Studying complex interventions : reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco

Peer reviewedPublisher PD

Clinical governance, education and learning to manage health information

Purpose – This paper aims to suggest that the concept of clinical governance goes beyond a bureaucratic accountability structure and can be viewed as a negotiated balance between imperfectly aligned and sometimes conflicting goals within a complex adaptive system. On this view, the information system cannot be separated conceptually from the system of governance it supports or the people whose work it facilitates or hinders. Design/methodology/approach – The study, located within the English National Health Service (NHS) between 1999 and 2005, is case study based using a multi method approach to data collection within two primary care organisations (PCOs). The research strategy is conducted within a social constructionist ontological perspective. Findings – The findings reflect the following broad-based themes: mutual adjustment of a plurality of stakeholder perceptions, preferences and priorities; the development of information and communication systems, empowered by informatics; an emphasis on education and training to build capacity and capability. Research limitations/implications – Limitations of case study methodology include a tendency to provide selected accounts. These are potentially biased and risk trivialising findings. Rooted in specific context, their generalisability to other contexts is limited by the extent to which contexts are similar. Reasonable attempts were made to minimise any bias. The diversity of data collection methods used in the study was an attempt to counterbalance the limitations highlighted in one method by strength from alternative techniques. Practical implications – The paper makes recommendations in two key governance areas: education and learning to manage health information. In practice, the lessons learned provide opportunities to inform future approaches to health informatics educational programmes. Originality/value – With regard to topicality, it is suggested that many of the developmental issues highlighted during the establishment of quality improvement programmes within primary care organisations (PCGs/PCTs) are relevant in the light of current NHS reforms and move towards commissioning consortia

The Essential Elements of Adolescent-Friendly Care in School-Based Health Centers: A Mixed Methods Study of the Perspectives of Nurse Practitioners and Adolescents

The Essential Elements of Adolescent-Friendly Care in School-Based Health Centers: A Mixed Methods Study of the Perspectives of Nurse Practitioners and Adolescents Alison Moriarty Daley Ph.D. University of Connecticut, 2016 The majority of the morbidity and mortality among adolescents results from preventable causes including risk-taking behaviors and injuries. Preventive care for this population therefore includes anticipatory guidance and screening aimed at reducing these risks. However, the rates of engagement in preventive care decline steadily throughout adolescence. School-based health centers (SBHCs) have been identified as an adolescent-friendly community resource for preventive care. The purpose of this study was to identify the essential elements of adolescent-friendly care in SBHCs from the perspectives of nurse practitioners (NPs) providing care to adolescents in SBHCs and adolescents, as the consumers of these services. Complex adaptive systems (CAS) provided the philosophical and theoretical foundation for this study. An explanatory sequential mixed methods study was conducted. The first phase consisted of a Delphi technique with an expert panel of NPs (N = 21) to identify the essential elements of adolescent-friendly care in SBHCs. In the second phase, a focus group study with adolescents was conducted (N = 30) to explain the Delphi results. Data from two phases were mixed in the final phase of the study. This study generated expert opinion regarding the essential elements of adolescent-friendly health care in SBHCs. After four Delphi rounds, consensus was reached on 98-items (49%; consensus level of .75). The results clustered into 6 essential elements: Confidentiality/ Privacy (n = 8; 42%), Accessibility, (n = 15; 46.9%), SBHC Environment (n = 4; 23.5%), Clinicians/Staff (n = 51; 58%), SBHC Clinical Services (n = 12; 37.5%) and Relationship Between the School and SBHC (n = 8; 66.7%). The adolescent focus groups provided data about what they liked about the SBHC, how the care differed from their other experiences, and explained the essential elements identified in the Delphi. Two overarching themes: Comfortable and Trusted Relationship emerged. The final phase mixed the data from the two phases. A conceptual model of adolescent-friendly care in SBHCs as a CAS is presented. This study identified six essential elements and two overarching themes essential to the delivery of adolescent-friendly care in SBHCs. These findings contribute to a greater understanding of what adolescents, as consumers of health care services in SBHCs, need to engage in preventive care during adolescence

