American health care. This "neoliberal turn" began as a reaction against the welfare state as it expanded during the New Deal and post-World War II period. What began as a movement associated with philosophers like Friedrich Hayek ultimately had a powerful impact via the attraction of powerful corporate sponsors and political supporters, and it was to historically transform American health care thought and organization. In health policy circles, for example, it can be seen in a rising emphasis on "moral hazard," overuse, and cost sharing above a concern with universalism and equity. It was likewise manifested by the corporatization of the health maintenance organization and the rise of the "consumer-driven" health care movement. By the time of the health care reform debate, the influence of corporate "stakeholders" was to prove predominant. These developments, however, must be construed as connected parts of a much larger political transformation, reflected in rising inequality and privatization, occurring both domestically and internationally.

Care for technology dependent children and their relationship with the health care systems.

OBJECTIVE: to understand the experience of care delivery to technology dependent children based on the mothers' experience. METHOD: exploratory study with qualitative approach, based on the theoretical framework of medical anthropology and the narrative method. Twelve mothers participated and, as the technique to obtain the narratives, open interviews were held at the participants' homes. RESULTS: the narratives were organized into three thematic categories: the family system, identifying the care forms, the association between popular and scientific knowledge and the participation of the social network; the professional system, which discusses the relations between professionals and family, the hegemony of the biomedical model and the role of nursing; and the popular system, presenting popular care practices like spirituality and religiosity. CONCLUSION: the study provided support for a health care project that takes into account the families' moral and symbolic values and beliefs in view of the illness of a technology-dependent child. The results found can contribute towards changes in the health work process, so that its foundation is guided not only by the biomedical model, allowing the integration of the sociocultural dimensions into the health care movement.

Reference Pricing: A Small and Mighty Solution to Bend the Health Care Cost Curve

There is no single antidote to the problem of rising health care costs. One strategy that has proven its effectiveness is reference pricing (RP). RP is an insurance benefit design mechanism in which a “reference” price is set for a specified service or procedure, which the health plan sponsor uses to cap its contribution. The beneficiary is responsible for any amount above the defined contribution. RP seeks to address the huge, unexplainable price variations that exist for medical procedures and services. This paper argues that RP can be structured to reap its price-saving potential, but it requires proper regulatory oversight to ensure it does not negatively impact the quality, affordability, and access to care. If implemented in a systematic and cautious manner, it can become an indispensable tool for employers and health plans, especially when combined with payment reform strategies. Section II of this paper defines RP and explains its origins in the consumer-driven health care movement. Section III highlights RP’s application in the international market for pharmaceuticals and domestic market for medical services and procedures. Section IV explores the Departments’ May 2014 FAQ, the comments in response to that FAQ, and the subsequent October 2014 FAQ. Section V evaluates the standards the Departments’ issued to evaluate RP programs and discusses certain features and limitations of RP that must be understood and monitored by its regulators to prevent limiting consumers’ access to affordable, high-quality care.

(Un?)Healthy Politics: The Political Determinants of Subnational Health Systems in Brazil

AbstractHow does political competition shape institutions that govern the expansion of social policy subnationally? Brazilian states have shown a surprising variation in the design of their public health institutions, which regulate the distribution of health resources and citizen access to public health care. While many states have experienced fragmentation, some have remained highly centralized and discretionary, and only a select few have established a coordinated system based on power sharing and rules-based distribution. Accounts that link public health care expansion to federal government imposition, the presence of the public health care movement, and leftist parties cannot fully explain this variation. Instead, in the three Brazilian states examined here, the nature of subnational political competition triggered different institution-building strategies. The findings indicate that plural political competition yielded incentives for limiting state-level discretion and for sharing power with municipal governments, while political concentration reinforced the attraction to centralized and discretionary policymaking.

What Would It Take? Stakeholders’ Views and Preferences for Implementing a Health Care Manager Program in Community Mental Health Clinics Under Health Care Reform

Health care manager interventions can improve the physical health of people with serious mental illness (SMI). In this study, we used concepts from the theory of diffusion of innovations, the consolidated framework for implementation research and a taxonomy of implementation strategies to examine stakeholders' recommendations for implementing a health care manager intervention in public mental health clinics serving Hispanics with SMI. A purposive sample of 20 stakeholders was recruited from mental health agencies, primary care clinics, and consumer advocacy organizations. We presented participants a vignette describing a health care manager intervention and used semistructured qualitative interviews to examine their views and recommendations for implementing this program. Interviews were recorded, professionally transcribed, and content analyzed. We found that a blend of implementation strategies that demonstrates local relative advantage, addresses cost concerns, and enhances compatibility to organizations and the client population is critical for moving health care manager interventions into practice.

