Multiple Stakeholder Perspectives Research Articles

Therapeutic Community Gardening as a Green Social Prescription for Mental Ill-Health: Impact, Barriers, and Facilitators from the Perspective of Multiple Stakeholders.

The UK government has invested £5.77 million in green social prescribing to prevent and tackle mental ill-health. Therapeutic community gardening, one type of green social prescription, provides a range of health outcomes. However, for increased accessibility, a greater understanding of how it impacts mental health and the facilitators and barriers to referral, uptake, and attendance by individuals with mental health problems is required. We conducted and thematically analysed interviews with thirteen stakeholders including social prescribing link workers and garden staff; and focus groups with twenty garden members. The mechanisms by which therapeutic community gardening were suggested to impact mental health were by engaging members with nature and the outdoors, providing hope for the future and facilitating social support and relationships. Factors facilitating referral, uptake, and attendance included a holistic and person-centred approach, which is flexible around health needs. Barriers included awareness of the full offering of therapeutic community gardens and accessibility, in terms of physical location and waiting lists. Given that nature-based interventions have the potential to protect and enhance population health and offer cost savings through reduced reliance on other health services; overcoming these barriers is key to ensuring that therapeutic community gardening is more widely available as an additional mental health treatment.

Exploring Language-Majored Undergraduates’ Needs of Entrepreneurial Mindset Competencies for an Effective Workplace Preparation Course in Vietnam

The present study is aimed at exploring the language undergraduates’ entrepreneurial mindset (EM) needs from the perspectives of multiple stakeholders to inform the design of the undergraduates’ EM course as an effective workplace preparation, helping them approach complex changes effectively in the era of globalization. Both qualitative and quantitative data were collected in an exploratory design of a mixed methods study. Specifically, nine interviews with EM lecturers, experts and entrepreneurs, and then a survey questionnaire with 253 valid responses from language undergraduates was conducted. As a result, EM course components including expected learning outcomes, assessment and instructional plan for language undergraduates were proposed with specifications based on the learners’ needs. The findings may have led to significant implications to course designers, lecturers, researchers, and institute administrators in their common practice towards developing not just an appropriate EM course but also a sustainable entrepreneurial ecosystem for language undergraduates.

Barriers to Accessing Mental Health Care Under the Mental Health Services Act: A Qualitative Case Study in Orange County, California.

Despite progress made under California's Mental Health Services Act, limited access to care for cultural and linguistic minority groups remains a serious issue in community mental health. In this qualitative study we report findings from a large-scale community-level assessment that explored barriers to accessing care from the perspectives of multiple stakeholders including county advisors, advocates, community members, and consumers representing a range of cultural and linguistic communities in Orange County, California. We conducted 14 focus groups with N = 112 participants. Qualitative analysis revealed that system fragmentation, limited availability of linguistically appropriate care, and stigma continue to undermine access to mental health care. Peer health navigation and culturally responsive peer support are potential ways to promote service engagement with persons from cultural and linguistic minority groups that encounter barriers when accessing mental health services.

Understanding the diversity of values underpinning forest conservation

Values are the motivational goals that underpin individual and group decisions, attitudes, and behaviours, and often influence the success of conservation. Existing studies have provided insight into the perceptions and attitudes of stakeholders towards forest conservation values. However, there are still contentions among different stakeholders regarding the values underpinning conservation policies and programs. It is still unclear what values matter most to people in forest conservation. Moreover, the specific values that can motivate and empower people to participate in conservation remain poorly understood. We examined these issues using the human value orientation lens, a framework that captures the features of human relationships and interactions with forests and with other forest users. Given the need for conservation policies and programs to align with the priorities of local people, characterising multiple stakeholder perspectives can help us to better understand and untangle the conflicting interests and diverse motivating values influencing conservation policies and programs. Working in Nigeria, a country with one of the highest rates of global deforestation, we use the Q-methodology to capture and describe the viewpoints of multiple stakeholders regarding the values that underpin forest conservation. We identify three factors representing these values, and show heterogeneity in the viewpoints held by different stakeholders. The first factor explained 24 % of the study variance and identified environmental and management values as essential. This viewpoint was largely held by hierarchical stakeholders, forest experts, and forest staff. The second factor explained 12 % of the study variance, and identified cultural values that were predominantly held by forest users. The third factor explained 13 % of the study variance, and identified economic values that were mostly held by forest experts and forest users. Our study shows a diversity of value types held for forest conservation and that there are broad differences between stakeholders regarding their viewpoints. To enhance conservation success, in addition to focussing on consensus values, decision- and policy-makers should better differentiate value types that target the specific needs of stakeholders.