Place-based approaches to child and family services

This paper synthesizes the conceptual and empirical literature on place-based approaches to meeting the needs of young children and their families. A specific focus of the paper is on the potential contribution of place-based approaches to service reconfiguration and coordination. Outline The paper begins by outlining the sweeping social changes that have occurred in developed nations over the past few decades and their impact on children, families and communities. It explores the ‘joined up’ problems faced by families and communities in the contemporary world, and highlights the need to reconfigure services to support families more effectively. The paper then focuses on ‘joined up’ solutions, on what we know about how to meet the challenges posed by the complex problems that characterise our society. Next, the paper explores what a place-based approach involves, and what role it can play in supporting families with young children. The rationale underpinning place-based approaches is outlined and the evidence for the effectiveness of the approach is summarised. The paper then looks at what can be learned from efforts to implement place-based initiatives in Australia and overseas, and explores the issues that need to be addressed in implementing this strategy. The ways in which the early childhood service system might be reconfigured are also considered, and the paper ends with a consideration of the policy and implementation implications.&nbsp

Anticipatory Care in Potentially Preventable Hospitalizations: Making Data Sense of Complex Health Journeys

Purpose: Potentially preventable hospitalizations (PPH) are minimized when adults (usually with multiple morbidities ± frailty) benefit from alternatives to emergency hospital use. A complex systems and anticipatory journey approach to PPH, the Patient Journey Record System (PaJR) is proposed.Application: PaJR is a web-based service supporting ≥weekly telephone calls by trained lay Care Guides (CG) to individuals at risk of PPH. The Victorian HealthLinks Chronic Care algorithm provides case finding from hospital big data. Prediction algorithms on call data helps optimize emergency hospital use through adaptive and anticipatory care. MonashWatch deployment incorporating PaJR is conducted by Monash Health in its Dandenong urban catchment area, Victoria, Australia.Theory: A Complex Adaptive Systems (CAS) framework underpins PaJR, and recognizes unique individual journeys, their dependence on historical and biopsychosocial influences, and difficult to predict tipping points. Rosen's modeling relationship and anticipation theory additionally informed the CAS framework with data sense-making and care delivery. PaJR uses perceptions of current and future health (interoception) through ongoing conversations to anticipate possible tipping points. This allows for possible timely intervention in trajectories in the biopsychosocial dimensions of patients as “particulars” in their unique trajectories.Evaluation: Monash Watch is actively monitoring 272 of 376 intervention patients, with 195 controls over 22 months (ongoing). Trajectories of poor health (SRH) and anticipation of worse/uncertain health (AH), and CG concerns statistically shifted at a tipping point, 3 days before admission in the subset who experienced ≥1 acute admission. The −3 day point was generally consistent across age and gender. Three randomly selected case studies demonstrate the processes of anticipatory and reactive care. PaJR-supported services achieved higher than pre-set targets—consistent reduction in acute bed days (20–25%) vs. target 10% and high levels of patient satisfaction.Discussion: Anticipatory care is an emerging trajectory data analytic approach that uses human sense-making as its core metric demonstrates improvements in processes and outcomes. Multiple sources can provide big data to inform trajectory care, however simple tailored data collections may prove effective if they embrace human interoception and anticipation. Admission risk may be addressed with a simple data collections including SRH, AH, and CG perceptions, where practical.Conclusion: Anticipatory care, as operationalized through PaJR approaches applied in MonashWatch, demonstrates processes and outcomes that successfully ameliorate PPH

Social networks : the future for health care delivery

With the rapid growth of online social networking for health, health care systems are experiencing an inescapable increase in complexity. This is not necessarily a drawback; self-organising, adaptive networks could become central to future health care delivery. This paper considers whether social networks composed of patients and their social circles can compete with, or complement, professional networks in assembling health-related information of value for improving health and health care. Using the framework of analysis of a two-sided network – patients and providers – with multiple platforms for interaction, we argue that the structure and dynamics of such a network has implications for future health care. Patients are using social networking to access and contribute health information. Among those living with chronic illness and disability and engaging with social networks, there is considerable expertise in assessing, combining and exploiting information. Social networking is providing a new landscape for patients to assemble health information, relatively free from the constraints of traditional health care. However, health information from social networks currently complements traditional sources rather than substituting for them. Networking among health care provider organisations is enabling greater exploitation of health information for health care planning. The platforms of interaction are also changing. Patient-doctor encounters are now more permeable to influence from social networks and professional networks. Diffuse and temporary platforms of interaction enable discourse between patients and professionals, and include platforms controlled by patients. We argue that social networking has the potential to change patterns of health inequalities and access to health care, alter the stability of health care provision and lead to a reformulation of the role of health professionals. Further research is needed to understand how network structure combined with its dynamics will affect the flow of information and potentially the allocation of health care resources