Prescription incentives: Concern for patient safety

I recently saw an ad in our local newspaper from one of our regional grocery/pharmacy chains that offered patients a savings on gas ($1.00 per gallon) for each prescription they transferred from another pharmacy. As a profession, we keep talking about the value of pharmacists,the need for pharmacists to be recognized as providers by CMS and other payers, and the importance of pharmacists in the health care system to ensure that patients are receiving safe and effective medications. Yet we continue to see prescription transfer incentives that not only cheapen our profession but also have the potential to negatively affect the care of our patients. I recently saw an ad in our local newspaper from one of our regional grocery/pharmacy chains that offered patients a savings on gas ($1.00 per gallon) for each prescription they transferred from another pharmacy. As a profession, we keep talking about the value of pharmacists,the need for pharmacists to be recognized as providers by CMS and other payers, and the importance of pharmacists in the health care system to ensure that patients are receiving safe and effective medications. Yet we continue to see prescription transfer incentives that not only cheapen our profession but also have the potential to negatively affect the care of our patients. Although I may not agree with this practice, I thought I’d better review the primary literature and the Iowa Pharmacy Association’s (IPA) policy statement. I discovered that IPA opposes the use of financial incentives to influence a patient’s choice of pharmacy services.1.Iowa Pharmacy Association policy 95-U1Google Scholar In addition, an article on community pharmacists’ perceptions about prescription transfer incentives made the following points:2.J Am Pharm Assoc. 2012;52(5):e53-58Google Scholar■Pharmacists perceived that patients who transferred prescriptions based on incentive coupons do not receive thorough drug interaction screenings.■Pharmacists perceived that patients who use these incentives may be at an increased risk of medication- related problems (e.g., wrong drug, dosing errors, drug interactions).■Some patients may fill prescriptions unnecessarily to qualify for the promotion.■Pharmacists felt that these incentives devalued the profession.■Pharmacists did not believe the incentives were effective in attracting and maintaining patients.■One pharmacist wrote a letter to the editor of a pharmacy journal indicating that the health of patients can be adversely affected by prescription transfer incentives because patients lose their pharmacy home.3.Am J Health Syst Pharm. 2011;68(9):787Google Scholar As I researched this topic, I was encouraged to see that I was not alone in my belief that prescription transfer incentives are potentially detrimental to patient care and devalue our profession. Pharmacists who practice in environments that use prescription transfer incentives may be put into a difficult professional situation. They strive to provide good patient care while being asked to promote a business practice that potentially puts their patients at risk of a medication-related problem.Prescription transfer incentives are potentially detrimental to patient care and devalue our profession. Also, I am sure that Iowa is not the only state to have its state pharmacy association broach this topic and have policy in place that opposes the practice. Yet I still see these incentives being promoted regularly. I hope that at some point this business practice is challenged and goes away. It is not consistent with the quality health care movement, it is not good for pharmacy, and most importantly, it is not good for patients!HIGHLIGHTS■Pharmacists perceived that patients who use these incentives may be at an increased risk of medication- related problems.■Patients’ safety should be paramount, and our practices should put in place processes that emphasize optimal patient outcomes and restrict business practices that do not. ■Pharmacists perceived that patients who use these incentives may be at an increased risk of medication- related problems.■Patients’ safety should be paramount, and our practices should put in place processes that emphasize optimal patient outcomes and restrict business practices that do not. As health care moves toward a value-based system in which health care providers are reimbursed based on patients achieving positive outcomes, it is important that pharmacists step up their efforts to ensure quality patient ^^ care. This means that we need to review our own practices and determine if our actions and the actions of our employers are _ consistent with good patient I care. Our patients’ safety should be paramount, and our practices should put in place processes that emphasize optimal patient outcomes and restrict business practices that do not. Perhaps we will see a change in this type of promotion when pharmacy networks are developed that restrict patient access to only quality pharmacy providers. At that point, payers may direct patients to a pharmacy based on the ability of pharmacists to provide quality patient care. We are closer to this model of health care and reimbursement than many people may believe. Now is the time to create the changes in practice to promote patient care!

The promise of data-driven care.

The growing adoption of electronic medical records and advances in health information technology are fueling an explosion of new health data. Expectations are high that new data resources will guide the transformation of the health care industry and positively influence population health. There have been challenges and opportunities at every turn, and progress has been slow, but mounting evidence suggests that better use of data is moving health care in the right direction.

Restoring Humanity to Health Care

In this first installment of a new quarterly column on lessons learned from the cutting edge of care innovation, we discuss the imperative for and insights on how to move health care away from its current transactional focus and towards a more human-centric model.