Effectiveness of a case management model for people with multimorbidity: Mixed methods study

The aim was to determine the impact of a case management model on indicators of health service utilization, polypharmacy, quality of life and dependency of patients with multimorbidity, and family caregiver overload in a group of patients insured with two insurance companies in the city of Bogotá (Colombia). This was a mixed methods study, which integrated a quantitative and qualitative component. The study was conducted between July 2019 and March 2020. A quantitative component is based on a pre-experimental study with a single group and pre- and post-test measurements. Patients with multimorbidity with a medium or high level of complexity were included in the study. A sample of 317 patients and their caregivers was estimated. Following the completion of the intervention, a descriptive study that explored the perspective of nurses, patients and caregivers was developed to better understand the process and results from their own words and experience. A total of 17 dyads of patients and caregivers were interviewed, as well as six nurse managers. The integration strategy was developed based on a comparison made from the perspective of multiple stakeholders. The model's impact on quality of life, particularly in terms of social functioning and mental health, has been documented. Caregiver overload was reduced and an improvement in the adoption of the role was observed, aspects that converge with the experience of the dyads and the caregivers in the support and backing provided by the model. The intervention was structured in five modules: case detection, complexity screening, comprehensive assessment with various instruments, individualized care and follow-up plan, and plan assessment. The nurse manager role is confirmed as that of a professional with the leadership capacity to articulate disciplines and actors, whilst also dealing with the day-to-day needs of people with complex health conditions. A comprehensive and integrated approach to patients with multiple diseases in a health insurance context marked by access barriers and fragmentation of health services. The study provides quantitative and qualitative evidence of the benefits of the case management model in Colombia for patients with multiple diseases and their family caregivers, particularly in terms of the psychosocial dimensions of health-related quality of life and dependence assessment. A significant impact on the caregiver role, as well as an improvement in perception and trust in the health system, was observed as a result of the overcoming of administrative barriers achieved by the nurse case manager. The findings are considered to be extremely useful for decision-makers and insurers in developing a case management model focused on comprehensive and individualized care plans, as well as for individuals with multiple diseases and their caregivers.

Understandings and applications of rural community resilience amongst Scottish stakeholders: Introducing dual discourses

ABSTRACT This paper seeks to examine understandings and applications of rural community resilience. Scottish policy has shifted toward neoliberalismand community empowerment, with communities encouraged to play a proactive rolein enhancing their own resilience. We argue that it is important to understandthe perspectives of multiple stakeholders to identify what practical factorsthey believe enhance community resilience and to provide a greaterunderstanding of the mechanisms through which community resilience can bedelivered. Drawing on qualitative data collection, we question what resiliencemeans and what factors can facilitate it in practice. We find that dualdiscourses of resilience emerge: the emergency which reflects the policy focuson short-term damage reduction, and the everyday which reflects the desire formore long-term adaptive capacities developing in response to gradual change inrural communities. We conclude that the discourse which stakeholders align withwill affect how they understand, adopt, and practice the concept.