High-quality health systems in the Sustainable Development Goals era: time for a revolution.

Executive summary: Although health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Quality should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems. Furthermore, the human right to health is meaningless without good quality care because health systems cannot improve health without it. We propose that health systems be judged primarily on their impacts, including better health and its equitable distribution; on the confidence of people in their health system; and on their economic benefit, and processes of care, consisting of competent care and positive user experience. The foundations of high-quality health systems include the population and their health needs and expectations, governance of the health sector and partnerships across sectors, platforms for care delivery, workforce numbers and skills, and tools and resources, from medicines to data. In addition to strong foundations, health systems need to develop the capacity to measure and use data to learn. High-quality health systems should be informed by four values: they are for people, and they are equitable, resilient, and efficient. For this Commission, we examined the literature, analysed surveys, and did qualitative and quantitative research to evaluate the quality of care available to people in LMICs across a range of health needs included in the Sustainable Development Goals (SDGs). We explored the ethical dimensions of high-quality care in resource-constrained settings and reviewed available measures and improvement approaches. We reached five conclusions: The care that people receive is often inadequate, and poor-quality care is common across conditions and countries, with the most vulnerable populations faring the worst Data from a range of countries and conditions show systematic deficits in quality of care. In LMICs, mothers and children receive less than half of recommended clinical actions in a typical preventive or curative visit, less than half of suspected cases of tuberculosis are correctly managed, and fewer than one in ten people diagnosed with major depressive disorder receive minimally adequate treatment. Diagnoses are frequently incorrect for serious conditions, such as pneumonia, myocardial infarction, and newborn asphyxia. Care can be too slow for conditions that require timely action, reducing chances of survival. At the system level, we found major gaps in safety, prevention, integration, and continuity, reflected by poor patient retention and insufficient coordination across platforms of care. One in three people across LMICs cited negative experiences with their health system in the areas of attention, respect, communication, and length of visit (visits of 5 min are common); on the extreme end of these experiences were disrespectful treatment and abuse. Quality of care is worst for vulnerable groups, including the poor, the less educated, adolescents, those with stigmatised conditions, and those at the edges of health systems, such as people in prisons. Universal health coverage (UHC) can be a starting point for improving the quality of health systems. Improving quality should be a core component of UHC initiatives, alongside expanding coverage and financial protection. Governments should start by establishing a national quality guarantee for health services, specifying the level of competence and user experience that people can expect. To ensure that all people will benefit from improved services, expansion should prioritise the poor and their health needs from the start. Progress on UHC should be measured through effective (quality-corrected) coverage. High-quality health systems could save over 8 million lives each year in LMICs More than 8 million people per year in LMICs die from conditions that should be treatable by the health system. In 2015 alone, these deaths resulted in US$6 trillion in economic losses. Poor-quality care is now a bigger barrier to reducing mortality than insufficient access. 60% of deaths from conditions amenable to health care are due to poor-quality care, whereas the remaining deaths result from non-utilisation of the health system. High-quality health systems could prevent 2·5 million deaths from cardiovascular disease, 1 million newborn deaths, 900 000 deaths from tuberculosis, and half of all maternal deaths each year. Quality of care will become an even larger driver of population health as utilisation of health systems increases and as the burden of disease shifts to more complex conditions. The high mortality rates in LMICs for treatable causes, such as injuries and surgical conditions, maternal and newborn complications, cardiovascular disease, and vaccine preventable diseases, illustrate the breadth and depth of the health-care quality challenge. Poor-quality care can lead to other adverse outcomes, including unnecessary health-related suffering, persistent symptoms, loss of function, and a lack of trust and confidence in health systems. Waste of resources and catastrophic expenditures are economic side effects of poor-quality health systems. As a result of this, only one-quarter of people in LMICs believe