Integrative health care: implications for nursing practice and education

The significance of complementary and alternative medicine (CAM) to contemporary health care is reflected in the relatively recent integrative health care (IHC) movement. Having emerged in response to the public's sustained use of CAM, IHC reflects the evolving needs and expectations of modern-day service users, making it consistent with today's culture of patient-responsive health care. IHC therefore carries important implications for nursing practice but, to fulfil their responsibilities with regard to these implications, nurses need a fundamental knowledge of CAM concepts as well as an understanding of the ways in which CAM and conventional health care might affect one another. An educational strategy that embeds IHC and makes explicit its relation to nursing practice is desirable if nurses are to engage with patients who use CAM. Evidence suggests, however, that neither CAM nor IHC are adequately represented in nursing curricula. This paper considers ways in which IHC could be incorporated into nursing curricula as a means to prepare nurses for this important challenge.

Personalized Health Care in 2013: A Status Report on the Impact of Genomics

This issue of the NCMJ describes the impact that genomics has had on the practice of medicine in the decade since the full sequencing of the human genome was completed in 2003. Specifically, it reports on how genomics is affecting health care delivery, describes the concept of personalized health care, and discusses the role that genomics plays in such care. The commentaries and sidebars that follow highlight the opportunities and challenges of bringing genomics into clinical practice. Reading these articles will hopefully give clinicians and others a better understanding of the benefits and limitations of genomic technologies. Emerging capabilities, resulting in part from genomic research, are providing an opportunity to move health care from a reactive, disease-focused model to one that is personalized, predictive, proactive, precise, and patient-centered. Genomics and related technologies have already changed many approaches to care, particularly in the field of oncology, and I believe they will help to transform our overall approach to the delivery of health care. With the rapidly accumulating capabilities being developed and the focus on patient-centered and personalized care, I expect that the practice of medicine will become proactive and personalized within the next decade.

Thinking Locally, Acting Globally?

The author looks at global- and local-focused public health philosophies, with particular emphasis on the development of the primary health care (PHC) movement. He argues for a global health care model in which international medical agencies allow local communities in low- and middle-income nations to address health resource disparities and help make decisions about priorities for regional disease control measures.

Developing DNP Students as Adaptive Leaders: A Key Strategy in Transforming Health Care

The success of graduates with a doctor of nursing practice (DNP) degree in transforming health care will depend significantly on their leadership ability to think strategically, innovate, and engage stakeholders in meaningful system improvement. Known as adaptive work, these graduates will need a portfolio of adaptive leadership skills that prepare them to move health care from a volume-driven to value-based system. This article describes development of a core DNP leadership course in a postmaster's point of entry DNP program at an academic health science center school of nursing. The course, designed as DNP students' initial step on their professional development journey to becoming adaptive leaders capable of driving transformative change, created an alternative lens for students to undertake strategic adaptive change initiatives within themselves and their organizations.

Advancing patient-centered care through transformative educational leadership: a critical review of health care professional preparation for patient-centered care

Advancing patient-centered care through transformative educational leadership: a critical review of health care professional preparation for patient-centered care Martine C Lévesque,1,2 Richard Bruce Hovey,2,3 Christophe Bedos2,4 1Faculté de médecine, Université de Montréal, Montréal, QC, Canada; 2Division of Oral Health and Society, Faculty of Dentistry, McGill University, Montreal, QC, Canada; 3Faculty of Medicine, University of Calgary, Calgary, AB, Canada; 4Département de médecine sociale et préventive, Faculté de médicine, Université de Montréal, Montréal, QC, Canada Abstract: Following a historical brief on the development of patient-centered care (PCC), we discuss PCC's value and role in counterbalancing the evidence-based movement in health care. We in turn make a case for a philosophical shift in thinking about the PCC concept, one based on a consideration for how knowledge is produced, used, and valued within care provision processes. A “shared epistemology” foundation is presented, defined, and promoted as essential to the authentic and ethical realization of “shared decision making” between patient and health care provider, and, more generally, of PCC. In accordance with these views, this article critically reviews the literature on health care professional education for the development of PCC. We uncover the disturbing ways in which education frequently undermines the development of patient centeredness, despite curricular emphasis on professionalism and ethical PCC. We also establish the need to raise awareness of how dominant approaches to evaluating student or practitioner performance often fail to reinforce or promote patient centeredness. Finally, we identify successful and inspiring cases of teaching and learning experiences that have achieved perspective transformation on PCC and on new ways of providing care. The pertinence of adopting the theoretical foundations of adult transformative learning is argued, and a call to action is proposed to the leadership of health professional educators across all disciplines. Keywords: patient-centered care, health professional education, transformative learning