An intelligent methodology for the use of multi-criteria decision analysis in impact assessment: the case of real-world offshore construction

Impact assessment of large-scale projects involves a plethora of technical, economic, social, and environmental factors that must be assessed along with the expectations of the stakeholders of each project. While impact assessment is required for a development project to receive regulatory approval to proceed, it is also an invaluable tool during the design phase of complex projects, providing for informed decision-making. Molding multiple perspectives of diverse stakeholders into a single collective choice is a key challenge in the process. Multi-Criteria Decision Analysis (MCDA) is the methodology used to rank a finite number of decision options based on a finite set of evaluation criteria. Different MCDA techniques, however, may lead to different decisions when applied to the same problem while different sets of criteria and weights may rank choices differently even when the same method is applied. This is a cause of concern, and even acrimony, amongst the stakeholders, often leading to protracted periods of negotiation and delaying project launching. The objective of this paper is to present an intelligent system to ameliorate the effects of the inherent subjectivity in MCDA techniques and to develop a consensus amongst the stakeholders in a data-driven setting. A case study from the field of offshore construction is used as a running example. This case study, informed by real-world experience in the field, demonstrates succinctly the issues involved and illustrates clearly the proposed intelligent methodology and its merits.

Measuring the effects of the COVID-19 pandemic on Diné and White Mountain Apache school personnel, families, and students: protocol for a prospective longitudinal cohort study

BackgroundThis paper describes the protocol for a longitudinal cohort study, “Project SafeSchools” (PSS), which focuses on measuring the effects of COVID-19 and the return to in-person learning on Diné (Navajo) and White Mountain Apache (Apache) youth, parents, and educators. The early surges of the COVID-19 pandemic led to the closure of most reservation and border town schools serving Diné and Apache communities. This study aims to: (1) understand the barriers and facilitators to school re-opening and in-person school attendance from the perspective of multiple stakeholders in Diné and Apache communities; and (2) evaluate the educational, social, emotional, physical, and mental health impacts of returning to in-person learning for caregivers and youth ages 4–16 who reside or work on the Diné Nation and the White Mountain Apache Tribal lands.MethodsWe aim to recruit up to N = 200 primary caregivers of Diné and Apache youth ages 4–16 and up to N = 120 school personnel. In addition, up to n = 120 of these primary caregivers and their children, ages 11–16, will be selected to participate in qualitative interviews to learn more about the effects of the pandemic on their health and wellbeing. Data from caregiver and school personnel participants will be collected in three waves via self-report surveys that measure COVID-19 related behaviors and attitudes, mental health, educational attitudes, and cultural practices and beliefs for both themselves and their child (caregiver participants only). We hypothesize that an individual’s engagement with a variety of cultural activities during school closures and as school re-opened will have a protective effect on adult and youth mental health as they return to in-person learning.DiscussionThe results of this study will inform the development or implementation of preventative interventions that may help Diné and Apache youth and their families recover from the negative impact of the COVID-19 pandemic, and positively impact their health and wellness.

Framing the Change and Changing Frames: Tensions in Participative Strategy Development

Participative strategy development serves to integrate the interests and perspectives of multiple stakeholders involved in today’s complex environmental challenges, aiming at a better-informed strategy for tackling these challenges, increased stakeholder ownership, and more democratic decision making. Prior research has however observed inherent tensions between the need of such participative strategy to be open to stakeholders’ input, and the need for closure and guidance. Drawing on case study evidence, we extend this reasoning and argue that tensions can emerge between strategy openness and several unintended consequences - the persistence of different interpretations of the strategy as well as stakeholders’ perceptions of lacking knowledge, guidance, and control. These tensions are important because they affect stakeholders’ willingness and ability for change and therefore counteract the strategy’s aim for major change. We propose how multi-stakeholder workshops, as interactive spaces, have a key function in mitigating the tensions inherent in strategy openness and in facilitating stakeholders’ willingness and ability for change.