that their health systems work well. Health systems should measure and report what matters most to people, such as competent care, user experience, health outcomes, and confidence in the system Measurement is key to accountability and improvement, but available measures do not capture many of the processes and outcomes that matter most to people. At the same time, data systems generate many metrics that produce inadequate insight at a substantial cost in funds and health workers' time. For example, although inputs such as medicines and equipment are commonly counted in surveys, these are weakly related to the quality of care that people receive. Indicators such as proportion of births with skilled attendants do not reflect quality of childbirth care and might lead to false complacency about progress in maternal and newborn health. This Commission calls for fewer, but better, measures of health system quality to be generated and used at national and subnational levels. Countries should report health system performance to the public annually by use of a dashboard of key metrics (eg, health outcomes, people's confidence in the system, system competence, and user experience) along with measures of financial protection and equity. Robust vital registries and trustworthy routine health information systems are prerequisites for good performance assessment. Countries need agile new surveys and real-time measures of health facilities and populations that reflect the health systems of today and not those of the past. To generate and interpret data, countries need to invest in national institutions and professionals with strong quantitative and analytical skills. Global development partners can support the generation and testing of public goods for health system measurement (civil and vital registries, routine data systems, and routine health system surveys) and promote national and regional institutions and the training and mentoring of scientists. New research is crucial for the transformation of low-quality health systems to high-quality ones Data on care quality in LMICs do not reflect the current disease burden. In many of these countries, we know little about quality of care for respiratory diseases, cancer, mental health, injuries, and surgery, as well as the care of adolescents and elderly people. There are vast blind spots in areas such as user experience, system competence, confidence in the system, and the wellbeing of people, including patient-reported outcomes. Measuring the quality of the health system as a whole and across the care continuum is essential, but not done. Filling in these gaps will require not only better routine health information systems for monitoring, but also new research, as proposed in the research agenda of this Commission. For example, research will be needed to rigorously evaluate the effects and costs of recommended improvement approaches on health, patient experience, and financial protection. Implementation science studies can help discern the contextual factors that promote or hinder reform. New data collection and research should be explicitly designed to build national and regional research capacity. Improving quality of care will require system-wide action To address the scale and range of quality deficits we documented in this Commission, reforming the foundations of the health system is required. Because health systems are complex adaptive systems that function at multiple interconnected levels, fixes at the micro-level (ie, health-care provider or clinic) alone are unlikely to alter the underlying performance of the whole system. However, we found that interventions aimed at changing provider behaviour dominate the improvement field, even though many of these interventions have a modest effect on provider performance and are difficult to scale and sustain over time. Achieving high-quality health systems requires expanding the space for improvement to structural reforms that act on the foundations of the system. This Commission endorses four universal actions to raise quality across the health system. First, health system leaders need to govern for quality by adopting a shared vision of quality care, a clear quality strategy, strong regulation, and continuous learning. Ministries of health cannot accomplish this alone and need to partner with the private sector, civil society, and sectors outside of health care, such as education, infrastructure, communication, and transport. Second, countries should redesign service delivery to maximise health outcomes rather than geographical access to services alone. Primary care could tackle a greater range of low-acuity conditions, whereas hospitals or specialised health centres should provide care for conditions, such as births, that need advanced clinical expertise or have the risk of unexpected complications. Third, countries should transform the health workforce by adopting competency-based clinical education, introducing training in ethics and respectful care, and better supporting and respecting all workers to deliver the best care possible. Fourth, governments and civil society should ignite demand for quality in the population to empower