Implementation of simulation-based health systems science modules for resident physicians

BackgroundHealth system science (HSS) encompasses both core and cross-cutting domains that emphasize the complex interplay of care delivery, finances, teamwork, and clinical practice that impact care quality and safety in health care. Although HSS skills are required during residency training for physicians, current HSS didactics have less emphasis on hands-on practice and experiential learning. Medical simulation can allow for experiential participation and reflection in a controlled environment. Our goal was to develop and pilot three simulation scenarios as part of an educational module for resident physicians that incorporated core and cross-cutting HSS domains. MethodsEach scenario included a brief didactic, an interactive simulation in small-group breakout rooms, and a structured debriefing. The case scenario topics consisted of educational leadership, quality and safety, and implementation science. Learners from four residency programs (psychiatry, emergency medicine, orthopedics, ophthalmology) participated January – March 2021.ResultsA total of 95 resident physicians received our curricular module, and nearly all (95%) participants who completed a post-session survey reported perceived learning gains. Emotional reactions to the session were positive especially regarding the interactive role-play format. Recommendations for improvement included participation from non-physician professions and tailoring of scenarios for specific disciplines/role. Knowledge transfer included use of multiple stakeholder perspectives and effective negotiation by considering power/social structures.ConclusionsThe simulation-based scenarios can be feasibly applied for learner groups across different residency training programs. Simulations were conducted in a virtual learning environment, but future work can include in-person and actor-based simulations to further enhance emotional reactions and the reality of the case scenarios.

Beauty lies in the eye of the beholder: consumers' and jobseekers' interpretations of the family business brand

PurposeBrands are relevant to multiple stakeholders and, as such, can have multiple meanings. Drawing on branding and stakeholder marketing theory, the purpose of this study was to provide in-depth insights into knowledge dynamics related to the so-called family business brand across different stakeholder perspectives.Design/methodology/approachThis study combines advanced brand concept mapping (BCM) with a scenario technique to graphically capture consumers’ and jobseekers’ brand knowledge related to the family business concept in the form of association networks.FindingsFindings show both a shared core meaning (e.g. associations such as “tradition” or “owner-managed”) and stakeholder-specific associations (e.g. consumer perspective: “high product quality,” “handmade”; jobseeker perspective: “appreciation within the company,” “outdated”). Significantly, the results reveal detailed insights into cross-stakeholder knowledge dynamics regarding the associations’ interconnections, strength and favorability.Originality/valueBy combining BCM with a scenario technique, this study adopts an approach that is aimed at better understanding and comparing brand knowledge with respect to the family business brand across multiple stakeholder perspectives. Given the prevalence of family businesses, this research enhances the theoretical and practical understanding of a branding resource that is often available but rarely exploited.

Successful Implementation of Peer Support for People with Severe Mental Illness in Germany: a Theory of Change Approach

Peer support is an established intervention in which people with mental illness receive support by trained peer support workers who have already overcome a mental health crisis. The implementation of peer support is complex due to interacting factors and can be achieved through the participatory Theory of Change method. Aim of this study is to develop a cross-site Theory of Change for the sustainable implementation of UPSIDES peer support in Germany. Based on site-specific Theories of Change workshops from Ulm and Hamburg in which 47 participants took part, a cross-site Theory of Change was designed and verified in three follow-up workshops with 12 participants. Participants' professional and experiential backgrounds were diverse, including peer support workers, hospital directors and managers, mental health professionals (psychiatrists, psychotherapists, nurses), and researchers. The first pathway of the cross-site Theory of Change focuses on the training of peer support workers, whereas the second pathway emphasizes recognition and integration by mental health institutions and professionals. The third pathway specifies the building of a cross-professional care network to integrate various peer support services. Procedures to approach prospective peer clients are depicted in the fourth pathway. The fifth path addresses the clarification of the role description of peer support workers and the implementation in other institutions through cooperation. Many of the identified implementation steps have been validated in comparable studies. The development of this Theory of Change by bringing together multiple perspectives of key stakeholders is an important basis for the sustainable implementation of UPSIDES peer support. Furthermore, it may serve as a blueprint for the implementation of similar interventions to advance scaling-up of evidence-based user-led and recovery-oriented interventions. The Theory of Change approach is a well-accepted and feasible method, which can be recommended for the implementation of complex interventions such as UPSIDES peer support.

The Health Impact of Social Community Enterprises in Vulnerable Neighborhoods: Protocol for a Mixed Methods Study.

BackgroundThis 4-year research project focuses on 6 social community enterprises (SCEs) that operate in 5 neighborhoods in a Dutch city. Residents of these neighborhoods face problems such as poor average levels of physical and mental health, high unemployment rates, and weak social cohesion. SCEs offer residents social, cultural, and work-related activities and are therefore believed to help these persons develop themselves and strengthen the social ties in the community. Because of a lack of empirical evidence; however, it is unclear whether and how SCEs benefit the health and well-being of participants.ObjectiveThis paper outlines a protocol for an evaluation study on the impact of SCEs, aiming to determine (1) to what extent SCEs affect health and well-being of participating residents, (2) what underlying processes and mechanisms can explain such impact, and (3) what assets are available to SCEs and how they can successfully mobilize these assets.MethodsA mixed methods multiple-case study design including repeated measurements will be conducted. Six SCEs form the cases. An integrated model of SCE health intervention will be used as the theoretical basis. First, the impact of SCEs is measured on the individual and community level, using questionnaires and in-depth interviews conducted with participants. Second, the research focuses on the underlying processes and mechanisms and the organizational and sociopolitical factors that influence the success or failure of these enterprises in affecting the health and well-being of residents. At this organizational level, in-depth interviews are completed with SCE initiators and stakeholders, such as municipal district managers. Finally, structurally documented observations are made on the organizational and sociopolitical context of the SCEs.ResultsThis research project received funding from the Netherlands Organization for Health Research and Development in 2018. Data collection takes place from 2018 until 2022. Data analysis starts after the last round of data collection in 2022 and finalizes in 2024. Expected results will be published in 2023 and 2024.ConclusionsDespite the societal relevance of SCEs, little empirical research has been performed on their functioning and impact. This research applies a variety of methods and includes the perspectives of multiple stakeholders aiming to generate new empirical evidence. The results will enable us to describe how SCE activities influence intermediate and long-term health outcomes and how the organizational and sociopolitical context of SCEs may shape opportunities or barriers for health promotion. As the number of these initiatives in the Netherlands is increasing rapidly, this research can benefit many SCEs attempting to become more effective and increase their impact. The findings of this research will be shared directly with relevant stakeholders through local and national meetings and annual reports and disseminated among other researchers through scientific publications.International Registered Report Identifier (IRRID)DERR1-10.2196/37966

A Stakeholder-Centered mHealth Implementation Inquiry Within the Digital Health Innovation Ecosystem in South Africa: MomConnect as a Demonstration Case

BackgroundThe internet is a useful web-based multimedia platform for accessing and disseminating information unconstrained by time, distance, and place. To the health care sector’s benefit, the advent and proliferation of mobile devices have provided an opportunity for interventions that combine asynchronous technology-aided health services to improve the lives of the less privileged and marginalized people and their communities, particularly in developing societies.ObjectiveThis study aimed to report on the perspectives of the different stakeholders involved in the study and to review an existing government mobile health (mHealth) program. It forms part of a study to design a re-engineered strategy based on the best demonstrated practices (considerations and methods) and learned experiences from the perspectives of multiple stakeholders within the digital health innovation ecosystem in South Africa.MethodsThis study used an ethnographic approach involving document review, stakeholder mapping, semistructured individual interviews, focus group discussions, and participant observations to explore, describe, and analyze the perspectives of its heterogeneous participant categories representing purposively sampled but different constituencies.ResultsOverall, 80 participants were involved in the study, in addition to the 6 meetings the researcher attended with members of a government-appointed task team. In addition, 46 archived records and reports were consulted and reviewed as part of gathering data relating to the government’s MomConnect project. Among the consulted stakeholders, there was general consensus that the existing government-sponsored MomConnect program should be implemented beyond mere piloting, to as best as possible capacity within the available resources and time. It was further intimated that the scalability and sustainability of mHealth services as part of an innovative digital health ecosystem was hamstrung by challenges that included stakeholder mismanagement, impact assessment inadequacies, management of data, lack of effective leadership and political support, inappropriate technology choices, eHealth and mHealth funding, integration of mHealth to existing health programs in tandem with Goal 3 of the Sustainable Development Goals, integration of lessons learned from other mHealth initiatives to avoid resource wastage and duplication of efforts, proactive evaluation of both mHealth and eHealth strategies, and change management and developing human resources for eHealth.ConclusionsThis study has only laid a foundation for the re-engineering of mHealth services within the digital health innovation ecosystem. This study articulated the need for stakeholder collaboration, such as continuous engagement among academics, technologists, and mHealth fieldwork professionals. Such compelling collaboration is accentuated more by the South African realities of the best practices in the fieldwork, which may not necessarily be documented in peer-reviewed or systematic research documents from which South African professionals, research experts, and practitioners could learn. Further research is needed for the retrospective analysis of mHealth initiatives and forecasting of the sustainability of current and future mHealth initiatives in South Africa.