people to hold systems accountable and actively seek high-quality care. Additional targeted actions in areas such as health financing, management, district-level learning, and others can complement these efforts. What works in one setting might not work elsewhere, and improvement efforts should be adapted for local context and monitored. Funders should align their support with system-wide strategies rather than contribute to the proliferation of micro-level efforts. In this Commission, we assert that providing health services without guaranteeing a minimum level of quality is ineffective, wasteful, and unethical. Moving to a high-quality health system—one that improves health and generates confidence and economic benefits—is primarily a political, not technical, decision. National governments need to invest in high-quality health systems for their own people and make such systems accountable to people through legislation, education about rights, regulation, transparency, and greater public participation. Countries will know that they are on the way towards a high-quality, accountable health system when health workers and policymakers choose to receive health care in their own public institutions.Fil: Kruk, Margaret E.. Harvard University. Harvard School of Public Health; Estados UnidosFil: Gage, Anna D.. Harvard University. Harvard School of Public Health; Estados UnidosFil: Arsenault, Catherine. Harvard University. Harvard School of Public Health; Estados UnidosFil: Jordan, Keely. New York College of Global Public Health; Estados UnidosFil: Leslie, Hannah H.. Harvard University. Harvard School of Public Health; Estados UnidosFil: Roder DeWan, Sanam. Harvard University. Harvard School of Public Health; Estados UnidosFil: Adeyi, Olusoji. Banco Mundial; Estados UnidosFil: Barker, Pierre. Institute For Healthcare Improvement; Estados UnidosFil: Daelmans, Bernadette. Organizacion Mundial de la Salud; SuizaFil: Doubova, Svetlana V.. Instituto Mexicano del Seguro Social; MéxicoFil: English, Mike. KEMRI - Wellcome Trust; KeniaFil: Garcia Elorrio, Ezequiel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Guanais, Frederico. Banco Interamericano de Desarrollo; Estados UnidosFil: Gureje, Oye. University Of Ibadan; NigeriaFil: Hirschhorn, Lisa R.. Northwestern University; Estados UnidosFil: Jiang, Lixin. National Center For Cardiovascular Diseases; ChinaFil: Kelley, Edward. Organizacion Mundial de la Salud; SuizaFil: Lemango, Ephrem Tekle. Federal Ministry of Health; EtiopíaFil: Liljestrand, Jerker. Bill and Melinda Gates Foundation; Estados UnidosFil: Malata, Address. Malawi University Of Science And Technology; MalauiFil: Marchant, Tanya. London School of Hygiene & Tropical Medicine; Reino UnidoFil: Matsoso, Malebona Precious. National Department of Health of the Republic of South Africa; SudáfricaFil: Meara, John G.. Harvard Medical School; Estados UnidosFil: Mohanan, Manoj. University of Duke; Estados UnidosFil: Ndiaye, Youssoupha. Ministry of Health and Social Action of the Republic of Senegal; SenegalFil: Norheim, Ole F.. University of Bergen; NoruegaFil: Reddy, K. Srinath. Public Health Foundation of India; IndiaFil: Rowe, Alexander K.. Centers for Disease Control and Prevention; Estados UnidosFil: Salomon, Joshua A.. Stanford University School Of Medicine; Estados UnidosFil: Thapa, Gagan. Legislature Parliament Of Nepal; NepalFil: Twum Danso, Nana A. Y.. Maza; GhanaFil: Pate, Muhammad. 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Global Innovations in Measurement and Evaluation

We researched the latest developments in theory and practice in measurement and evaluation. And we found that new thinking, techniques, and technology are influencing and improving practice. This report highlights 8 developments that we think have the greatest potential to improve evaluation and programme design, and the careful collection and use of data. In it, we seek to inform and inspire—to celebrate what is possible, and encourage wider application of these ideas

Randomised controlled trials of complex interventions and large-scale transformation of services

Complex interventions and large-scale transformations of services are necessary to meet the health-care challenges of the 21st century. However, the evaluation of these types of interventions is challenging and requires methodological development. Innovations such as cluster randomised controlled trials, stepped-wedge designs, and non-randomised evaluations provide options to meet the needs of decision-makers. Adoption of theory and logic models can help clarify causal assumptions, and process evaluation can assist in understanding delivery in context. Issues of implementation must also be considered throughout intervention design and evaluation to ensure that results can be scaled for population benefit. Relevance requires evaluations conducted under real-world conditions, which in turn requires a pragmatic attitude to design. The increasing complexity of interventions and evaluations threatens the ability of researchers to meet the needs of decision-makers for rapid results. Improvements in efficiency are thus crucial, with electronic health records offering significant potential