Involving Multiple Stakeholder Perspectives in a Needs Assessment for a Postgraduate Educational Experience in HIV Psychiatry.

Involving Multiple Stakeholder Perspectives in a Needs Assessment for a Postgraduate Educational Experience in HIV Psychiatry.

Spatial justice, informal sport and Australian community sports participation

ABSTRACT Participation in Australian club-based sport has either plateaued or declined across a broad array of sports over the last 20 years. In contrast, participation in informal forms of sport has increased across the time. Despite the increasing popularity of informal sport, this form of participation continues to lack recognition as a legitimate and valuable avenue for population-wide sport participation. This article focuses on examining the spatial exclusion of informal sport within community sport systems. Theoretically informed by concepts of spatial justice and Lefebvre’s theories of spatial production this article utilises the perspective of multiple stakeholders and a multi-level policy analysis to demonstrate the current spatial injustice that manifests within policy, planning, and use of public spaces and the significant constraints consequently arising for communities wishing to participate in informal sport. We argue that the marginalisation of informal sport is at odds with Australian policy agendas that emphasise an urgent need to increase population levels of physical activity. The article concludes that action to counter spatial injustice within community sport is essential to capitalise on the opportunities that informal participation presents to address key health and social policy priorities.

Allied health assistants' perspectives of their role in healthcare settings: A qualitative study.

Allied health assistants (AHAs) are important members of the health workforce and key to meeting population health needs. Previous studies exploring the role and utility of AHAs from multiple stakeholder perspectives suggest AHAs remain poorly utilised in many healthcare settings. This qualitative study explores the experiences and perspectives of AHAs working in healthcare settings to determine the contextual factors influencing their role, and mechanisms to maximise their utility. We conducted semi-structured interviews using purposive sampling with 21 AHAs, from one regional and three metropolitan health services in Australia, between February and July 2021. We used a team-based framework approach to analyse the data. Four major themes were identified: 1) AHAs' interpersonal relationships, 2), clarity and recognition of AHA roles and role boundaries, 3) AHAs accessing education and professional development, and 4) the professional identity of the AHA workforce. Underpinning each of these themes were relationships between AHAs and other healthcare professionals, their patients, health services, and the wider AHA workforce. This study may inform initiatives to optimise the utility of AHAs and increase their role in, and impact on, patient care. Such initiatives include the development and implementation of guidelines and competencies to enhance the clarity of AHAs' scope of practice, the establishment of standardised educational pathways for AHAs, and increased engagement with the AHA workforce to make decisions about their scope of practice. These initiatives may precede strategies to advance the AHA career structure.

‘The whole world was lifted off me’: the importance of relational supports and peer mentoring for under-represented students accessing university in Ireland

ABSTRACT Despite efforts to increase the number of students from socio-economically marginalised communities in higher education (HE) they remain under-represented, a situation likely to perpetuate economic and social inequality. University is a form of HE that is especially vulnerable to decreased representation of students from marginalised communities. This study draws on the perspectives of multiple stakeholders in HE access to identify contemporary barriers to attending university in the Republic of Ireland. It highlights the perspectives of stakeholder groups connected with a university peer mentoring access initiative, including secondary education students and their parents, HE students and graduates, and university and secondary school staff. Findings suggest that contemporary barriers to accessing universities are manifold and include socio-cultural, financial and structural factors involved in applying for, and attending, university. Stakeholders identified supports that would address these factors, with a strong emphasis on the need for relational supports provided through the peer mentoring programme to ensure students feel included in, and prepared to succeed at university. Differences in perspectives by stakeholder group were evident. Secondary education students frequently highlighted socio-cultural and structural barriers to university, for example the low expectations of themselves or others and the ‘points’ entry system. In contrast, university students and graduates emphasised the need for relational support, knowledge and preparedness in applying for and attending university. The series of barriers identified in this study begin in secondary education and continue throughout HE indicating a need for ongoing responsive supports at various stages throughout students’ educational journey.

Post-Intensive Care Syndrome in a Cohort of School-Aged Children and Adolescent ICU Survivors: The Importance of Follow-up in the Acute Recovery Phase

AbstractPediatric intensive care unit (PICU) survivors experience a collection of physical, cognitive, emotional, and social symptoms named post-intensive care syndrome (PICS). We aimed to quantify PICS morbidities from multiple stakeholder perspectives across domains. Using physician, neuropsychologist, and parent/caregiver-completed outcome measures across domains in a cross-sectional analysis of 186 children between the ages of 8 and 19 years with data from a PICU follow-up clinic 1 to 3 months after PICU discharge, we quantified PICS morbidities and used Spearman correlation to evaluate interdependence of PICS domains. Compared with pre-hospitalization functioning, new PICS-related morbidities were observed and significant correlations were identified between the PICS domains. Results highlight the need to identify and support patients and families for multiple morbidities simultaneously across all relevant PICS domains; moreover, an important divergence between caregiver report, physician, and neuropsychologist assessment was also found, showcasing the importance of multiple assessments and perspectives. New PICS morbidities across domains are common after discharge from the PICU, and timely follow-up care is needed that involves collaboration/integration of physicians, neuropsychologists, youth, and families to effectively identify and treat PICS-related issues.

Incentivizing performance in health care: a rapid review, typology and qualitative study of unintended consequences

BackgroundHealth systems are increasingly implementing policy-driven programs to incentivize performance using contracts, scorecards, rankings, rewards, and penalties. Studies of these “Performance Management” (PM) programs have identified unintended negative consequences. However, no single comprehensive typology of the negative and positive unintended consequences of PM in healthcare exists and most studies of unintended consequences were conducted in England or the United States. The aims of this study were: (1) To develop a comprehensive typology of unintended consequences of PM in healthcare, and (2) To describe multiple stakeholder perspectives of the unintended consequences of PM in cancer and renal care in Ontario, Canada.MethodsWe conducted a rapid review of unintended consequences of PM in healthcare (n = 41 papers) to develop a typology of unintended consequences. We then conducted a secondary analysis of data from a qualitative study involving semi-structured interviews with 147 participants involved with or impacted by a PM system used to oversee 40 care delivery networks in Ontario, Canada. Participants included administrators and clinical leads from the networks and the government agency managing the PM system. We undertook a hybrid inductive and deductive coding approach using the typology we developed from the rapid review.ResultsWe present a comprehensive typology of 48 negative and positive unintended consequences of PM in healthcare, including five novel unintended consequences not previously identified or well-described in the literature. The typology is organized into two broad categories: unintended consequences on (1) organizations and providers and on (2) patients and patient care. The most common unintended consequences of PM identified in the literature were measure fixation, tunnel vision, and misrepresentation or gaming, while those most prominent in the qualitative data were administrative burden, insensitivity, reduced morale, and systemic dysfunction. We also found that unintended consequences of PM are often mutually reinforcing.ConclusionsOur comprehensive typology provides a common language for discourse on unintended consequences and supports systematic, comparable analyses of unintended consequences across PM regimes and healthcare systems. Healthcare policymakers and managers can use the results of this study to inform the (re-)design and implementation of evidence-informed PM programs.